## Abstract - Background | Despite many efforts to achieve better coordination, fragmentation is an enduring feature of the global health landscape that undermines the effectiveness of health programmes and threatens the attainment of the health-related Sustainable Development Goals. In this paper we identify and describe the multiple causes of fragmentation in development assistant for health at the global level. The study is of particular relevance since the emergence of new global health problems such as COVID-19 heightens the need for global health actors to work in coordinated ways. Our study is part of the Lancet Commission on Synergies between Universal Health Coverage, Health Security and Health Promotion. - Methods | We used a mixed methods approach. This consisted of a non-systematic literature review of published papers in scientific journals, reports, books and websites. We also carried out twenty semi-structured expert interviews with individuals from bilateral and multilateral organisations, governments and academic and research institutions between April 2019 and December 2019. - Results | We identified five distinct yet interconnected sets of factors causing fragmentation: proliferation of global health actors; problems of global leadership; divergent interests; problems of accountability; problems of power relations. We explain why global health actors struggle to harmonise their approaches and priorities, fail to align their work with low- and middle-income countries’ needs and why they continue to embrace funding instruments that create fragmentation. - Conclusions | Many global actors are genuinely committed to addressing the problems of fragmentation, despite their complexity and interconnected nature. This paper aims to raise awareness and understanding of the causes of fragmentation and to help guide actors’ efforts in addressing the problems and moving to more synergistic approaches. - Keywords: Synergies, Fragmentation, Coordination, Harmonisation, Alignment, Aid effectiveness, Interests, Accountability, Power ## Results Based on themes presented in the literature and described by our interviewees, we drew out five distinct yet interconnected sets of factors causing fragmentation, represented in Fig. 1: proliferation of global health actors; problems of global leadership; divergent interests; problems of accountability; problems of power relations. ![[CleanShot 2023-12-23 at 12.16.07.png]] ### Proliferation of global health actors: 'The Tower of Babel' Dodd et al. suggested that ‘...there are now well over a hundred major international organizations involved in health, far more than in any other sector, and literally hundreds of channels for delivering health aid’ #to-read Dodd R. Aid Effectiveness and Health. Working Paper No. 9. Geneva: WHO; 2007. > A total of 175 such actors were estimated by McColl in 2008 , while Hoffman and Cole listed 203 global health actors in 2018, up from around fifty in 1960. A government interviewee reflected on the extent of fragmentation at the global level: ‘*Well, fragmentation is everywhere! ... the higher you go, the more you see fragmentation ...*’, while an academic interviewee commented: ‘*...we’re getting a lot of fragmentation and it’s getting worse as you get new entrants into the global health marketplace and there’s no overall plan or cohesion ...*’ Some commentators in the literature point to the vast numbers of civil society organisations involved in global health efforts. Estimates suggest there were 1983 in the early Twentieth Century, and by 2000 as many as 37,000 were estimated. [Fidler used the phases ‘unstructured plurality’ and ‘open source anarchy’]([[Global health governance now is more about informal mechanisms between state and non-state negotiations. The governance space is now accessible by states and non-state actors, a condition Fidler called "open-source anarchy"]]) to highlight the ways governments are increasingly sharing their influence over global policy with the vast number of civil society organisations operating at global level, some of which are formally engaged in powerful decision making mechanisms such as the [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]]’s Board. Global health actors' priorities, rules, etc. are often imposed on and not aligned with the receivers (LMICs) and place a considerable burden on the health systems of those countries Global health actors’ priorities, rules and regulations, cultures, systems and processes are often imposed on and not aligned with those of low- and middle-income countries receiving their largesse. Sridhar explains: *... lack of alignment of donors with the national approach, lack of harmonization among donors, and excessive transaction costs on recipient governments. ==Too often donors have their own ways of implementing initiatives in a country, thereby weakening national health strategies and systems== ...* #to-read Sridhar D. Seven challenges in international development assistance for health and ways forward. Journal of Law, Medicine and Ethics. 