Reshaping global health.

Dybul, Mark ; Piot, Peter ; Frenk, Julio 等

MOVEMENT ALONG THE arc of development has been propelled by new worldviews and the creation of institutions to respond to them. In the 19th and 20th centuries, development efforts evolved from colonial expansion to missionary zeal, the aftermath of two world wars, the Cold War, economic self-interest, and postcolonial guilt. Numerous private and public organizations were created to respond to shifting demands, including multilateral and bilateral organizations wholly or partially dedicated to global health.

The opening ten years of the 21st century arguably were the decade of global health. Resources increased significantly and many millions of lives were saved and improved. The rapid expansion in global health was part of a broader conceptual movement that created core principles for the use of resources in a new era in development. The first expression of new thinking was the historic Monterrey Consensus, which was later refined by the Paris Declaration and the Accra Accord. The foundational principle outlined in those agreements is a move from paternalism to shared responsibility and mutual accountability. Key to shared responsibility are leadership and strategic direction for the use of resources by the country in which they are deployed ("country ownership"). Achieving country ownership requires good governance, a results-based approach, and the engagement of all sectors of society.

Several large global health institutions were born out of the heady days of the opening of this century; they were intended to reflect and be responsive to the demands of a new generation in development. Governments in emerging economies such as Mexico, Thailand, China, and Brazil have developed innovative models and invested significant resources in the health of their people. Although governments in many middle-income countries provide a great share of health resources, many of the gains in low-income countries and aspects of gains in middle-income countries have been financed and supported by newly created disease-specific programs including the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund); the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and Malaria Initiative (PMI); and the Global Alliance for Vaccines and Immunizations (GAY i). In addition, the Bill and Melinda Gates Foundation and other philanthropists became major investors in global health, and numerous public-private partnerships and product development partnerships were created. The large funding organizations have supported many country-owned programs that have saved and lifted up millions of lives while being the driving force in shifting the benchmark of success in global health--and development--from the amount of money committed to results achieved. Furthermore, health became part of the world's top agendas, including at the G8, the UN Security Council, CARICOM, and the African Union.

However, the focus on specific diseases has imposed and exposed fault lines in delivering services in places where many suffer from multiple health issues at the same time or at varying points in their lives. Although studies have shown that HIV interventions have reduced overall mortality and that malaria and immunization programs have reduced childhood mortality in the near term, it seems highly likely that more lives will be durably saved if a person afflicted by different health problems has access to services for all of them. Although there are limited supportive data, we believe it is likely that an integrated approach focused on the health of a person and community is more cost-effective than a silo approach focused on a specific disease or health threat. Yet, existing global health institutions were designed for specific diseases and have not effectively shifted to embrace a broader vision.

The resources currently available could have significantly greater impact with a more rational global health strategy and institutional structure focused on stewardship of available resources to achieve public goods what is commonly called global health architecture. Put more directly, today and every day, people will die and lives will not be improved because of the way global health is governed and implemented. Therefore, there is an urgent moral imperative that we act now. But there is also a complementary aspect of realpolitik to reorient global health architecture to the public good: Economic and political realities make financing of inefficient programs and institutions unsustainable. Support for a radical change in the current global health architecture is therefore in the interest of every disease- or issue-specific advocate.

In 1944, a historic meeting occurred at a hotel in Bretton Woods, New Hampshire, and created the International Monetary Fund and the International Bank for Reconstruction and Development (the World Bank). The new institutions were established to rationalize global economic policy and secure organizational order amidst chaotic and splintered systems to lift the world from the devastation of World War II. As we approach the 35th anniversary of the Alma Ata Declaration calling for universal access to essential health services and the final years of the Millennium Development Goals (MDG), there is no realistic chance of achieving many of the global health targets despite progress in many countries. Following a decade of unprecedented expansion, global health is at a significant crossroads, with the World Health Organization (WHO) facing a major budgetary shortfall and many multilateral and bilateral programs bracing for limited growth or significant cuts.

