002 Michel Sidibe 2013 375As we approach the watershed year of 2015, it is time to take a look in the mirror and ask: are we ready to meet the challenges of the next development era?

In the past 15 years, we have rightly seen health occupy a more central place in development and on occasion rise to a foreign policy issue of utmost salience. AIDS was the first health issue brought to the UN Security Council and General Assembly. Today, Ebola is creating diplomatic challenges for African countries as they struggle to limit the horrific damage it is inflicting on their communities and economies.

More and more, political actors are deploying soft power as a means to reach agreement on priorities and strategies for global health. In 2007, seven far-sighted Foreign Ministers from Africa, Asia, Latin America and Europe came together to form the Foreign Policy and Global Health Initiative in an attempt to use diplomacy to secure better health for all and to raise the profile of global public health. One year later, the UN recognized “the close relationship between foreign policy and global health and their interdependence” in Resolution 63/33.

In an increasingly complex, interdependent and hyper-connected world, people’s health is determined ever more by forces operating outside the traditional “health” sector — be it climate change, trade regimes or the advertising strategies of multinational food and tobacco corporations. Reflecting the need for joint action and health diplomacy with other sectors, new partnerships, networks and regimes have proliferated as the international community seeks to strengthen collective action to address specific health concerns. Non-state actors and entrepreneurs have entered the arena in unprecedented numbers.

As power and influence shift, in some cases becoming more diffuse and in others more concentrated, new systems of governance are emerging. While multilateralism is in crisis, we are seeing new forms of “minilateralism” in the form of unconventional alliances. Sometimes this means greater democratic involvement of civil society and the private sector in shaping policy and progress—but certainly not always.

A complex landscape of multiple and sometimes competing governance clusters and diffused accountability are the fruits of this ad hoc expansion. As a result, we have witnessed irrational and even perverse allocation of resources across issue-areas and countries. Countries are faced with multiple funding streams and intricate reporting requirements, and increased transaction costs. Equally damaging, these regimes often advocate competing narratives delivering mixed signals on priorities and approaches which exacerbate challenges of agreeing strategies and ensuring policy coherence. But this state of hyper-connectivity and interdependence can also bring results and opportunities — for example, in information sharing and using data to hold the powerful to account.

Cognizant of both the challenges and opportunities a shifting world offers, I am pleased to see a number of governments asking whether the global health architecture is fit-for-purpose. In my view, it is not. It is high time to democratize this conversation.

Changing landscape of poverty, inequality and disease burden

When we launched the Millennium Development Goals almost 15 years ago, nearly 90 percent of the world’s poor lived in low-income countries. Today, three out of four poor people reside in middle-income countries. Meanwhile, inequality is on the rise. In 2013 President Obama called growing income inequality “the defining challenge of our time”. While the global picture is a varied one, the numbers of ultra-wealthy are soaring the world over. Emerging economies are, on average, more unequal than rich ones. Add to this the growing burden of non-communicable disease (NCDs), interpersonal violence, injuries and other human miseries caused by unhealthy and unsafe environments and lifestyles, and we can see that things need to change. Indeed, these shifts in demography, wealth distribution and disease burden turn on its head how we need to be thinking about the governance and architecture of global health over the next 20 years.

The recent Ebola outbreak has shone a bright light on the deep cracks in the current system. It has revealed that our health systems are not sufficiently shock proofed to withstand emerging and future threats. The challenge is no longer scaling up service access for millions of people — the challenge has become how to advance a major prevention revolution while providing chronic care, often over a lifetime, to billions.

We need multi-sector responses like never before. The Open Working Group on Sustainable Development Goals (OWG) has been grappling with how to articulate and concretize this in its proposed goal for health. With targets related to road traffic accidents, substance abuse, hazardous chemicals and pollution, along with NCDs and communicable diseases, the proposed goal reflects the burgeoning global health portfolio and the urgent need for the health guardians to practice the kind of diplomacy that will drive coordinated governance beyond the health sector. The report of The Lancet-University of Oslo Commission on Global Governance for Health made a strong case for a multi-stakeholder platform for health to coordinate efforts to address the political, economic and social determinants of health — something the global community could build on as it discusses means of implementation of the post-2015 agenda.