2010:2–12. ### Problems of global leadership: 'The [[World Health Organization (WHO)]] stands on a crowded stage' [[Government vs governance]] | A second cause of fragmentation is the lack of effective leadership for global health. No single lead actor, institution or process exists that is able to harmonise the multitude of global health actors, and there is of course no ‘global government’ with jurisdiction over different countries in the same way that sovereign nations have national governments. > Article 2 of the WHO’s constitution clarifies its coordination role: ‘In order to achieve its objective, the functions of the Organization shall be ... to act as the ==directing and coordinating authority== on international health work’. While directing role of WHO continues to be held in high esteem (WHA as the supreme legislative body), WHO experienced difficulties in fulfilling its coordination role. 1. there are many other global actors with power and resources influencing global health, making coordination increasingly challenging for any single organisation 2. while the WHO’s formal coordination role remains, other actors’ ideas and approaches have challenged the WHO’s power and leadership. For example, [UNICEF’s selective primary healthcare programme was a counter to the WHO’s ideas of ‘comprehensive’ primary healthcare]([[global health governance]]). The World Bank has been famously called the ‘*8000 lb gorilla*’ in global health, a reference to its substantial resources, expertise, power and influence. [[The World Bank’s ascendancy in the field of health is often linked to the influential 1993 World Development Report ‘Investing in Health’]], which challenged the ideas of primary healthcare and universal health coverage advocated by the WHO, and ==displaced them with ideas of efficiency and the role of the market== in the health sector. [[The Gates Foundation has become an important funder of the WHO, the World Bank and indeed many other global health actors]]. 3. The WHO and other UN agencies are sometimes criticised for having internal organisational problems that have reduced their power. 4. WHO’s limited effectiveness as a global health leader is undermined by inadequate resources to meet its mandate in the context of new global health challenges such as HIV/AIDS, infectious disease pandemics and non-communicable diseases, coupled with pressure from its donors, each with different agendas and expectations, and with substantial control over its budget and priorities. 5. Some high-income countries see their national sovereignty, and hence their power and ability to further their own interests, as being threatened by strong health global actors and institutions such as the UN agencies and other multilateral efforts such as the Global Fund and similar partnerships and initiatives. Hence, they tend to be cautious in their support, or ==indeed have an interest in maintaining the fragmented global order==. > [[The World Health Organisation is a donor driven agency]] ... 80% of its budget comes from donations ... the best thing is for the WHO to be more focussed ... don’t be dragged by donors!’. An interviewee from a multilateral organisation added: ‘... WHO ends up with its hands tied – not able to do much because of the conditions put to them ... . ’ ### Divergent interests: 'It's tied to trade and security and influence' > A third cause of fragmentation is global health actors’ self-interests, and therefore their tendency to adopt priorities and approaches that do not always align with those of low- and middle-income countries receiving DAH. Indeed, the interests of global health actors can be divergent, competing and therefore incompatible with one another, making it difficult to harmonise the different priorities and approaches they adopt. [[Insights]] I think this is where TBI shines because we are not competing with anyone. Our interest is the government's interest. Our funding came with no strings attached since the institute refunnel their money from clients elsewhere. [[DAH is primarily, although not entirely, driven by the interests of high-income countries]] For example, responding to criticism about wasteful spending on international development, the UK’s Department for International Development openly admits that its aid budget benefits the UK: ‘Our aid commitment - which is enshrined in law - increases Britain’s global influence and allows us to shape the world around us. This is a win for the developing world and win for the UK too’ [51]. Our interviewees also observed that nationalistic concerns about immigration have made the idea of global health security more politically attractive since people crossing sovereign borders are assumed to transmit communicable diseases. It is also argued that structural adjustment policies, with their aim of reconfiguring countries’ health sectors into more market orientated ones, helped to facilitate the entry of companies from high-income countries, including pharmaceutical corporations, private healthcare providers and insurers, into the markets of low- and middle-income countries. And of course, the negative impacts on health and the damage caused to low- and middle-income country health systems by structural adjustment policies have been acknowledged, including weakening governments’ roles in planning, coordination and regulation – and thereby contributing to fragmentation. #to-read Thomson M, Kentikelenis A, Stubbs T. Structural adjustment programmes adversely affect vulnerable populations: a systematic-narrative review of their effect on child and maternal health. Public Health Review. 