Amy Barnes

The Idea of Partnership within the Millennium Development Goals: context, instrumentality and the normative demands of partnership

Abstract The word’ partnership’ is pervasive within debates about participatory global governance and the idea of partnership acts as an underwriting principle within both the Millennium Development Goals (MDGs) and the Paris Declaration. However, there remains general ambiguity about the meaning of the idea of partnership and how its conceptualisation is meant to normatively guide a more co-ordinated move from theory to practice. Indeed, the idea of partnership remains an impoverished theoretical and practical appeal, which is under-defined, poorly scrutinised and unconvincingly utilised as a normative tool in applied practice. This article will provide a more theoretical examination of what an appeal to ideas of partnership means and explore what a normative commitment to a robust conceptualisation of partnership might look like within the MDGs. To do so, it will examine the underwriting normative language of partnership as it is found within the MDGs, theoretically explore the principles inherent within this normative language, and locate present gaps within the MDGs between its normative theory and applied practice. By doing so, it will be possible to outline some additional principles and commitments that are normatively required to satisfy the underwriting spirit of the MDGs in order to bring them in line with said spirits own normative values.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Expertise, Accountability, and the Depoliticisation of Global Health Governance

During his tenure as the Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (hereafter the Global Fund), Richard Feachem argued that the autonomous, multisectoral, and technically focused design of the Global Fund is ‘really insulated … from the political dynamic, which inevitably and appropriately permeates the UN. We are a very apolitical organization … we’ve been able to take principled and technical decisions … because we’re not subject to the political influences that would come to bear in the UN’ (Feachem, 2005). This is a notable quote, for it not only draws attention to the potential apolitical merits of the multisectoral Global Fund but also criticises the ‘politicisation’ of multilateral forms of global health governance. Charges of politicisation have been levelled at the UN throughout much of the organisation’s history, and there are two commonly cited examples from the arena of global health. First, it is common practice for wealthy nations to withhold financial contributions to bodies such as the WHO and UNICEF in order to manipulate policy priorities for their own interests (Brown et al., 2006; Godlee, 1994; Walt, 1993; Walt and Buse, 2006). Secondly, there is a history of competition and conflict between the multilateral health agencies over their relative authority, influence, and leadership in global health (Brown et al., 2006, pp. 67–68; Walt, 1993; Walt and Buse, 2006, pp. 661–664). Though a contested concept, the term ‘politicisation’ implies a pejorative influence of politics (Siddiqi, 1995, pp. 30–34) through which power and wealth has corrupted and colonised decision-making, thus leaving a multilateral system of governance that is unrepresentative of the global community; inefficient and ineffective in responding to collective action problems; and also lacking in both credibility and legitimacy (Brown, 2010; Ghebali, 1985).

International palliative care research in the context of global development: a systematic mapping review

Context An increasing amount of health policy is formulated at global level. At this global level, palliative care has attracted support primarily from normative institutions (WHO), not funding agencies. To attract greater global attention from policymakers, it has been argued that an international approach to research is required. However, the extent to which an international approach is being undertaken is unknown. Objectives To systematically identify and thematically synthesise all international palliative care research, defined as research involving two or more countries, or focused on the global level. Methods Five bibliographic databases (CINAHL, Cochrane Library, ASSIA, Web of Knowledge, Psychinfo) were searched for journal articles relevant to international and global palliative care and end-of-life care. Data were extracted using a piloted extraction form and findings were synthesised. Results 184 studies were included, published across 75 different academic journals. Research emanates from and focuses on all world regions and there is increasing focus on the global level. Thematically, there is a high focus on Evaluation (n=53) and views of Stakeholders (n=38). The review revealed a predominantly observational research approach and few interventional studies were identified. Conclusions International palliative care research is a relatively new, but growing field. However, many gaps in the evidence base remain and palliative care research continues to take place outside broader discourses of international development. The relative absence of interventional research demonstrating the effectiveness and cost-effectiveness of palliative care risks limiting the tools with which advocates can engage with international policymakers on this topic.

Understanding global health and development partnerships: Perspectives from African and global health system professionals

Partnership is a key idea in current debates about global health and development assistance, yet little is known about what partnership means to those who are responsible for operationalising it or how it is experienced in practice. This is particularly the case in the context of African health systems. This paper explores how health professionals working in global health hubs and the health systems of South Africa, Tanzania and Zambia understand and experience partnership. Drawing on semi-structured interviews with 101 professionals based in each country, Washington DC and Geneva between October 2012 and June 2013, the paper makes four key arguments. First, partnership has a legitimating function in global health policy processes for international development institutions, government agencies and civil society organisations alike. Second, the practice of partnership generates idiosyncratic and complicated relationships that health professionals have to manage and navigate, often informally. Third, partnership is shaped by historical legacies, critical events, and independent consultants. Fourth, despite being an accepted part of global health policy, there is little shared understanding of what good partnership is meant to include or resemble in practice. Knowing more about the specific socio-cultural and political dynamics of partnership in different health system contexts is critical to equip health professionals with the skills to build the informal relations that are essential to effective partnership engagement.