As we approach the post-MDG era, now is the time for a new framework to establish an accelerated trajectory to achieve a healthy world. The conceptual foundations of a new era in global health and development have already been established to guide a new international strategy. We propose, below, some principles of implementation to translate those ideals into lives saved and lifted up. It is also time for a Bretton Woods-style international agreement to rationalize the institutional structure of global health led by the G20) with the active engagement and leadership of the emerging economies and other middle- and low-income countries. We acknowledge that our principles are mainly applicable to the structures created for low-income countries, but in certain cases they have broader relevance. In addition, the approach outlined could be a model for other areas of development.

Focus on the health of persons

FIGNIFICANT ADVANCES IN disease-specific programs have saved and orimproved many millions of lives and have definitively shattered the paternalistic and pernicious myth that low- and middle-income countries are not capable of designing and implementing national programs to tackle complex health issues, including chronic disease management.

Disease-specific programs have also revealed important problems, including disparities and inadequacies in health systems, the crucial role of sectors beyond the health sector for improving health, and the inefficient and duplicative use of resources in the financing and implementation of global health. The renewed discussion of the importance of health systems is possible because of disease-specific programs, not despite them. In a paradoxical way, the rapid expansion and success of disease-specific programs has made clear the need to move beyond them.

At the base of the health care pyramid, in villages and communities around the world, it makes little sense to define health by reference to a specific disease. A mosquito is equally content to make a meal of an HIV-positive or an HIV-negative person. A child whose mother's life is first saved by antiretroviral therapy or sleeping under a bed net but is then lost while she gives birth is no more likely to survive or go to school than the child whose mother dies from HIV or malaria and, of course, the woman and her community are no better off. Without immunizations, other health care, and nutrition in the first months of life, a newborn is increasingly exposed to infections that can lead to stymied physical and emotional growth or death. As the child grows without clean water, diarrhea] diseases pose the greatest threat to survival. As children reach adolescence and adulthood, they and their offspring enter into the same cycles of health risk that demonstrate the need for integrated health systems. In fact, because high levels of multiple diseases and health threats in the same locale create a forum of competing risks, interventions to save one's life from a single disease or health threat could increase the probability that the person will die from another disease or threat that is prevalent in the same environment. For example, when a maternal death is averted, that same woman is now exposed to the risk of developing cervical or breast cancer. Such realities should never be a pretext for inaction, and disease specific programs have been important in the evolution of global health. But as we look to the future, focus on the health of a person requires ever-expanding integration.

Silos in health not only make little sense to local providers, they make little sense to policymakers. Although significant investments in disease-specific programs can have positive ripple effects on other areas of health, such benefits are often haphazard and unintentional. Each program has its indicators, processes, records, communications, logistics, and supply chain systems that may overwhelm an already weak health system. Inefficiencies waste significant financial resources and also strain limited management and human resource capacity. Although it must be proven, there is likely a multiplier effect to integrated health, achieving better outcomes for several diseases for less money and providing a more sustainable approach to global health.

It is also important to recognize that the goal of health interventions is healthy people and populations. While health systems are an essential means to achieve that primary goal, creating health systems is a secondary objective not a primary goal.

The ecosystem of interrelated and competing risks of disease and death, accompanied by the potential multiplier effect of more rational service delivery, has prompted heads of state, first ladies, ministers of finance and health, and local care providers to weave together integrated programs from funding dedicated to disease-specific initiatives and to call on the global health community to support their efforts to focus on the health of a person rather than a particular issue. If we take seriously the foundational principle of country ownership for a new era in global health and development, a significant shift must begin to an integrated approach to health that is centered on the survival and health of individuals, families, and communities rather than on the eradication of specific diseases. In a similar way, the post-MDG strategy could focus on the overall development needs of a person rather than one aspect such as health.

