Good governance is increasingly understood as necessary for improving access to medicines and contributing to health systems strengthening. This chapter reviews the findings of studies carried out in 25 countries that have examined governance of key functions of pharmaceutical systems within the framework of WHO’s Good Governance for Medicines (GGM) programme. The country studies, which are based on a common methodology, have revealed strengths and several weaknesses in existing pharmaceutical systems and have provided policy-makers with relevant information to help them better understand the nature of the problems facing the sector and where interventions need to take place. Common strengths in the pharmaceutical systems and procedures include the use of standard application forms in the registration process of medicines, use of national essential medicines lists, existence of standard operating procedures for procurement of medicines and well-established tender committees. Common weaknesses include a lack of access to information, poor enforcement and implementation of laws and regulations, absence of conflict of interest policies among members of various committees, and an inability to ensure that the proper incentives are in place to lessen the likelihood of corruption at both the individual and institutional levels. Governments can reduce corruption by promoting transparency and ethical practices, and by introducing simple measures, such as justification for committee membership, terms of reference, conflict of interest policies and descriptions of the purpose of the committees. International organisations, such as WHO, can provide technical support for these efforts.
Governance and participation in health
On 8 April 2011 over 400 civil society activists gathered in New York for a one-day hearing with United Nations (UN) Member States on progress toward reaching Universal Access to HIV treatment, prevention, care, and support. This Civil Society Hearing took place as Member States began drafting a new Outcome Document on HIV, to be adopted at a UN High-Level Meeting on AIDS on 8 June 2011. Advocates are calling for a renewed and urgent commitment from member States to reach Universal Access goals by 2015. During the Hearing, civil society advocates stressed that in pursuing Universal Access goals the international community must prioritise public health over politics. They urged Member States to make available to their citizens the full complement of evidence-based HIV prevention, care, treatment, and support technologies and tools as a commitment to the human right to health. They called for the Outcome Document that will emerge from the UN High Level Meeting on HIV AND AIDS to acknowledge global failures to reach Universal Access by 2010, recommit to upholding and implementing priorities in the global AIDS response articulated by key existing global frameworks on HIV, including the UNAIDS 2011-2015 Outcome Strategy, and commit to bold, new targets.
Representatives of organisations working on campaigns for health and social justice, as well as academia, governments and multilateral institutions, gathered in New Delhi from 2-4 May 2011 to address the need for an effective and accountable global governance for health. They believe that WHO needs to rediscover its fundamental multilateral identity. Drawing on its strengths, the organization has to take advantage of its reform process to rethink and reassert itself as the leading actor in a broader governance for health that is coherent with the need for solid public policy responses to the neoliberal prescriptions, so that globalization be shaped around the core values of equality and solidarity. Beyond mere institutional approaches, issues related to public policies in health have to be democratically debated and tackled at the local, national and regional level. This entails the continued participation and meaningful contribution of communities, public opinions, and their direct empowerment through education and knowledge sharing. Health democracy, namely participation, transparency and accountability in health, is a pre-condition for countries to make an impact in the decision making processes at the global level, within WHO and in other multilateral fora.
In this report, the African Power and Politics Programme (APPP) argues that economic growth is slower and more inequitable than it could be, and has not necessarily produced the poverty reduction that might have been hoped for. There is a growing consensus around the world that this is due to failures in governance, to which the APPP adds the hypothesis that the immediate problem is in part due to the application of a ‘good governance agenda’ that is ideological rather than evidence-based. APPP presents four recommendations. First, moving from ‘best practice’ to ‘best fit’ in thinking about institutional development is necessary. Second, a more realistic take on elections and citizen empowerment as means of addressing problems of public goods insufficiency requires us to rely less on the congenial assumption that all good things go together. Third, the leadership factor and the politics thereof are perhaps the biggest influence on the extent to which particular regimes are developmental or not. Fourth, these findings have important implications for aid effectiveness ahead of the Fourth High Level Forum on Aid Effectiveness in Korea later in 2011. Specifically, the concept of country ownership is due to be revamped, and it should be tied explicitly to this leadership question rather than to democracy, parliamentary oversight, or civil society participation.
In this article, the authors describe how governance issues have influenced human resources for health (HRH) policy development and to identify governance strategies that have been used, successfully or not, to improve HRH policy implementation in low- and middle-income countries (LMIC). They performed a descriptive literature review of HRH case studies which describe or evaluate a governance-related intervention at country or district level in LMIC. In total 16 case studies were included in the review and most of the selected studies covered several governance dimensions. The dimension 'performance' covered several elements at the core of governance of HRH, decentralisation being particularly prominent. Although improved equity and/or equality was, in a number of interventions, a goal, inclusiveness in policy development and fairness and transparency in policy implementation did often not seem adequate to guarantee the corresponding desirable health workforce scenario. This review shows that the term 'governance' is neither prominent nor frequent in recent HRH literature. It provides initial lessons regarding the influence of governance on HRH policy development and implementation. The review also shows that the evidence base needs to be improved in this field in order to better understand how governance influences HRH policy development and implementation. Tentative lessons are discussed, based on the case studies.
