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Globalization and Health
Published in: Globalization and Health 1/2020

Open Access 01-12-2020 | Research

‘It’s far too complicated’: why fragmentation persists in global health

Authors: Neil Spicer, Irene Agyepong, Trygye Ottersen, Albrecht Jahn, Gorik Ooms

Published in: Globalization and Health | Issue 1/2020

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Abstract

Background

Despite many efforts to achieve better coordination, fragmentation is an enduring feature of the global health landscape that undermines the effectiveness of health programmes and threatens the attainment of the health-related Sustainable Development Goals. In this paper we identify and describe the multiple causes of fragmentation in development assistant for health at the global level. The study is of particular relevance since the emergence of new global health problems such as COVID-19 heightens the need for global health actors to work in coordinated ways. Our study is part of the Lancet Commission on Synergies between Universal Health Coverage, Health Security and Health Promotion.

Methods

We used a mixed methods approach. This consisted of a non-systematic literature review of published papers in scientific journals, reports, books and websites. We also carried out twenty semi-structured expert interviews with individuals from bilateral and multilateral organisations, governments and academic and research institutions between April 2019 and December 2019.

Results

We identified five distinct yet interconnected sets of factors causing fragmentation: proliferation of global health actors; problems of global leadership; divergent interests; problems of accountability; problems of power relations. We explain why global health actors struggle to harmonise their approaches and priorities, fail to align their work with low- and middle-income countries’ needs and why they continue to embrace funding instruments that create fragmentation.

