Tackling the wicked problems of global health

Can the Global Action Plan shift mindsets? Reporting from the World Health Summit 2019

Final panel at WHS 2019

A sense of urgency characterised this year’s World Health Summit. Many discussions focused on the need to change ‘the nature of the dialogue’ between countries, multilateral and bilateral institutions, and public and private sector bodies in order to overcome entrenched challenges in global health. But how exactly can this be done?

A little over a year ago, Germany’s chancellor, Angela Merkel, Ghana’s president, Nana Akufo-Addo, and Norway’s prime minister, Erna Solberg, jointly wrote a letter to the Director General of the World Health Organization (WHO), Dr Tedros Adhanom Ghebreyesus, requesting that he lead the United Nations agencies in accelerating their joint efforts to achieve Sustainable Development Goal 3 and other health-related SDGs. The nucleus of what became the Global Action Plan for Healthy Lives and Well-being for All (GAP) was presented at the World Health Summit 2018 and, one year later, was once again the center of attention.

In the intervening year the WHO brought together 12 multilateral agencies to commit to a new way of working together at international and national levels. Together the organisations have a budget of 12.7 billion USD – a third of the global budget for development cooperation in health – and, through the Plan, aim to spending it more efficiently and effectively. In September 2019 the Action Plan was presented at the occasion of the High-Level Meeting on Universal Health Coverage. 

One theme running through many of the contributions to this year’s Summit was recognition of the daunting task ahead: the Action Plan calls for a fundamental shift in established ways of working and for much closer cooperation between key actors, with implications for multilateral and bilateral partners and for institutions in recipient countries alike. At the same time, delegates in a number of sessions pointed to the way to how this could be done, presenting examples of ‘horizontal’ collaboration, promising alliances between different sectors, and new ways of complementing national efforts with multilateral and bilateral, civil society and private sector support.

The Federal Ministry for Economic Cooperation and Development (BMZ) actively supports the Global Action Plan and the new forms of partnership and collaboration it champions for the coming ‘decade of delivery’. Examples of BMZ-support for such new partnerships that featured at this year’s Summit include hospital partnerships tackling cervical cancer (covered in an upcoming article) and leveraging of German healthcare industry investments in Africa (covered in this article). The Summit also hosted a panel discussion on the Global Action Plan between two African health ministers and representatives of global health institutions, including the Global Fund and Gavi, to which BMZ is the fourth-largest contributor.

Changing the nature of the dialogue: A thought-provoking session concludes the World Health Summit 2019

Ruth Aceng, Minister of Health, Uganda

In the 49th and final session of this year’s Summit, the ministers of health of Guinea Bissau and Uganda, Dr Magda Robalo Correia de Silva and Dr Jane Ruth Aceng, WHO chief of staff Dr Bernhard Schwartländer, Gavi and Global Fund directors Dr Seth Berkley and Peter Sands, and Wellcome Trust director Prof Jeremy Farrar looked at the complex challenges involved in implementing the Global Action Plan. Prof Ilona Kickbusch, of The Graduate Institute of International and Development Studies, moderated the high-level line-up, making sure that the exchange did not just skim the surface. Penetrating questions about the ‘wicked problems’ in global health were at the heart of the discussion.

Asked for their perspectives on the Global Action Plan, both health ministers acknowledged that their countries have been receiving valuable multilateral support and that coordination between the agencies is beginning to improve. Yet both also expressed the view that for the aims of the Action Plan to be realised, greater transparency and accountability is needed on all sides, including on the part of multilateral and bilateral development partners. 

‘The bottom line is to eliminate duplication of effort and to streamline processes,’ says Jane Ruth Aceng. ‘This will enable us to know how much money is actually coming into the country and what difference it’s making. When vertical programs are aligned to my plan then we can all come together and understand whether targets have been achieved. So let’s strengthen the collaboration, yes, but let’s also add to the table transparency.’

Seth Berkley pointed out that both Gavi and the Global Fund have tried to be fully transparent about their use of resources, with every penny publicly accounted for on their websites. As part of the Global Action Plan, the 12 agencies are now taking this commitment further, asking countries to evaluate the technical assistance they receive: ‘It is right to do this, but it’s also painful and difficult, asking a country to rate if your offices and in-country staff are meeting their needs.’

Peter Sands noted that ‘we can tick off deliverables, but what we actually want to do is change the nature of the dialogue in a way that is inclusive and draws in bilateral partners’. In Sands’ view, it is imperative to keep the Action Plan open for all actors, including bilateral organisations, civil society and the private sector: ‘There are varying levels of comfort with this, but we have to push it because ultimately we need governments leading an all-of society movement to deliver SDG3. Just governments talking to multilaterals won’t get us there.’

Jeremy Farrar lauded the multilateral agencies for the way they united behind the Action Plan, and noted that research organisations like his own could learn from this to support the agencies’ work more effectively: ‘In the next decade we are going to face climate change, NCDs, drug resistance, demographic shifts and other headwinds we don’t yet know about. Science has a critical role in addressing these and must play its role as accelerator.’

Time to face up to the wicked problems

Peter Sands, Director, GFATM

In the final round of the discussion Ilona Kickbusch asked panelists which wicked problems they thought had to be resolved for the Action Plan to be a success and for the SDGs to be achieved. 

For Seth Berkley, it is the need to tackle ‘the last mile first’ and to get vaccines to places and people that still aren’t being reached: ‘It’s more expensive, it’s harder to do. There is a reason that people are being missed, it’s displaced people and refugees, people in urban slums. With climate change they will become more and we must not forget them.’

Peter Sands underscored that many health issues are not caused by ‘lack of money, drugs or science, but by a tolerance of stigma, marginalisation, criminalisation of communities, or high levels of gender-based violence. We have to have uncomfortable discussions and governments have to be ready to do tough things in societies in order to solve them.’ Referring specifically to the persistent high rates of HIV among adolescent girls and women, Sands acknowledged his own organisation’s limitations: ‘This is not something the Global Fund or ministries of health can do alone – it requires collaboration with ministries of education, UNFPA, UN Women, UNICEF, WHO and others. We’re all doing good work, but we are not on top of the problem. If we haven’t massively reduced rates among this group in the next years we will have collectively failed.’

Robalo de Silva underlined that all parties involved will have to leave their comfort zones: ‘Realising this Action Plan is going to take a different kind of courage and ambition. The slowing down of economic growth will make reaching our goals tougher and tougher. We talk about no more business as usual, but our mindsets have to change. It still takes far too long to translate global agreements into country results.’

Bernhard Schwartländer added that, in the past, worrying about potential risks has often led to detrimental delays or non-action: ‘Why don’t we ever ask what’s the risk of not doing something? If I don’t do something, will I be equally able to reach better global health? If we asked this every time we have to take tough decisions, it could make a big difference.’

Kickbusch concluded both panel and Summit with a plea that resonated with many of the points expressed over the past three days: ‘I want to ask you to really develop and keep strengthening the sense of urgency that has come across in this discussion. If we don’t accelerate and push, we will not achieve the SDGs in health and in a whole number of other areas. We’ve made tremendous strides, but we cannot rest. I hope you all leave the room with just this sense of urgency – let’s take it as a challenge that each time we come together we continue to instill it.’

Anna v. Roenne and Karen Birdsall,
October 2019

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