Public health drives resource allocation

TO UNDERSTAND THE need for integrated health, it is important to begin with the health of a person. In fact, all good public health begins with the health of individuals. However, it is equally important to view the promotion of healthy individuals in a context of maximizing health outcomes for families, communities, and nations. Unfortunately, even in the most advanced economies, funding for health is limited. Policymakers must consider how to save and improve the largest number of lives and to have the greatest impact on their society with the resources that are available. The latter point is often lost in discussions of global health and is an important aspect of understanding public health as a public good.

Prevention efforts provide some of the best returns on investment in personal and public health. The number of persons made healthy is important, but who gets sick and dies also matters. Any death is tragic, but health threats that cause premature death and disproportionately affect the productive and reproductive segments of a population can have a greater impact on society. The potential for a new health threat to rapidly endanger a large proportion of a population requires an equally rapid response. As in economics, where "consumer confidence" can affect the health of an economy, intangibles such as panic around a perceived threat, belief in the quality of services in a health facility, in the benefits and side effects of vaccines, or in the gravitas of persons delivering health prevention messages can impact health. A refocus on health as a public good and the implications for resource allocations requires a new discussion and consensus on the ideal and the achievable.

Human rights, shared responsibility

HUMAN RIGHTS HAVE been the bedrock of advances in global health since at least the 19th-century public health movements and the formation of the World Health Organization. It is essential to maintain the centrality of human rights in any discussion of access to health care. However, it is equally important to provide policy space that respects the ideal of universal access while setting achievable goals and pragmatic approaches to create global and local institutions, both public and private, to provide it.

Too often a devotion to human rights serves as the backdrop to making commitments that cannot be met without concrete plans, financial commitments, or institutions to ensure they are achieved. Too often, high-income countries or the c 8 set targets or create initiatives without the engagement of the implementing countries. While this might have been acceptable and even necessary to secure resources a decade ago, today's issues require a new framework for shared responsibility and mutual accountability. That frame-work includes the following key elements:

Partnership, not abdication. In the near term, significant resources are needed from high-income countries. But there is much that must be done nationally and locally to establish the policies, organizations, programs, systems, and support needed for effective implementation. There is also a need for good governance to prevent corruption and optimal use of the resources that are available. Unfortunately, implementation of shared responsibility often leads to bad outcomes. Countries are frequently left to design their own programs and proposals without sufficient input from funders about what is required, or without the technical support the countries want and need. Things fall apart during the review or grant negotiation process when requirements and demands surface, effectively eliminating country ownership while creating tension on all sides. Shared responsibility does not mean abdicated responsibility. It means working together. Partnership is also undermined when countries are exposed to international partners who plan without countries' involvement, in some ways the opposite problem

Transition planning for financial responsibility. It is essential that all countries contribute financial resources to the health of their own people. The very low levels of national financing for public health in certain countries, including emerging economies, are not acceptable. And nothing is more likely to halt interest in global health than recent data that some governments have treated increased international resources for health as an opportunity to redirect their own funding to other areas. It is also essential that clear parameters and processes be established to transition health care support from international sources to local sources. Bilateral and multilateral financiers have attempted such transition planning without much success.

Effective transitions will require different time horizons for each country, but developing a global agreement on the framework must begin now and be enforced. A new structure for global health must create transition parameters with teeth. It is difficult to conceive of a more effective way to create shared responsibility and mutual accountability that would transform health care.

Principal financiers of integrated national health strategies

TO MOVE FROM disease-specific programs to support for integrated public health within the tangled web of multilateral and bilateral financing and technical institutions for low- and certain middle-income countries is virtually impossible. Such institutions were created at specific times to meet specific demands or fill gaps and were structured for those purposes. In many cases they have been operating for decades and their structures and cultures have become entrenched. True integration requires these institutions to give up a lot of turf, and many of the internal and interorganizational incentives have evolved to defend control of processes and resources. Fundamentally, integration is not in the genes of existing bilateral and multilateral institutions.