Conclusions

Many global actors are genuinely committed to addressing the problems of fragmentation, despite their complexity and interconnected nature. This paper aims to raise awareness and understanding of the causes of fragmentation and to help guide actors’ efforts in addressing the problems and moving to more synergistic approaches.
Literature
1.
WHO. Towards a Global Action Plan for Healthy Lives and Well-Being for All. Geneva: WHO; 2018.
2.
3.
Buse K, Walt G. Aid coordination for health sector reform: a conceptual framework for analysis and assessment. Health Policy. 1996;38(3):173–87.PubMed
4.
Spicer N, Aleshkina J, Biesma R, et al. National and sub-national HIV/AIDS coordination: are global health initiatives closing the gap between intent and practice? Glob Health. 2010;6:3.
5.
Balabanova D, Mckee M, Mills A, Walt G, Haines A. What can global health institutions do to help strengthen health systems in low income countries? BMC Health Research Policy and Systems. 2010;8(22).
6.
Shorten T, Taylor M, Spicer N, Mounier-Jack, S McCoy D. The International Health Partnership Plus: rhetoric or real change? Results of a self-reported survey in the context of the 4th high level forum on aid effectiveness in Busan. Globalization and Health. 2012;8:13.
7.
Gostin L, Mok E. Grand challenges in global health governance. Br Med Bull. 2009;90:7–18.PubMed
8.
Walt G, Spicer N, Buse K. Mapping the global health architecture. In: Buse K, Hein W, Drager N, editors. Making sense of Global Health governance: the policy perspective. London: Palgrave Macmillan; 2009.
9.
Evans T, Kieny M 2015. The International Health Partnership+. In OECD Development Co-operation Report 2015: Making Partnerships Effective Coalitions for Action; 2015. p99–103.
10.
IHP+Results. 2016 Performance Report; 2017.
11.
Frenk J, Moon S. Governance challenges in Global Health. New Engl J Med. 2013;368:936–42.PubMed
12.
Hoffman S, Cole C. Defining the global health system and systematically mapping its network of actors. Glob Health. 2018;14:38.
13.
Ooms G, Ottersen T, Jahn A, Agyepong I. Addressing the fragmentation of global health: The Lancet Commission on synergies between universal health coverage, health security, and health promotion. Lancet. 2018;September 7.
14.
Martinez-Alvarez M, Acharya A, Arregoces L, Brearley L, Pitt C, Grollman C, Borghi J. Trends in the alignment and harmonization of reproductive, maternal, newborn and child health funding, 2008–13. Health Aff. 2017;36(11):1876–86.
15.
16.
Grant M, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Inf Libr J. 2009;26:91–108.
17.
Bolger A, Littig B, Menz W. Introduction: expert interviews – an introduction to a new methodological debate. In A Bolger B, Littig W, Menz, editors. Interviewing Experts. Palgrave Macmillan; 2009. P1–13.
18.
Buse K, Mays N. Walt G. Making Health Policy: Open University Press; 2012.
19.
Dodd R. Aid Effectiveness and Health. Working Paper No. 9. Geneva: WHO; 2007.
20.
McColl K. Europe told to deliver more aid for health. Lancet. 2008;371(9630):2072–3.PubMed
21.
Development Initiatives. Global humanitarian assistance report. Development Initiatives; 2017.
22.
Grey K, Gills B. South–south cooperation and the rise of the global south. Third World Q. 2016;37(4):557–74.
23.
Fengler W, Kharas H. Delivering Aid Differently: Lessons from the Field. World Bank; 2010. Fidler D. Architecture Amidst Anarchy: Global Health's Quest for Governance. Indiana University; 2007.
24.
Burcky U. Trends in in-country aid fragmentation and donor proliferation: an analysis of changes in aid allocation patterns between 2005 and 2009: OECD; 2011.
25.
Annen K, Moers L. Donor competition for aid impact, and aid fragmentation. International Monetary Fund; 2012.
26.
Maximising Positive Synergies Collaborative Group 2009. An assessment of interactions between global health initiatives and country health systems. Lancet 2009; 373: 2137–2169.
27.
Kates J, Wexler A, Lief E. Donor government funding for HIV in low- and middle-income countries in 2016. Kaiser Family Foundation and UNAIDS; 2017.
28.
Anheier H, Glasius M, Kaldor M. Introducing global civil society. In: Anheier H, et al., editors. Global civil society. Oxford: Oxford University Press; 2001.
29.
McCoy D, Hilson M. Civil society, its organizations, and global health governance. In: Buse K, Hein W, Drager N, editors. Making. Sense of Global Health Governance: A Policy Perspective Palgrave MacMillan; 2009.
30.
Spicer N. Non-government actors in global health. In J Hanefeld, editor. Globalisation and Health. Open University Press; 2014.
31.
Fidler D. Architecture amidst anarchy: global health’s quest for governance. Articles by Maurer Faculty Paper 329; 2007.
32.
Fidler D. A theory of open-source anarchy. Indiana Journal of Global Legal Studies. 2008;15(1):259–84.
33.