In this commentary, the authors offer five proposals for re-establishing WHO’s leadership. First, WHO should give real voice to multiple stakeholders, including philanthropies, businesses, public/private partnerships, and civil society. Second, WHO should improve transparency, performance and accountability, as stakeholders demand clarity on how their resources will achieve improved health outcomes. Also, WHO should exercise closer oversight of regions, and exert legal authority as a rule-making body. Finally, WHO should ensure predicable, sustainable financing, reducing extra-budgetary funding, which now represents almost 80% of the agency's budget. The ideal solution would be for the World Health Assembly (WHA) to set higher member state contributions. Failing decisive WHA action, the WHO should consider charging overheads of 20-30% for voluntary contributions to supplement its core budget.
This article is a review of the January 2011 Executive Board meeting of the World Health Organisation (WHO). The author identifies a new sense of purpose and willingness of member states to address politically complex issues head on and work towards acceptable compromises in the interest of global health. This was exemplified by the negotiation of a proposal from the African group of countries to institute a policy of rotation between geographic regions for the election of future WHO Director-Generals. The issue could have led to political deadlock on the board, the author argues, but it was artfully avoided through a deft show of statesmanship and above all a collective desire to see the board succeed in its work. The African group of countries also called for a greater involvement of developing nations and emerging economies in global health governance. Concrete proposals for how to move forward with a sense of urgency were raised, and Director General Margaret Chan received a clear mandate to develop reform proposals for discussions at the World Health Assembly in May 2011.
In this article, the author briefly examines various definitions of ‘global health diplomacy’ (GHD), reviews possible fundamental principles and discusses unresolved challenges. He argues that fundamental principles of GHD should include: ethical participation and decision making; human rights concerns and enforcements; rule of law and clear process for settling disputes; social determinants of health and how to mitigate their impact; shared bilateral and international interests and priorities; centrality of target populations and sensitivities to local customs, religions and social mores; research as part of efforts to expand the frontiers of the field; training and field experience for all practitioners; an understanding of political, policy making, advocacy and implementation issues in global health; globalisation and international trade issues; integration and mainstreaming of policies and programmes in the relationship between global health, bilateral diplomacy and multilateral development; and public/private/civil society partnerships and alliances. He identifies five challenges for GHD. The first challenge is to further develop the field of GHD as a discipline. The second challenge is how to harmonise the divergent orientation of public health experts, trained diplomats and development experts. Thirdly, stakeholders must ensure that global health diplomacy retains a significant focus on the needs of target populations around the world. Finally, stakeholders must find strategies to maintain the current non-partisan support of policy makers on global health issues over the long term.
The author of this article argues that the emerging global health diplomacy movement points to the need for core capacities in the public health and diplomatic arenas. Among these are an understanding of international relations among public health professionals and greater recognition by diplomats of the population health outcomes of foreign policy. More specifically, the author notes that their training should include perspectives on globalisation, social determinants of health and cultural competence, macro-economics and political negotiation. Communities and citizens are often not considered in the formal policy arena but play an important role in meeting foreign policy goals and in cultivating trust and friendship across national borders, particularly in times of crisis and emergency. Future foreign policy and global health efforts need to ensure dialogue with affected communities and be more intentional in engaging and citizens groups in defining needs and goals. While it is likely that health security will remain a prominent rationale for developed countries to invest in global health initiatives, a the author concludes that more coherent approach to foreign policy and health diplomacy could result in better alignment between the health security goals of developed countries and health equity and development goals of developing countries, while at the same time recognising and channelling the growing financial and technical contributions of private citizens, companies and organisations.
In this interview, Lilian Celiberti of Feminist Dialogues reports that the World Social Forum (WSF), held in Dakar, Senegal from 6–11 February 2011, was an opportunity for a variety of activists and other civil society stakeholders to take part in discussions across varying perspectives and experiences. She highlights the strong and active participation of African women and youth, and the barriers of poor logistics and translation. She comments that the Declaration of the Women's Organisations was heavily focused on international conventions and UN-Resolutions, despite multiple tensions and conflicts amongst African groups and regions. She recognises that although interpersonal exchanges enable the deepening of debates, ‘colonisation continues in the divisions that we experience in different parts of the world’, and questions remain unanswered about how to develop collective thinking and solidarity in social movements.