As an example, within the UN system alone, and in spite of the existence of UNAIDS, eleven organizations are engaged in HIV/AIDS; the Global Fund provides 14 percent of external funding and the U.S. government 45 percent. Other bilateral institutions are in the game, as are large contributors like the Bill and Melinda Gates Foundation. Multiply that across all areas of health and one has a sense of the enormity of the challenge of coherent governance to support integrated health services.

A good start: increased coordination. Focusing on the coordination of existing organizations makes sense. They were created for a purpose and nearly all have done much good. There is much merit in utilizing the vast experience and expertise they possess. There has been much admirable thought and experimentation with forms of coordination across and within areas of global health to achieve some degree of integration. Most efforts to date have focused on process. The Three Ones initiative started by African countries with the U.S., the UK, and UNAIDS aimed to improve coherence in the Hi v/AiDs field by committing funders to work under one national action framework, one national coordinating body, and one national monitoring and evaluation system. As part of the One UN initiative, UNAIDS led a process under the Global Task Team to identify the optimal role for each of the eleven UN organizations that are engaged in HIV/AIDS. As another example, the H4+ Group comprising members from UNITA, UNICEF, the World Health Organization and the World Bank was established to work jointly on maternal and child health. The Health 8 (H8) brings together the heads of seven multilateral organizations as well as the Bill and Melinda Gates Foundation to harmonize policies and activities Recently the World Bank, GAVI, and the Global Fund have agreed to coordinate and collaborate on health systems strengthening, although details, including what health systems strengthening means on the ground, require elucidation.

Bilateral partners are also in the game. PEPFAR and PMI in the Bush administration and the Global Health Initiative in the Obama administration are designed to have one strategic approach and integrated programming across multiple agencies and departments of the U.S. government and to partner with other bilateral and multilateral institutions. Recently, the George W. Bush Institute and Obama administration joined with Susan G. Komen for the Cure, UNAIDS) and private corporations and foundations to create the Pink Ribbon Red Ribbon Initiative to use the investments in chronic care for HIV/AIDS. The investment in HIV treatment was the first time in the history of global health that a chronic disease was addressed, creating a foundation to combat cervical and breast cancer and a model for other chronic diseases. Perhaps the most promising effort to coordinate was the International Health Partnership (IHP+) because it focused on national plans for health with cost estimates. One of the principal problems was a lack of commitment to finance the plans.

Each of the coordination efforts can point to successes and improvements. But thus far, such coordination efforts have fallen short of expectations. In addition, the proliferation of global health institutions over half a century has been mirrored by a decade of proliferating efforts to coordinate. While well-intentioned, these efforts have imposed significant transaction costs on already stretched local governments and partners that devote significant time and resources to planning big ideas which often lead to no real change.

The next step: principal financiers. Efforts to coordinate global health institutions have revealed the fundamental problem: There is no mechanism to finance integrated national health strategies. Funds are shared across myriad bilateral and multilateral institutions for specific issues or diseases. Even if other barriers were overcome through coordination, that fatal flaw would remain.

Principal financiers for integrated national health strategies could provide the evolutionary jump to a z 1 st century approach. In essence, principal financiers would serve as the mechanism to fund integrated national health strategies in an accountable and transparent way, with results measured and reported for specific health outcomes but delivered in a coherent fashion. The highest-level indicators would be crude and disability-adjusted life expectancy, as well as death rates for adults and children, but there would also be outcomes, outputs, and process markers for each health intervention.

Principal financiers would promote country ownership by being responsive to local demand for integrated health services and harmonized funding and by providing a tool against internal barriers to achieving more rational approaches to health care delivery. Bureaucracy is bureaucracy no matter where it is found. Multiple funding streams within and across the health-related MDGS have the perverse incentive for low- and middle-income countries to follow the bad example of high-income countries and create silos. Principal financiers could produce an innovative benefit by encouraging national processes to integrate. A funding source with incentives for integration could lead to more rational governance in low- and middle-income countries than in high-income countries and serve as models for the latter to follow. That would be true development partnership and would add to the rapidly growing list of lessons the "developed" world can learn from the "developing" world. However, there are already good examples of integration in low- and, in particular, middle-income countries that have not yet been adopted by others.

