GLOBAL HEALTH INITIATIVES AND SEXUAL AND REPRODUCTIVE HEALTH RIGHTS

1. Subha Sri Balakrishnan Rural Women's Social Education Centre, India SONGs, Brussels, June 30th, 2010 GLOBAL HEALTH INITIATIVES AND SEXUAL AND REPRODUCTIVE HEALTH RIGHTS

2. GLOBAL HEALTH INITIATIVES • Partnerships at global level usually of UN agencies, bilateral/multilateral agencies, international NGOs, private sector • Common features • Focusing on specific diseases, select interventions, commodities or services • Relevance to several countries • Ability to generate substantial funding bringing in additional resources for health efforts • Direct investments in countries • Inputs related to performance • Specific implementation mechanisms

3. GLOBAL HEALTH INITIATIVES • More than 100 GHIs. • Examples – President's Emergency Plan for AIDS Relief (PEPFAR), Multi country HIV/AIDS Programme (MAP), Roll Back Malaria, Stop TB, Global Alliance for Vaccines and Immunization • The Global Fund to Fight HIV/AIDS, TB and Malaria – Funding mechanism rather than implementing initiative

4. GLOBAL HEALTH INITIATIVES Major partners • GAVI - UNICEF, WHO, World Bank, civil society organisations, public health institutes, donor and implementing country governments, Gates Foundation • Global Fund to Fight AIDS, Tuberculosis and Malaria - UNAIDS, WHO, World Bank, Stop TB, Roll Back Malaria, bilateral donors, recipient governments, Gates Foundation, CSOs and business sector • Partnership for Maternal, Newborn and Child Health - WHO, World Bank Group, UNICEF, ODA plus over 240 partners including IGOs, universities, foundations, advocates and governments

5. GLOBAL HEALTH INITIATIVE • President Obama's Global Health Initiative – 2009 -2014 • USD 63 billion over 6 years • HIV/AIDS, maternal health, family planning • Woman and girl centred approach

6. GLOBAL HEALTH INITIATIVES IN SRH • Accelerating Access Initiative • Global Initiative on Contraceptive Requirements and Logistic Management Needs • Global Initiative on Reproductive Health Commodity Management • International Partnership for Microbicides • Consortium for Industrial Collaboration in Contraceptive Research • Partnership for Maternal Newborn and Child Health • G8 Muskoka Initiative for Maternal and Child Health

7. GHIs – History and context of development • Need to govern health at a global level • Health care is globalized • Need for disease control across national borders felt by developed countries • Underlying determinants of health global in nature – globalized economic system, climate change • Financial imperatives • World Bank, USAID – Increased reliance on private sector donors • UN agencies – Need to engage with corporate sector

8. GHIs – History and context of development • World Trade Organization – Expand market for health services in developing countries • Corporate sector • Need to protect business interests – Larger role in international organizations • Pharma industry interested in evolving international regulatory mechanisms – TRIPS. GHIs provided a bargaining space • Possibility of penetrating new markets T K Sundari Ravindran, Silvana Weller. Public Private Interactions in Health, in Ravindran TKS and de Pinho H (eds) 2005. The Right Reforms? Health Sector Reforms and Sexual and Reproductive Health. Women's Health Project, School of Public Health, University of Witwatersrand, South Africa.

9. GLOBAL HEALTH INITIATIVESAn analysis • Development Assistance for Health (DAH) increased dramatically • USD 2.5 billion in 1990 to USD 14 billion in 2005 • New players • New donors - Private foundations • New recipients – Non state health service providers, Global Health Initiatives • New channels – global health financing agencies (eg. GFATM) • A crisis of identity for many of the more established actors such as the WHO, UNICEF McCoy D, editor. Global Health Watch 2. London: Zed; 2008.

10. GLOBAL HEALTH INITIATIVESAn analysis • Additional resources • Involved new actors – civil society organizations • Garnered the political will of donors • Pioneered new performance-based approaches • Provided support for interventions that had been thought to be unsustainable (antiretroviral drugs, treatment for multidrug-resistant tuberculosis) World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. Lancet; 373: 2137–69, 2009.

11. GLOBAL HEALTH INITIATIVESDisease/service/commodity specific intervention • Verticalization accentuated • Technocentric rather than holistic, system focused • Access and uptake of the health services targeted by global health initiatives (GHIs) has increased in many cases • New dimension of health service inequity - Increase in access to some targeted health services has been faster than that to services not targeted by the GHIs

12. GLOBAL HEALTH INITIATIVESGlobal “public good” - External agendas? • Disease-specific funding might not be sufficiently aligned with country priorities or the national burden of disease • The plans developed in funding applications to GHIs and the priorities articulated in strategies for the country health sector are not always well aligned • Comparisons of aggregate spending with mortality and disability data show the discrepancy between burden of disease in low-income and middle-income countries, and the focus of disease-specific funding.

13. Sridhar D, Batniji R. Misfinancing global health: a case for transparency in disbursements and decision making. Lancet; 372: 1185–91, 2008

14. Sridhar D, Batniji R. Misfinancing global health: a case for transparency in disbursements and decision making. Lancet; 372: 1185–91, 2008

15. GLOBAL HEALTH INITIATIVESEffect on overburdened health systems • Scale-up of disease-specific efforts has increased the burden on the existing health workforce • Associated with some attrition of the health workforce from the public sector to specific non-state sector projects funded by GHIs • The promotion of performance-based assessment has been associated with improved quality of services in some cases but, in others, pressures to meet targets has produced distortions and led to compromises in quality • Establishment of some parallel information systems • Parallel financing mechanisms

16. GLOBAL HEALTH INITIATIVESPoor coordination, duplication, fragmentation of efforts • Integration and coordination challenges among different donors • 2005 Paris Declaration on Aid Effectiveness, the Three Ones Agreement, the International Health Partnership (IHP) initiative • Will they work? • Too many actors • Lack of consensus on health system development agenda • Inadequate monitoring of policies and actions of GHIs McCoy D, editor. Global Health Watch 2. London: Zed; 2008.

17. GLOBAL HEALTH INITIATIVESWhat about accountability? Buse, K., and A. Harmer (2007). ‘Seven habits of highly effective public–private health partnerships: Practice and potential’. Social Science and Medicine 64: 259–71.

18. Where is SRH in the GHIs? • Difficult to find. • HIV/AIDS, Maternal health divorced from SRH • Focus on treatment rather than prevention • Focus on child health rather than maternal health • SRH as one component of a disease specific programme • Small presence for family planning / contraception – Population control? • What about abortion? • What about Sexual and Reproductive Health? • What about rights?

19. Global level initiatives for health • Who defines Global Health Initiatives? • What about other initiatives – People's Health Movement, International Women's Health Movement? • Rights based • Similar values and principles – Equity, justice, rights, participation • SRH core component

20. Challenges Narrow focus Technocentric Lack of connection to social determinants Take away money from health systems development Lack of a rights based perspective GHIs – Opportunities and challenges for SRH • Opportunities • Influence global policy • Increased resources

21. Do we really want to be part of GHIs in their present form? GHIs – Opportunities and challenges for SRH

22. GHIs – Opportunities and challenges for SRH • Possible ways forward • Network with “the Alternative Global Initiatives for Health” • Identify like minded institutions/individuals within institutions and push agenda forward • Research into impact of GHIs on health systems, SRH and advocacy based on this.

23. Thank you