Buse K, Walt G. Global public-private partnerships: part I – a new development in health? Bulletin of the World Health Organisation. 2000;78(4):549–61.
34.
Sridhar D. Seven challenges in international development assistance for health and ways forward. Journal of Law, Medicine and Ethics. 2010:2–12.
35.
Szlezak N, Bloom B, Jamison D, et al. The global health system: actors, norms, and expectations in transition. PLoS Med. 2010;7(1):1–4.
36.
Hawkins B. Globalization – the state, bilateral and multilateral cooperation. In J Hanefeld, editor Globalisation and Health. Open University Press; 2015.
37.
WHO. Constitution of the World Health Organization. Geneva: WHO; 2006.
38.
39.
Wenham C. What have we learnt about the World Health Organization from the Ebola outbreak. Philosophical Transactions B. 2017;372.
40.
Huang Y. How to reform the ailing World Health Organization. Council for Foreign Relations; 2016.
41.
Clift C. The role of the World Health Organization in the international system. London: Chatham House; 2013.
42.
Ashoff G. Enhancing policy coherence for development: justification. German Development Institute: Recognition and Approaches to Achievement; 2005.
43.
44.
Dhillon R, Karan A. The blind men and the elephant—aligning efforts in Global Health. N Engl J Med. 2018;378(15):1374–5.PubMed
45.
Carbonnier G. Official development assistance once more under fire from critics. Geneva: The Graduate Institute; 2010.
46.
Lencucha R. Cosmopolitanism and foreign policy for health: ethics for and beyond the state. BMC Int Health Hum Rights. 2013;13:29.PubMedPubMedCentral
47.
Nunnenkamp P, Thiele R. Targeting aid to the needy and deserving: nothing but promises? TWEC World Economy. 2006;29(9):1177–201.
48.
Girod D. ‘Cut from the Same Cloth? Bilateral vs. Multilateral Aid’, in Annual Meeting of the International Political Economy Society. Philadelphia; 2008.
49.
Girod D. Effective foreign aid following civil war: the nonstrategic-desperation hypothesis. Am J Polit Sci. 2012;56(1):188–201.
50.
Gulrajani N. Bilateral verses multilateral aid channels: strategic choices for donors. ODI; 2016.
51.
52.
Thomson M, Kentikelenis A, Stubbs T. Structural adjustment programmes adversely affect vulnerable populations: a systematic-narrative review of their effect on child and maternal health. Public Health Review. 2017;38(13).
53.
Action Aid International. Real aid: an agenda for making aid work. London: Action Aid; 2005.
54.
Rogerson A, Hewitt A, Waldenberg D. The international aid system 2005–2010: forces for and against change. London: Overseas Development Institute; 2004.
55.
IHME. Financing Global Health 2017. Seattle, WA: IHME; 2018.
56.
GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1736–1788.
57.
Reich M. Introduction: public-private partnerships for public health. In: Reich M, editor. Public-private partnerships for public health. Cambridge, MA: Harvard Center for Population and Development Studies; 2002.
58.
Owen J, Lister G, Stansfield S. The role of foundations in global governance for health in K Buse, W Hein, N Drager, editors. A Policy Perspective. Palgrave MacMillan: Making Sense of Global Health Governance; 2009.
59.
Hayter T. Aid as Imperialism. Harmondsworth: Penguin Books; 1971.
60.
Easterly W. The white Man’s burden: why the West’s efforts to aid the rest have done so much Il and so little good. New York: Penguin Press; 2006.
61.
Tandon A, Cain J, Kurowshi C, Postolovska I. International dynamics of public financing for universal health coverage: accounting for fiscal space across countries. World Bank Group; 2018.
62.
Moyo D. Dead aid: why aid is not working and how there is a better way for Africa. New York: Farrar, Straus and Giroux; 2009.
63.
Acharya A, de Lima A, Moore M. Proliferation and fragmentation: transactions costs and the value of aid. J Dev Stud. 2006;42(1):1–21.
64.
Escobar A. Encountering development: the making and unmaking of the third world. Princeton University Press: Princeton; 1995.
65.
Easterly W. Tyranny of experts: economists, dictators, and the forgotten rights of the poor: Basic Civitas Books; 2014.
66.
IHP+Results. 2014 Performance Report; 2015.
67.
Spicer N, Berhanu D, Bhattacharya D, et al. ‘The stars seem aligned’: a qualitative study to understand the effects of context on scale-up of maternal and newborn health innovations in Ethiopia, India and Nigeria. Globalization and Health. 2016;12(1):75.
68.
Gehring K, Michaelowa K, Dreher A, Sporri F. Aid fragmentation and effectiveness: what do we really know? World Dev. 2017;99:320–34.
Metadata
Title
‘It’s far too complicated’: why fragmentation persists in global health
Authors
Neil Spicer
Irene Agyepong
Trygye Ottersen
Albrecht Jahn
Gorik Ooms
Publication date
01-12-2020
Publisher
BioMed Central
Published in
Globalization and Health / Issue 1/2020
Electronic ISSN: 1744-8603
DOI
https://doi.org/10.1186/s12992-020-00592-1

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