A Bretton Woods-type meeting for global health could consider the best approach to financing integrated health. Options include creating something new, or transforming current institutions to meet the demands of the a r st century. Candidates in the latter category include the World Bank and the Global Fund, each with strengths and weaknesses. Recent changes in leadership at both institutions, and reforms that began with the former executive director of the Global Fund, could provide an opportunity for the Bank and Fund to develop their own, or collaborative, institutional change to maximize financing for integrated health delivery. In addition, a concerted effort to explore options for principal financiers could create some healthy competition and spur innovative proposals to recreate existing institutions to maximize the return on investment in global health.

Moving beyond the "pooled funding" debate. Pooled funding schemes, including basket funds or sector-wide assistance programs, have dominated global health discussions for more than a decade and were among the most contentious issues in the negotiations around the founding documents of a new era in development. Global principal financiers focused on integrated health systems, with transparency and accountability that supports country-owned national health strategies spanning the public and private sectors, providing an opportunity to transcend the debate. The greatest hurdle for supporting pooled funding by certain international partners has been a concern about "following the money" in countries. The creation of a clear, results-based system with routine and standardized reporting against outcome and process indicators to initiate and maintain funding, as discussed here, should provide the detailed information that some have found lacking in existing, country-level pooled mechanisms. Indeed, it is precisely this approach that has allowed funders concerned about country-level pooled mechanisms to support globally pooled funds such as the Global Fund and the World Bank's International Development Association program. A principal financier builds on such approaches while rationalizing and streamlining the global architecture to maximize results and minimize duplication and waste.

Non-health-sector actors must engage

THE FOUNDING DOCUMENTS of a new era in development established shared responsibility and mutual accountability beyond the scope of governments. Governments as a whole, not just ministries of health, are ultimately responsible for the health of their people and must set national policy, lead planning processes, set normative and regulatory frameworks, provide oversight of ethical standards, and provide stewardship of the social response to health challenges. Achieving the health of individuals and communities and nations requires the engagement of different relevant departments in government, but also requires nongovernmental actors and, increasingly, actors beyond the health sector.

Civil society has played a key role in advocating for increased resources for health and in ensuring accountability and transparency. Faith-based organizations are responsible for 30 to 70 percent of health infrastructure in Africa. Community, traditional faith, and private-sector leaders have played an instrumental role in promoting behavior changes that link individuals and families to health services. The key role of the private sector is finally being recognized as an important element of global health and development. The private sector could play a particularly useful role in rationalizing the structure of global health. Bringing the looming pandemic of noncommunicable diseases under control will require a major engagement of various sectors in government, the food and beverage industry, urban planning, etc.

Many prevention activities occur outside of conventional health infrastructure and professions. For example, local civil society, including community, faith, and tribal leaders, can have a disproportionate impact on prevention interventions, stigma, and health service uptake in both a positive and negative direction. An unfortunate example of the latter is the reemergence of polio in Nigeria and seven neighboring nations after faith leaders promulgated the belief that the vaccine was an attempt to control population.

Discussions of health systems are often limited to care, treatment, and clinical prevention activities. However, when considering the public good, it is essential to cast a wider net. An effective approach to integrated health, one that begins with the health of a person and moves on to public health, requires the full integration of effective approaches to prevention, care, and treatment using both conventional and unconventional vehicles.

Accountability and transparency

THE PHRASE "ACCOUNTABILITY and transparency" is used so frequently in global health and development that it often loses its meaning. In a time of scarce resources, it is essential that accountability and transparency be clearly defined and be the foundation of all activity. The following parameters are a bare minimum and should serve as the basis for a new structure for global health governance Implied in the parameters is mutual accountability--a principle highlighted in the Monterrey Consensus ten years ago. All partners--hinders, implementers, those accessing services, technical support providers, policymakers, advocates--must be accountable to each other. Accountability and transparency are not for some actors and organizations only: They must apply to all who are engaged, from the global to the individual level.