Shaking it up

It is clear that the global health architecture needs a shakeup. It needs to be simplified and streamlined. The new arrangements should focus less on donors and benefactors and more on country ownership, shared responsibility and joint leadership. Not only this, we must adapt our skills and capacities in order to govern health moving forward. Our ability to engage other sectors, craft regulation and stimulate innovation will determine our success.

Two major reforms stand out. First, while networked forms of governance are here to stay, a simplified global health superstructure is much needed. This requires just one funding mechanism — what I have been calling a Global Health Equity Fund — which would build on the success of the GAVI Alliance, the Global Fund to Fight AIDS, TB and Malaria as well as instruments such as UNITAID — but would be broader in scope and, importantly, include global solidarity for vulnerable populations in middle-income countries. Such an architecture would benefit from one primary global advocacy and accountability mechanism. In the future we won’t need UNAIDS advocating for AIDS, or other organizations advocating exclusively for malaria or for TB. We need one very strong organization with a clear, transparent mandate that advocates on the basis of the evidence of the burden of disease and the efficacy of interventions. It would be guided by an independent accountability mechanism and the most accurate and timely data to help foster public confidence in what we do. Such data would be critical for the third pillar of this simplified global health architecture — a single agency that would provide normative leadership not simply for disease management but for health promotion and protection — grounded in principles of evidence, human rights and multi-sectoral action for health.

Second, we must take a proactive approach to reforming our portfolio of skills to better engage a range of actors, deploy soft power and build our political advocacy and accountability capacity for a more complex world.

Principles of the AIDS response can inform a new architecture for health

The AIDS response was unprecedented in generating global solidarity and political leadership on global health. There are a number of innovations that have been critical in driving the success of the AIDS response which can inform how we govern global health in an ever more inter-dependent world.

AIDS was the first major pandemic to strike in the era of globalization. With high-speed travel and rapid and vast flows of people between cities, countries and continents, the virus had found its way into people the world over before anyone knew HIV existed. The response demanded coordinated international action by governments and, simultaneously, generated unprecedented global solidarity among the citizens of the world who built a movement around their shared condition.

The movement was triggered by the refusal from a small number of gay men to accept injustice and indifference. It has been defined from the outset as a movement for human rights, equal opportunity and social justice. Further, communities affected by AIDS have demanded a seat at the table of decision-makers. Civil society has also driven multi-sectoral action, demanding action from governments and the private sector to work together, for example, to curb costs for treatment and negotiate TRIPS flexibilities. The response has also developed powerful accountability mechanisms to enable people to hold governments and policy-makers to account. In essence, the AIDS movement has been a forerunner for global health citizenship — a re-thinking of citizenship which is defined by citizen activism, citizen accountability and citizen compacts.

As we negotiate the post-2015 development agenda in the coming year, lessons from the AIDS response can be leveraged to build a governance system for health that is inclusive, accountable and effective, and which places the global health citizen at its core.

The courage to do things differently

Implementing the reforms I have articulated will not be easy. They demand that the art of skilled diplomacy be practiced not simply by national leaders, but by health advocates the world over. It may not happen overnight but will require incremental efforts, conviction and courage over years to streamline our current architecture to the level I believe is necessary to meet challenges of the 21st century. Reforming our own capacities and diversifying our skill-set in global health governance will also be a challenge.

However, it is not a challenge from which we should shy away. Now for the Long Term, the report of the Oxford Martin Commission for Future Generations, calls for embedding sunset clauses in the governance structures of publicly funded international institutions such that resources can be redirected when the mandate of an organization has been achieved. I am calling for ending the AIDS epidemic as a public health threat by 2030. I am not alone — the UN Secretary-General supports this as does my Board. The African Union and the OWG have also joined the movement. We need to reconsider the future of UNAIDS in this light. With ending the AIDS epidemic as our mandate, let AIDS actors walk the talk and start simplifying the global health architecture one step at a time.