Introduction: Global Politics of Health Reform in Africa

Participation and performance have become two master concepts for wider health reform in Africa. These concepts were initially used in the delivery of HIV/AIDS and maternal and newborn child health programmes as part of the UN Millennium Development Goals; however, key international donors such as the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria are now seeing the potential of such concepts in mechanisms of wider health reform in Africa. This chapter introduces the context, aims, and argument of the book and provides a detailed account of the qualitative methods used to conduct research in South Africa, Tanzania, and Zambia and two global health hubs: Geneva and Washington, DC.

Reframing Global Palliative Care Advocacy for the Sustainable Development Goal Era: A Qualitative Study of the Views of International Palliative Care Experts

CONTEXT The World Health Assembly Palliative Care Resolution in 2014 and the inclusion of palliative care within the sustainable development goals raised optimism that palliative care would no longer be a peripheral aspect of global health. However, no funding, accountability measures, or indicators for palliative care development accompanied these policy developments. This risks health actors continuing to prioritize the attainment of better known target-driven aspects of health care. OBJECTIVES To explore the attitudes of international palliative care experts regarding how the future development of palliative care can be accelerated. METHODS About 16 international palliative care experts were interviewed for their epistemic expertise. Participants were interviewed face to face or via Skype. Interviews were recorded, transcribed nonverbatim, and analyzed using a thematic approach (NVivo). RESULTS Participants strongly supported the rollout of national palliative care policies around the world for two reasons: to ensure palliative care attracts national funding streams and to attract global funding for palliative care. The absence of a global indicator for palliative care development was considered a severe impediment to the inclusion of palliative care within global efforts toward universal health care. Advocacy partnerships, using human rights approaches with economic frames, were considered the most effective methods of influencing policymakers. CONCLUSION Palliative care represents a value proposition that is not currently being maximized by advocacy. Advocates should consider palliative care developmentally, focusing on key asks for development and consider how palliative care can contribute to other international development priorities, in particular poverty reduction.

Reframing “participation” and “inclusion” in public health policy and practice to address health inequalities: Evidence from a major resident-led neighbourhood improvement initiative

There is a need for greater conceptual clarity in place-based initiatives that seek to give residents of disadvantaged neighbourhoods more control over action to address the social determinants of health inequalities at a local level. In this article, we address this issue as it relates to the concepts of participation and inclusion. We draw on qualitative data generated during the first phase of the Communities in Control Study, a longitudinal multisite independent evaluation of the impact of Big Local on the social determinants of health and health inequalities. Big Local is a resident-led area improvement initiative in England, funded by the UK Big Lottery Fund. Initiatives focused on community empowerment are increasingly prominent in public health policy and practice globally. Approaches emphasise the promotion of greater control over decisions and action among individuals, groups, and communities, particularly those living in disadvantaged circumstances. However, when it comes to participation and inclusion in taking action and making decisions, the field is characterised by conceptual confusion. This risks undermining the impact of these initiatives. While participation and inclusion are necessary conditions for empowerment and collective control, they are not necessarily sufficient. Sufficiency requires attention to the breadth of participation (i.e., to inclusion) and to the depth of participation (i.e., the extent to which it is experienced as empowering and ultimately enables the exercise of collective control over decisions and actions). In observing how different Big Local resident-led partnerships across England are tackling the day-to-day challenges of engaging with their communities, we reveal the potential for policy and practice of reframing, and therefore clarifying (to highlight the different roles they have) the concepts of participation and inclusion in terms of depth and breadth.

The Performance-Based Funding (PBF) Debate

This chapter outlines the main debate over results and performance-based funding (PBF) and the application of PBF to health system reform in Africa. It introduces the reader to principal-agent theory as the central approach to PBF adopted by the World Bank and Global Fund and outlines the many concerns and contentions associated with PBF. In so doing the chapter begins to show how global health institutions have adopted a positive bias to PBF as a tool for health system reform and that we know little about the role of African actors in the shaping and implementing of PBF programmes and in generating the evidence base that underpins them.

The Politics of Performance-Based Funding (PBF)

This chapter introduces the reader to how performance-based funding (PBF) works in practice in South Africa, Tanzania, and Zambia and where the idea for PBF came from. In so doing it reviews how health workers in these countries understand PBF, the problems associated with implementing PBF and its multiple levels of governance, and the origins of PBF as a health reform tool. The chapter shows evidence of discontent towards PBF in South Africa and how a positive bias is reproduced by donors in Tanzania and Zambia through the promise of finance and study tours to ‘success story’ countries. The chapter outlines the role of consultants and international agencies, which increasingly have a brokerage role in global health governance that challenges the practical application of the principal-agent model of PBF.

The Politics of Participation in Health Reform

This chapter examines how multi-sectoral and multi-level stakeholders have participated in the formation of performance-based funding (PBF) design and implementation at the global and national levels in South Africa, Tanzania, and Zambia. The chapter looks at what is meant by participation and what we know about its role in health system reform, and formal and informal mechanisms of participation at multiple levels of governance. In so doing, it demonstrates the dominance of informal mechanisms that undermine meaningful participation as they privilege elites, lock out other stakeholders from the participatory process, and maintain a positive bias towards PBF with little meaningful engagement. The chapter also explores the problems of participation fatigue and the culture of per diems and paying for participation.