Resources meet commitments. The rhetoric of commitments to health rarely matches reality. Overall, during 1998 zoo4, the G8 complied on average with only 45 percent of its commitments made during the annual meeting of leaders. As of 2009, Canada and the United States have achieved 107 and 111 percent of their commitments to Africa, respectively. Others in the group were as low as six percent. This shortcoming is not unique to international partners. African heads of state from 54 countries committed to provide fifteen percent of their budgets for health in 2001; as of 2010, only six have reportedly met the target.

Aggressive but achievable goals. The era of advocates demanding unachievable new commitments, and organizations and leaders acquiescing with the full knowledge that they are unreachable, must end. It is the job of advocates to push the limits; it is the job of policymakers to make commitments that will be met.

Repeatedly setting unachievable targets and failing to meet them shatters a sense of accountability and perpetuates commitments that no one intends to keep. But that does not mean big ideas should not be pursued. The yearly increases in resources for global health during the past decade were largely driven by the confidence created by setting, and then meeting, annual targets towards multiyear goals.

Results-based financing. At this distance, it is difficult to remember that PEPFAR was heavily criticized for setting numeric targets for prevention, treatment, and care. Global health was supposed to he too complicated for something as pedestrian as specific goals. Despite criticism, funding was evaluated yearly and shifted based on progress towards targets. That results-based approach was essential to securing increased resources.

One concern about moving from financing specific diseases to financing integrated health services is a loss or dilution of results-based financing. However, the purpose of an integrated approach to health delivery is to improve an array of health outcomes and reduce morbidity and mortality. National health strategies that promote integrated service delivery through an expansion of primary health care providers and facilities and links to the community still have indicators for each component piece. Monitoring health progress must include an understanding of change in the major causes of disease, disability, and death. And no health system can know if it is succeeding, or modify interventions to improve outcomes, unless progress on specific diseases is addressed. This is the essence of what has been called the "diagonal" strategy, as a synthesis of pure vertical and horizontal approaches. In fact, one significant advantage of a principal financier would be reconciliation of the many different indicators currently required by multilateral and bilateral development partners that are often not used to promote better service delivery. Indicators could actually promote integration and results-based financing. For example, a high-level indicator on the number of pregnant women receiving antiretroviral therapy in certain countries where HIV is a major cause of maternal death could drive a reduction in the perinatal transmission of HIV, increased HIV treatment, and an improvement in maternal mortality.

The purpose of integrated delivery is to save and lift up more lives for the same investment. Cost per outcome is an important indicator that also must be measured, as is financial protection against the risk of catastrophic expenditures.

Results-based reporting. For the most part, a country with a track record of good stewardship of resources and high performance is burdened by the same reporting requirements as a country with a history of corruption and poor results. That makes little sense. It is unnecessary to absorb significant human and financial resources from both the international funder and the country implementing programs. Of course, all programs need to collect and report top line results. But it should be possible to develop performance strata with a gradation of reporting requirements. In fact, reduced reporting requirements could be a powerful incentive for strong performance.

21st-century technology. Effective accountability and transparency require 21st-century tools to collect, synthesize, analyze, manage, and store programmatic and financial data, as well as information on human resources, logistics, and other aspects of management The systems used for global health were largely built in the 20th century. There are efforts to update and retrofit them. But resources have not been invested at the level that is required. There is one advantage: In many low- and middle-income countries, there are few, if any, data collection systems in place. To some degree, then, there is an opportunity for a technological leap that could be transformational.

Clear standards for success, and an evaluation process. For transparency and accountability to he meaningful, it is important to define success and to establish processes to regularly evaluate and modify programs. Bureaucracy and inertia will prevent change in any endeavor without clearly established parameters and systems to evolve as the facts on the ground dictate.

