The effects of Global Fund financing on health governance in Brazil

A review and analysis of accountability in global health funding, research collaborations and training: towards conceptual clarity and better practice

INTRODUCTION

Accountability is a complex idea to unpack and involves different processes in global health practice. Calls for accountability in global health would be better translated to action through a better understanding of the concept and practice of accountability in global health. We sought to analyse accountability processes in practice in global health funding, research collaborations and training.

METHODS

This study is a literature review that systematically searched PubMed and Scopus for articles on formal accountability processes in global health. We charted information on processes based on accountability lines ('who is accountable to whom') and the outcomes the processes were intended for ('accountability for what'). We visualised the representation of accountability in the articles by mapping the processes according to their intended outcomes and the levels where processes were implemented.

RESULTS

We included 53 articles representing a wide range of contexts and identified 19 specific accountability processes for various outcomes in global health funding, research collaborations and training. Target setting and monitoring were the most common accountability processes. Other processes included interinstitutional networks for peer checking, litigation strategies to enforce health-related rights, special bodies that bring actors to account for commitments, self-accountability through internal organisational processes and multipolar accountability involving different types of institutional actors. Our mapping identified gaps at the institutional, interinstitutional and broader system levels where accountability processes could be enhanced.

CONCLUSION

To rebalance power in global health, our review has shown that analysing information on existing accountability processes regarding 'who is accountable to whom' and 'accountability for what' would be useful to characterise existing lines of accountability and create lines where there are gaps. However, we also suggest that institutional and systems processes for accountability must be accompanied by political engagement to mobilise collective action and create conditions where a culture of accountability thrives in global health.

A scoping review of the uses and institutionalisation of knowledge for health policy in low- and middle-income countries

There is growing interest in how different forms of knowledge can strengthen policy-making in low- and middle-income country (LMIC) health systems. Additionally, health policy and systems researchers are increasingly aware of the need to design effective institutions for supporting knowledge utilisation in LMICs. To address these interwoven agendas, this scoping review uses the Arskey and O’Malley framework to review the literature on knowledge utilisation in LMIC health systems, using eight public health and social science databases. Articles that described the process for how knowledge was used in policy-making, specified the type of knowledge used, identified actors involved (individual, organisation or professional), and were set in specific LMICs were included. A total of 53 articles, from 1999 to 2016 and representing 56 countries, were identified. The majority of articles in this review presented knowledge utilisation as utilisation of research findings, and to a lesser extent routine health system data, survey data and technical advice. Most of the articles centered on domestic public sector employees and their interactions with civil society representatives, international stakeholders or academics in utilising epistemic knowledge for policy-making in LMICs. Furthermore, nearly all of the articles identified normative dimensions of institutionalisation. While there is some evidence of how different uses and institutionalisation of knowledge can strengthen health systems, the evidence on how these processes can ultimately improve health outcomes remains unclear. Further research on the ways in which knowledge can be effectively utilised and institutionalised is needed to advance the collective understanding of health systems strengthening and enhance evidence-informed policy formulation.

Closing the gap: A novel metric of change in performance

BACKGROUND

Interventions to improve performance of global programs in the HIV cascade of care are widespread and increasing the focus of implementation science. At present, however, there is no clear consensus on how to conceptualize their improvement at the program level. The commonly used measures of association, based on ratios of probabilities (or odds), have well-known defects in public health applications. They yield large effect sizes even when the absolute effects, and therefore the public health impact, are small. On the other hand, risk differences create problems because settings with higher baseline values are penalized. We aim to examine ways of quantifying improvement in each health center of a cluster-randomized trial in Uganda to accelerate antiretroviral therapy initiation among HIV-infected adults.

METHODS

We formalize the concept of the 'improvement index,' defined as the fraction of gaps closed as a metric of improvement, and suggest that it has unique features and strengths when compared to risk ratios and risk differences.

RESULTS

Overall agreement between the different indices was not high, especially among health centers that were among the top 5 or 10. However, all ranking showed broad similarities at the far ends of the spectrum. On scatter plots, there was a positive linear relationship between the metrics, and the Bland Altman (B-A) plots were in agreement.

