Is the World Bank becoming obsolete?

Written by Helen Fry, a recent MSc graduate from the UCL Institute for Global Health.

The game of global health governance is changing, and if global health players such as the World Bank and the World Health Organization do not rethink themselves they will become obsolete, argued Michel Sidibé in the UCL Lancet Lecture 2012 on 13th November.

Drawing on his experience as Executive Director of UNAIDS, Sidibé outlined his vision of global health governance for the post-2015 development era.

Sidibé began by exploring the history of AIDS, which he described as “a journey from despair to hope”.

He described how AIDS began as the “gay plague” with no medicines or research. But, as it galvanised relationships between the global north and global south, AIDS brought civil society, scientists and policymakers together and made space for global solidarity.

To illustrate the success of UNAIDS, Sidibé quoted that today more than eight million HIV-positive people have access to treatments, and more than 56 countries have been able to stabilise and reduce significantly the number of new infections.

The context: “a profound transformative moment”

On how to build upon this success, Sidibé recommended first that we take note of the “profound transformative moment” of change that the world is experiencing today.

He talked passionately of the financial crisis as an ethical “crisis of trust” where citizens do not trust their leaders, and expressed concern at the resulting problems in promoting social action.

He also talked about urbanisation, a “global seismic shift” of more than five billion people now living in cities. On young people and technology, he questioned what new forms of activism social media will bring out and talked of the potential of leveraging this increased connectivity of people across the world.

With this in mind, how does global health governance move forward? Sidibé suggested that, for a new type of governance to emerge, capacity is needed in five areas:

1. The architecture of global health

Controversially, he argued that the current system lacks sustainability, and proposed a radical overhaul of the United Nations system, which would consist only of global financiers, an organisation for norms and standards and an advocacy and accountability mechanism.

However, when questioned by Peter Piot, Founding Executive Director of UNAIDS, on how this can be achieved, Sidibé admitted he did not have the answers.

Sidibé warned that, as the flaws in the UN system are made apparent, multilateralism will be increasingly in crisis, and he predicted an emergence of “mini-lateralism” of groups bypassing the UN structures.

2. Global actors

Sidibé suggested that we could change the lives of many more poor people if we could manage to “bring new voices to the table”, particularly governments.

According to Sidibé, the G20 is giving space to the emerging economies which will result in a more complex system, and asked, “who will be representing the rest of the G177 who are poor?”

He observed that emerging countries are bringing a new perspective and new solutions, with technological and economic strength.

3. The delivery system

We have been thinking about how to reach millions of people; if we look at non-communicable diseases, we need to think about how to reach billions, Sidibé argued.

He outlined a redesign of the global health delivery system, which included a move from a disease- to a patient-centred approach, and training of community health workers to increase coverage.

Beyond coverage, he said we need to look at quality of care, and promote the thinking that health is an investment for national governments. But, while investment from governments must be encouraged, global health actors need to prioritise, and “not just think of global health or a disease from infinite money”.

4. Innovation and technology

In South Africa, there are more mobile phones than there are people in the population, a fact that Sidibé believes represents a technological revolution in Africa. He argued that we need to think about how we leverage this so it will help us to deliver services more effectively, and reduce the cost.

Sidibé then took the example of the CD4 machine. New CD4 machine technology may reduce the cost for the ten million people waiting for treatment from US $700 million to US $20 million.

On the innovation–access dilemma, Sidibé agreed that the costly process of research and development must continue to be incentivised. He spoke emphatically about the restrictiveness of patents and, while he spoke of the need to identify creative ways to find incentives, he admitted he did not hold the solution on how to do this.

5. Human rights and dignity: “central to debate in health”

Finally, he discussed the human rights approach, which he argued was the most important element of global health governance.

He challenged homophobic laws that discourage people from accessing HIV services and argued that the global health debate should be guided by equity, dignity, inclusiveness and justice.

Sidibé’s radical re-conceptualisation of global health governance was concluded by a recommendation to the audience to use the space that has been created for the post-2015 agenda, which he described as an “unprecedented opportunity to rewrite global health”.