Technical support: A conflict of interest

BILATERAL PROGRAMS, AS well as some UN agencies and the World Bank, provide both technical support to develop and design programs and direct program funding, often through calls for applications for grants that are informed by technical experts working for, or affiliated with, the funding institution.

There is an unintentional but inherent conflict of interest in setting standards and providing technical support and procurement mechanisms while also funding programs. That conflict of interest undermines country ownership. Technical experts often have divergent views; there is nearly always more than one way to implement standards and many options for implementing partners and procurement agents. If organizations and institutions provide both technical support and financing for implementation there is an unavoidable tendency for the program dollars to follow the path laid out by the technical advisors. When both the technical support and financing are provided by an external source, the options for national programs to choose can be significantly constrained, thereby limiting country ownership. If national leaders were responsible, with technical support they value, for designing the strategies and operational plans to he financed externally as a supplement to their own financial, human, and other resources, country ownership would increase exponentially.

A division of labor among global health organizations in which a principal financier would provide the vast majority of resources for program implementation and other multilateral organizations, including much of the UN system, and bilateral organizations, would both provide technical support and increase country ownership, while also being a more rational strategy for delivering integrated health services. Rather than a division of labor by specific disease categories, the plurality of global health actors should primarily distribute responsibilities according to functions.

The WHO's central role

IT HAS OFTEN been said that if the World Health Organization did not exist it would have to be created. But it likely would not be created with its current structure and function. The WHO is essential to set global standards and to perform key surveillance and monitoring functions, as well as evaluation for accountability. Over the past decades, driven in part by the demands of funders, the WHO has ventured into extensive implementation and other areas beyond its original mission and core competencies. A symptom of what is wrong with the current institutional architecture of global health is the paradox that, at a time of financial expansion around disease-specific programs, there is severe underfunding of the knowledge-related global public goods that are essential for improving health outcomes.

The current financial crisis at the WHO provides an opportunity to redirect its structure and function to focus on its core strengths and the value it adds to global health. No other institution can provide global standards, surveillance, and accountability. Many other organizations can and do provide excellent technical support and program implementation, though. Unfortunately, austerity measures seem to be cutting across the board rather than protecting core competencies. A consideration of governance structures of the WHO, including the autonomy of the regional offices and changes that would allow for greater engagement of nonhealth stakeholders to maximize its key convening authority, could strengthen the institution. With a view to a more rational global architecture for health, the WHO's fiscal challenges could be an opportunity for a more rational approach to global health governance while ensuring its preeminence among global health institutions, whose roles should also be reviewed.

Competition and innovation

AS THE ARC of development and global health progresses, a certain degree of healthy pluralism and competition will be essential to ensure openness to evolution. A division of labor that keeps principal financiers and multilateral and bilateral partners in the game not only promotes integration of health services today but also helps ensure innovation tomorrow. If a principal financier operated inefficiently or began to violate the principles of development, others would be standing by to step in, and financing responsibility could shift back to bilateral or multilateral partners. Healthy competition among agencies was an important factor in the growth and success of PEPFAR and the Global Fund, and has served as a driver for efforts on multilateral coordination. It will he an important factor in ensuring innovation and efficiency in a new division of labor. Of course, the principle of competition and innovation is relevant for many aspects of global health architecture beyond financiers and providers of technical support.

Innovative financing for sustainability

THE TERM "SUSTAINABILITY" is as prolific as are "transparency" and "accountability" and is, perhaps, even less well defined. It is clear that traditional mechanisms for development and global health--high-income countries using their tax base to finance services in low- and middle-income countries--is insufficient to provide integrated health services for all who need them. There has been much emphasis on innovative financing, including an important recent high-level UN task force. Thus far, much of the effort has focused on repackaging old mechanisms, such as taxes (for example, on airfares or financial transactions). While there is merit in that approach, it has its limitations both in resources raised and in contributing to the proliferation of financiers. For example, UNITAID was originally intended to raise resources for the Global Fund but then developed its own institutional priorities.