CONCLUSION

The improvement index can be used as an alternative measure of association in implementation science interventions. It can be useful for public health purposes as it demonstrates how much can be covered from the baseline.

District Health Officer Perceptions of PEPFAR's Influence on the Health System in Uganda, 2005-2011

BACKGROUND

Vertically oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the President's Emergency Plan for AIDS Relief (PEPFAR), have successfully contributed to reducing HIV/AIDS related morbidity and mortality. However, there is still debate about whether these disease-specific programs have improved or harmed health systems overall, especially with respect to non-HIV health needs.

METHODS

As part of a larger evaluation of PEPFAR's effects on the health system between 2005-2011, we collected qualitative and quantitative data through semi-structured interviews with District Health Officers (DHOs) from all 112 districts in Uganda. We asked DHOs to share their perceptions about the ways in which HIV programs (largely PEPFAR in the Ugandan context) had helped and harmed the health system. We then identified key themes among their responses using qualitative content analysis.

RESULTS

Ugandan DHOs said PEPFAR had generally helped the health system by improving training, integrating HIV and non-HIV care, and directly providing resources. To a lesser extent, DHOs said PEPFAR caused the health system to focus too narrowly on HIV/AIDS, increased workload for already overburdened staff, and encouraged doctors to leave public sector jobs for higher-paid positions with HIV/AIDS programs.

CONCLUSION

Health system leaders in Uganda at the district level were appreciative of resources aimed at HIV they could often apply for broader purposes. As HIV infection becomes a chronic disease requiring strong health systems to manage sustained patient care over time, Uganda's weak health systems will require broad infrastructure improvements inconsistent with narrow vertical health programming.

Globalization and Health: developing the journal to advance the field

Founded in 2005, Globalization and Health was the first open access global health journal. The journal has since expanded the field, and its influence, with the number of downloaded papers rising 17-fold, to over 4 million. Its ground-breaking papers, leading authors -including a Nobel Prize winner- and an impact factor of 2.25 place it among the top global health journals in the world. To mark the ten years since the journal's founding, we, members of the current editorial board, undertook a review of the journal's progress over the last decade. Through the application of an inductive thematic analysis, we systematically identified themes of research published in the journal from 2005 to 2014. We identify key areas the journal has promoted and consider these in the context of an existing framework, identify current gaps in global health research and highlight areas we, as a journal, would like to see strengthened.

A concept in flux: questioning accountability in the context of global health cooperation

BACKGROUND

Accountability in global health is a commonly invoked though less commonly questioned concept. Critically reflecting on the concept and how it is put into practice, this paper focuses on the who, what, how, and where of accountability, mapping its defining features and considering them with respect to real-world circumstances. Changing dynamics in global health cooperation - such as the emergence of new health public-private partnerships and the formal inclusion of non-state actors in policy making processes - provides the backdrop to this discussion.

DISCUSSION

Accountability is frequently reduced to one set of actors holding another to account. Changes in the global health landscape and in relations between actors have however made the practice of accountability more complex and contested. Currently undergoing a reframing process, participation and transparency have become core elements of a new accountability agenda alongside evaluation and redress or enforcement mechanisms. However, while accountability is about holding actors responsible for their actions, the mechanisms through which this might be done vary substantially and are far from politically neutral.Accountability in global health cooperation involves multipolar relationships between a large number of stakeholders with varying degrees of power and influence, where not all interests are realised in that relationship. Moreover, accountability differs across finance, programme and governance subfields, where each has its own set of policy processes, institutional structures, accountability relations and power asymmetries to contend with. With reference to the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, this paper contributes to discussions on accountability by mapping out key elements of the concept and how it is put into practice, where different types of accountability battle for recognition and legitimacy.

SUMMARY

In mapping some defining features, accountability in global health cooperation is shown to be a complex problem not necessarily reducible to one set of actors holding another to account. Clear tensions are observed between multi-stakeholder participatory models and more traditional vertical models that prioritise accountability upwards to donors, both of which are embodied in initiatives like the Global Fund. For multi-constituency organisations, this poses challenges not only for future financing but also for future legitimacy.