The Political DELTA

While musing over what to write about for my blog post, it occurred to me that mine may be a relatively unique DELTA experience in that it departs from the academic realm and sits squarely in within global health governance and politics. Given this departure from the norm (I’m not sure what I mean by norm, given that ours is only the second batch of DELTAs to be sent into the oven!), here is my story, which I hope may be of use for someone considering a similar path.

Whaaat..?

My DELTA topic is “innovative financing at the Global Fund for TB, HIV, and Malaria”. The Global Fund is a multilateral global health financing mechanism set up in 2002 to combat the three diseases. It is funded by bilateral donors including most developed countries, and recently, emerging economies; and by private foundations and the commercial sector. The genius of the Global Fund is in its governance structure, which consists of an active Board comprising members of the donor countries, recipient countries, representatives from communities of people affected by the diseases and civil society representatives. This structure is replicated at the recipient country level where a country-based “Country Coordinating Mechanism” (CCM), which is also as broadly constituted is charged with contributing to and approving the proposals put forth by the countries to the Fund.

In recent times, “innovative financing” has been advocated as a measure to address the challenge of how to transition from countries whose income level has risen above the Global Fund threshold, and which, according to policy, the Fund must withdraw from in a given period. These innovative financing instruments (IFIs) have also been proposed for use more broadly to address the funding gap for the HIV response. The current Global Fund strategic plan proposes the scaling up of such initiatives as a means not only of expanding the funding space for healthcare, but also increasing the social impact of Global Fund grant-making.

And then?

Open Society Foundations – my host organization – was one of the earliest champions of the Global Fund and have played a key role in influencing the Fund’s principles of country ownership, community, and civil society engagement; and pushed for a human right’s based approach to the Global Fund’s grant-making, with focus on marginalized key affected populations (such as sex workers, injecting drug users, LGBTQI individuals etc.) who tend to be criminalized and excluded from health systems.

The aforementioned move towards the use of innovative financing instruments[1], the ones under consideration currently consisting mainly of debt-based and performance-based (loan buy-downs, social impact bonds), raises concerns for GFTAM stakeholders, including OSF, for the following reasons:

  • Philosophically incompatible with Global Fund ethos: Many in the global health world see multilateral organizations such as the Global Fund not as “charitable” mechanisms, but as necessary redistributive tools to address historical injustices and existing economic inequalities. Shifts towards encouraging debt financing essentially shift the economic burden back to developing countries and are seen as a move towards withdrawal by developed countries from their shared responsibilities in the misfortune of the developing world

  • Incompatibility with Global Fund founding principles and governance: Innovative financing arrangements could mean a shift towards the external partners for program design and implementation, transparency, and accountability. External partners e.g. development banks have very different standards of transparency and accountability, and different, sometimes conflicting, principles of program design from the Global Fund.

  • Impact on countries and key populations: Debt is a tool which has the potential to have significant macroeconomic consequences for a country. Debt in health, especially to fund recurrent expenditure which has no easily measurable economic return, is economically imprudent. Debt financing in countries which are struggling to fill the gap left by the Global Fund in their limited budgets does not, even at face value, inspire confidence.

  • The narrative: There is, in essence, nothing innovative about debt-financing. However, framing an arrangement such as a loan-buy-down as an “innovative financing instrument” takes the focus away from the fact that it is simply a debt-based financing arrangement, and instead lends loan-buy-downs a zeitgeist-y air of desirability.

So what?

The mission of OSF’s Global Health Financing and Governance team with whom I am currently working is “to expose and challenge the influence of donor state, economic and private sector actors on health-related decision-making in countries, and to mitigate the impact of this influence on the health of their people, especially key populations.”

As such, the shift in principle introduced by this trend towards loan financing from grants, and the potential effect of this on decision-making at country level, and extrapolated, on the health of their populations, is of concern to OSF. My initial project here (which is also my DELTA) is, therefore, to conduct a politico-economic inquiry into the agenda setting, the actors and the power dynamics behind this move (what was that I said about not being in an academic setting again?)[2]; and to use this information to empower our community and civil society partners to engage meaningfully in this shifting space.

How do you do it, Mamka?

The vast majority of work on my DELTA has been political negotiation around OSF and the Global Fund. I have done much, some of which I can’t write about in detail, but here’s a brief glance into my activities.

The first step was to familiarize myself with my team, their ethos and their work plans[3]. This is still very much a work in progress (a pleasant coincidence that I write this on my third month-i-versary of being at OSF) as this organization is massive, with many programs, and an expansive network of regional and country offices etc. Understanding the position that OSF has as a powerful and decidedly political funding organization, and reflecting on how to exist within and employ that in an ethical way, is something which I am also learning every day.

The second step was to acquaint myself with the relationship between OSF and the Global Fund. OSF, as mentioned before, has had a longstanding relationship with GFTAM. There is almost a revolving door of staff between the two organizations; and OSF, being a grant-making organization, has had a funding relationship with many of the civil society and community stakeholders who are on the Board and country-level CCMs. OSF is also one of the constituents of the Private Foundation Delegation which has a seat on the Board. All these factors lend real weight to OSF on matters of the Global Fund[4].

I will be traveling (with my boss) to the Global Fund Board meeting this November in Geneva, and I will have a chance to observe the dynamics in that space[5], and hopefully, to network with stakeholders and maybe conduct some interviews as well.

Then I mapped out the stakeholders, categorizing them into spheres of influence (e.g. Board member, external stakeholder) and buckets of agendas (pro, con, undecided), and finally, by their relationship with my organization (love us, hate us… just kidding, nobody hates us!)[6]. I have then been conducting in-depth interviews with the stakeholders. It is important to note that there is a snowball sampling aspect to these interviews which is iterative to my mapping, because each interviewee leads me on to others I may not have known about.

I am also planning an internal Brown Bag event during which my team and the wider OSF family can discuss the topic of innovative financing in the context of global health, with the aim of developing some kind of coherent shared framework of thinking as we engage outwardly on this topic.

I am involved in the planning of a wider convening of civil society and community stakeholders, which will probably happen in early 2018, during which they will discuss these mechanisms and what they mean for their engagement at the Global Fund. Given that these trends go further than the Global Fund, this platform will serve as an essential space for forecasting future trends in global health financing and thinking about ways in which to engage with the trends.

I am also scoping for grant-making for country cases where these mechanisms have either been proposed for use or are already at an advanced stage of development. The aim of this is to empower civil society in those countries to engage in decision-making surrounding this and to monitor the impact of these instruments on the health of their populations and the economy of their countries.

We’ve heard enough, go away Mamka!

So, in summary, my DELTA involves working with a political organization to influence the politics of change at the global governance for health level. It is an exciting opportunity and would recommend such an approach to anyone hoping to sharpen their political chops during their DELTA. There is no way of honing skills in diplomacy and negotiation that’s better than putting them to practice, I hereby attest!

[1] The fact that I didn’t define innovative financing is deliberate – no consensus exists on what it consists of, and, conceptually speaking, as soon as a set of tools are deemed innovative, they cease to be so by virtue of the inherent transience of novelty… No? What’s more interesting to me isn’t what tools are in the box, but why certain tools are re-purposed to fit within this box

[2] JOHN KINGDON

[3] These didn’t happen in any actual linear order – they’re all coinciding and colliding in interesting ways – the ordering here is just to have a framework by which to organize my thoughts

[4] Remember though, heavy lies the head that wears the crown…

[5] Lucky me, I’ll be there while they’re electing their new ED. As if I haven’t had enough of electoral politics…

[6] I used the Reich mapping tool