Mechanisms to guarantee financing for technologies--for xample novel vaccines or drugs for diseases that occur only in low-income countries and therefore have no competitive market--showed promise to stimulate innovation. However, they too relied on the traditional tax base of high-income countries and did not ensure resources to deliver the new tools. In addition, because of the way the U.S. government manages budget cycles, it has been difficult for the largest global health funder to participate. Until recently, European governments could account for the guarantees "off budget"--or off the balance sheet--until the bill came due. That flexibility was eliminated with new accounting requirements for the European Union following the financial crisis.

With few exceptions, mechanisms for innovative finance have been developed and driven by high-income countries. To achieve sustainable financing, the direct and deep engagement of emerging economies and other middle- and low-income countries is essential. Truly innovative financing mechanisms such as health bonds that would require back-end commitments by large institutions and risk-taking investors on the front end can and should require the commitment of resources by countries that would benefit. Several countries have begun to experiment, with some notable successes, with public and private insurance, including national health insurance, and other vehicles to ensure integrated health services. Certain middle-income countries have made significant progress. But because such approaches cross the bounds of restrictions on out-year financing and programmatic silos, it has been difficult to develop steady resource flows for low-income countries.

There should be a significant effort to evaluate avenues to link macrofinance programs that support economic growth and trade with global health. Although out of pocket expenditures are significant, international contributions for health can rival national budgets and be a significant source of foreign exchange and cash flow into many low- and even some middle-income countries. Health is already linked to macrofinance unintentionally. It is time that it is linked intentionally.

The unfulfilled promise of innovative finance could be the clearest demonstration of the need for a Bretton Woods-type agreement led by the G20 countries to restructure global health with principal financiers and with more flexible mechanisms for the 21st century.

As delegates convened at a hotel in Bretton Woods, New Hampshire, in 1944, it was clear that the existing global finance governance mechanisms were too divided and chaotic to cope with the world economic situation. As we emerge from a decade of rapid expansion in global health that began with the conceptual foundations for a new era in development and approach the post-MDG era, now is the time for a Bretton Woods styled consensus to create a new architecture for the governance of global health. It is as clear today as it was in 1944 that existing structures were created for a different time and that a 21st-century approach to global health requires a radical restructuring of 20th-century institutions to support coherent, country-owned, national health strategies that engage all sectors in design and implementation; that begin with the health of people to design integrated systems for public good in an accountable and transparent way; that balance human rights with pragmatism and shared responsibility; and that are underpinned by innovative approaches to finance ultimately leading to an orderly transition of funding towards national mechanisms driven by economic growth. The investments being made are not being maximized. Bringing coherence and direction to the institutional structure of global health could radically improve investment outcomes and propel global heath from a 20th-to a 21st-century approach. Governments, civil society organizations, and the private sector all have a key role to play in designing a new global health architecture and sustainable financing. A critical first step is to rationalize the tangled web of global health through principal financiers separated from technical support organizations and with a leading stewardship role for the WHO.

This radical vision can be achieved only with the leadership of an expanded G20 which includes more low income countries and the active participation of other emerging economic powers and middle- and low-income countries. A bold restructuring of global health architecture could establish models and lessons learned for other areas of development. A focus on the health of a person could provide insights for a post-MDG era that focuses on creating the opportunities needed for every human being to realize his or her full potential. That is an audacious vision, but the recent history of global health and a long history of great human achievements teach us that what seems impossible can be done. The only question that remains is: Will it be done?

Mark Dybul is a distinguished scholar and co-director of the Global Health Law Program and the inaugural global health fellow at the George W. Bush Institute. Peter Piot directs the London School of Hygiene and Tropical Medicine. Julio Frenk is the dean of the Harvard School of Public Health. The authors acknowledge and are enormously grateful for the significant contributions of Gordon Brown and are deeply thankful to Eugenia Pyntikova for her expert editing and research.