169. We are attracted by elements of all three
models. The International Health Partnership has the considerable
advantage of being already in existence and of having influential
participants. It is, in effect, a 'coalition of the willing' which
is trying to bring greater rationality and synergy into the management
of global health, especially at the all-important country level.
Such self-help initiatives can often be successful where other,
more top-down structures are difficult to bring about. As observed
above, we believe the principle of mutuality underlying the Global
Compact concept has much to commend it. It recognises that effective
global control of infectious disease depends crucially on all
countries, whatever their circumstances, cooperating for the common
good, whether that takes the form of developing affordable vaccines
and medicines, building up good disease surveillance or supplying
virus samples, and that that is more likely to be achieved if
each of the many actors perceives that it has a vested interest
in actively participating.
170. Networked governance, in our view, represents
the most accurate analysis of the problem which global health
management now facesin particular, the rise of powerful
non-State actors and the rapid dissemination of knowledge around
the globe. We note Professor Fidler's view that top-down
imposition of a new global health order is simply not realistic
and that there is at the moment a process of natural selection
taking place from which we can expect to see emerge in due course
greater coherence. What concerns us is whether this process, left
to itself, will necessarily lead in the direction of more synergetic
and generally more effective global infectious disease control.
While we recognise that a new order cannot be imposed, we cannot
help feeling that the present situation cannot responsibly be
left simply to work itself out in a laissez faire manner
and that the future will be safer if there is a shared vision
of where we are going and a body that is recognised as having
responsibility for overseeing what is happening, promoting integrated
or collaborative working and alerting the global community if
the system shows signs of malfunctioning.
171. In our view, and indeed in that of most
of those who gave evidence to us, the natural choice of organisation
to exercise such a role is WHO. Its mandated functions of health
policy formulation, standard-setting and technical support have
recently been enhanced by a more proactive role in the crucial
field of global infectious disease surveillance and response.
WHO is therefore now well-placed to prepare, with the agreement
of its Member States, a strategy for the future governance of
global health and to encourage the many players on the global
health stage to move towards it. On the basis of the evidence
we have received, there should be broad support for WHO to assume
such a role.
172. If, however, such an initiative is to succeed
in bringing greater rationality and synergy to global disease
control, it must be supported by resources as well as words. We
have drawn attention above to WHO's budgetary structure, in which
only a small proportion of total resources is available for investment
in programmes which, from WHO's centrally-placed perspective,
are essential to strengthen global disease control capacity. In
the world in which we now live, where effective surveillance and
response is crucial to disease control, we regard this situation
as unacceptable and we have recommended above that WHO's budget
should be re-balanced and increased. We would not wish to be misunderstood.
We are not suggesting that Member States should sign a blank cheque
and leave it to WHO to decide how much of its total resources
should be spent on programmes to which it attached importance.
What we are suggesting is that there should be some re-balancing,
based on evidence of need from WHO, of the organisation's budget
between Assessed and Voluntary Contributions in favour of the
former. A management initiative currently being undertaken by
the Department of Health in relation to funding of WHO, to which
we refer below, may
provide a model.
173. We therefore recommend that the Government
should take the initiative, within the global health community,
to promote a strengthening of WHO's role in two principal respects.
First, Member States should be asked to agree, at the 2009 World
Health Assembly, on a new Mission Statement which would give WHO
a role of preparing a strategy for global health governance and
promoting, through negotiation, an increase of collaborative working
among the various actors, State and non-State, in the field of
infectious disease control. Second, Member States should be asked
to agree, on the basis of evidence of need presented to them by
WHO, a re-balancing of the WHO budget between Assessed and Voluntary
174. Moving health governance forward at the
global level is essential, but it is by no means the whole story.
It is at the country level where the real problems of unintegrated
working make themselves felt and where they have the potential
to do most damagefor example, if health aid does not reach
the sick people for whom it is intended or if host governments
are so burdened with responding to a multiplicity of donors that
they cannot do their work effectively. There was consensus among
all those who gave evidence to us that the most appropriate way
of promoting collaborative working among donors at country level
was to align such efforts behind the health strategy and planning
of the country concerned. Dr Lob-Levyt, from GAVI, told us
that "the priorities should be set by the countries themselves
and we should try and work behind those priorities, no question"
(Q 824). Dr Getahun, from Stop TB, agreed that "an
important line should be to work under the national government,
under the national plan" (Q 748). We were encouraged
to hear, from Diane Stewart of the Global Fund, that these principles
are now being acted upon in some areas. Ms Stewart told us that
"we are trying to move towards the approval of national strategies
for funding, so countries will be able to develop their national
strategies, say which piece of it they do not have the funds for,
what is the gap, and submit that to the Global Fund for funding"
175. It is important to recognise, however, that
in some countries the preparation and implementation of sound
national plans cannot be carried out without external support.
The Centre for Global Development wrote to us that, "where
a host country's plan is weak or has gaps, donors should coordinate
efforts to assist the government and other country stakeholders
to strengthen it"(p 470), and Dr Lob-Levyt commented
that "in some areas, in order to ensure that there is informed
decision-making and priority-setting, information is needed, and
I think we rely on the normative role of agencies, such as WHO
and others, to ensure that the correct information is available
to the country to make those decisions" (Q 824). In
other words, it is not enough simply for donors to align themselves
with in-country health plans: they must, in many cases, support
the development of sound plans which reflect real priorities and
are capable of being implemented efficiently.
176. We therefore recommend that the Government,
working with other donors and with recipients, should aim to lighten
the administrative burden of health aid on developing countries
and to strengthen the capacity of those countries to manage health
programmes. The aim should be to secure the alignment of donor
inputs to disease control programmes within the national health
programmes of recipient countries and to simplify the procedures
for their management and reporting.