The Lancet  
Dec 08, 2012   Volume 380  Number 9858  p1967 – 2052
http://www.thelancet.com/journals/lancet/issue/current

Offline: The struggle for leadership
Richard Horton

Excerpt
Shortly after the UN General Assembly concluded its September meeting, the Director-General of WHO, Margaret Chan, wrote to, among others, heads of UN agencies, the World Bank, USAID, GAVI, and the Gates Foundation—Anthony Lake, Michel Sidibé, Babatunde Osotimehin, Jim Kim, Rajiv Shah, Seth Berkley, and Chris Elias. Her message was candid: “You will recall that we discussed what we can do to step up our collective action and collaboration to accelerate progress on the health MDGs before the 2015 deadline. There was agreement on the following points: the urgent need to stop competition and fragmentation among global health agencies, and improving harmonisation and alignment at the country level with a focus on results.” Her note went on to make specific recommendations for revitalising the International Health Partnership (IHP+). But her general intention was clear: a sharp warning to colleagues for pursuing agendas that were more about their own interests than the needs of countries. She was expressing the frustration of someone who sees the global health architecture as failing those it is supposed to defend and protect. She knows that the competition for influence and authority between WHO, UNICEF, UNAIDS, UNFPA, the World Bank, the Gates Foundation, and other Global Health Initiatives is leading her and other leaders to overpromise and underdeliver.

Two weeks after Dr Chan sent her email, Michel Sidibé replied (during the annual University College London/Lancet Lecture). Sidibé began by recalling the fear that AIDS once instilled in nations. That sense of crisis created an utterly new social compact between countries. In 2000, there were few signs of real or lasting success in the battle against AIDS. Now 8 million people have access to antiretrovirals and there is “a serious belief in ending the epidemic”. But Sidibé also offered a warning. None of these achievements are sustainable if the global community continues to work in the same way. There is not only a financial crisis afflicting countries. There is also an “ethical crisis…a crisis of trust”. If there is no trust between countries it is impossible to inspire global solidarity around any notion of justice. Sidibé argued that global health was at a “moment of transition”. It was moving away from a disease-centred to a people-centred vision of development. Yet just as this transition was upon us, “multilateralism is more and more in crisis”. Perhaps the ideal of achieving global consensus has passed forever. The world is multipolar. The idea of one central authority of knowledge or power is no longer credible.    China and India are already strong voices. Africa is rising. Governance mechanisms are slowly giving space to these emerging nations. In this “new world”, five key issues will demand our attention. First, the architecture of global health, although changing, is still “not good enough”. Second, better ways have to be devised to engage new actors, especially new country voices. Third, despite billions of dollars of aid pouring into countries, delivery systems for health have to be rethought. Fourth, technology will be a much bigger determinant of success. Finally, none of this manifesto can be delivered without applying principles of human rights to health…