2017;38(13). [[Insights]] Not always. When we don't push and rather open up and balance things out with our counterpart to let them have access while balancing the socioeconomic benefits, ensuring [distribution of outcomes]([[Health policymakers must see, that liberalisation that may resulted in aggregated increase in GDP, but it doesn't guarantee the distribution outcomes of trade]]). [[Interesting Phrase]] Finally, there is the phenomenon of ‘[[phantom aid]]’. A substantial proportion of DAH takes the form of professional staff and consultants’ salaries, administration and transaction costs, meetings and conferences. There are vast numbers of people employed by the aid industry and so, organisations have a strong interest in maintaining their existence, thereby contributing the proliferation described earlier. ### Problems of accountability: 'I see a certain reluctance to more transparency' > global health actors’ unbalanced accountability, that is weak accountability to governments and populations in low- and middle-income countries receiving their DAH contributions, while being more accountable to the high-income governments and taxpayers that fund them. ### Problems of power relations: 'Dependent on playing by donors' rules' A fifth cause of fragmentation relates to the power relations that exist between rich and poor countries. Some critics argue that DAH is part of an apparatus that helps to maintain unequal power relations by holding back or even damaging the economies of low- and middle-income countries while serving the interests of high-income countries and their [[MNCs]]. [[Interesting Phrase]]Some writers adopting a ‘[[dependency theory]]’ approach argue that aid can make recipient countries dependent on high-income countries, and therefore more likely to follow their political ideologies and agendas, although this is a contentious issue. ## Discussion Indeed, fragmentation was publicly presented by the WHO’s current Director General as a critical barrier to achieving the health-related SDGs, and there have been many high-profile efforts to reduce fragmentation, and now, improving coordination is a central aim of the Global Action Plan. [[Open Question]] Fragmentation remains a sticky problem, and the COVID-19 crisis makes it more important than ever to tackle. Can anything be done to address or mitigate the problems we outline in this paper? Proliferation of global health actors is a major factor. The global health landscape is becoming more and more complex with the addition of new global health actors, many of which fund their own separate programmes and interventions rather than contributing to existing ones or working collectively. We suggest global health actors now need to avoid adding to this complexity. In most cases, they should aim to contribute to existing programmes and interventions, build on existing declarations, targets and initiatives, and strengthen existing actors, institutions and processes rather than launching new and potentially ephemeral initiatives. As much as possible, high-income countries should channel funding through multilateral actors and initiatives, and thereby aim to reduce the number of parallel bilateral programmes they fund. The COVID-19 pandemic may heighten the importance that some high-income countries attach to global health security in order to protect their own populations. China’s influence over global health agendas is likely to increase as it extends its role as a global health funder. [[Insights]] As we have seen with the presence of AIIB to shake the global state of power. Chatib argued that AIIB and ADB can overcome anti-globalization sentiment by creating regional cooperation success stories from policies that are politically feasible and economically sound.[[@basriRoleAIIBNew2019]] Strengthening accountability mechanisms could help to reduce fragmentation. These might include government-led mutual accountability mechanisms such as common monitoring frameworks promoted by the International Health Partnership Plus that started to yield results in some lowand middle-income countries involved in that initiative. The global monitoring partnership known as IHP + Results helped identify successes and reveal limited progress, and hence put pressure on participating actors and countries to follow through on their commitments. Finally, power relations create fragmentation as many low- and middle-income countries receiving DAH find it difficult to insist on global health actors aligning their activities with their priorities and systems [24,63]. Yet, some low-income countries receiving high levels of development assistance, such as Ethiopia and Rwanda, have been able to ensure DAH meets their needs, as well as manage the activities of multiple global health actors in their countries – or at least to mitigate some of the damage. Ethiopia benefits from strong leadership and country ownership in the health sector, the existence of strong, long-term government-led national health strategies and having in place strong donor coordination mechanisms. [[Insights]] [[Open Question]] Is it because of TBI presence? What role does TBI play that Ethiopia and Rwanda gets mentioned here?