Editorial: The World Health Organization and multi-stakeholder governance. To be or not to be?
Dear reader,
Member states of the World Health Organization (WHO) recently gathered in Geneva for two meetings that will probably shape the direction of the organization for the coming years. End of March, a second informal consultation on WHO’s engagement with non-state actors took place, and from 23-25 April, WHO member states came together to discuss a global coordinating mechanism for Non-Communicable Diseases (NCDs).
The meetings are closely related to each other, because they both discussed cooperation and coordination of WHO with other actors than state governments, defined as “Non-State Actors” (NSAs). While the first meeting on WHO’s engagement with NSAs discussed a general policy framework for how WHO should interact with different actors in (global) health, the second meeting focused on the governance mechanism for cooperation between different actors to address the burden of NCDs. Interestingly, both meetings were for member states only. Outside observers were not allowed. Formal decisions and resolutions are taken during the WHO’s Executive Board (EB) meetings and the annual World Health Assembly (WHA). Observers, such as NGOs, are allowed during these meetings and can even provide formal statements for consideration of the member states. Due to an often cramped agenda during the EB and the WHA, more and more of the multilateral diplomatic debate on global health issues takes place outside these governance bodies and hence away from public scrutiny. This is a worrying trend, as the ongoing reform of WHO should make the organization more accountable and transparent instead.
What is at stake?
The debate on WHO’s involvement with NSAs is not new. Early 2000s there was already a proposition for WHO to cooperate with NGOs in a so-called civil society initiative. This proposition didn’t pass the WHA in 2004, due to opposition by some member states. As part of the WHO reform, new models for cooperation have been suggested since 2010, such as a proposal for a committee C of the World Health Assembly and a proposal for a World Health Forum (see par. 84-89). They both didn’t make it either. These days, a new policy proposal for WHO’s engagement with NSAs is being considered (note the different terms used over time; “Non-State Actors”, “Civil Society Organisations”, and “Non-Governmental Organisations”). The main debate between the member states is to what extent there should be a distinction between NGOs and private entities, and what the mechanisms should be to address potential conflicts of interest. In this report about the March member state consultation, it seems that there is no consensus about the policy.
A diplomat who attended the consultation said that ‘the United States and the United Kingdom complained that the draft policy sets a high degree of scrutiny for the private sector compared to other NSAs.’ Indeed, pharmaceutical companies, but also food and beverage industries, have much (legitimacy and financial profit) to gain if they can work in a more strategic partnership with WHO. And yes, this would likely have an impact on the public health programs and health standards that WHO provides. I find it quite amazing that in the papers there is little discussion about the actual public health benefits of these partnerships: “In the main, WHO’s engagement with non-State actors brings important benefits to global public health and to WHO itself (p15)”. The US, EU and other donors of WHO push for these multi-stakeholder approaches, including a role for private commercial entities. There is resistance from a number of low and middle-income countries to this as many of them already face an overload of selected patented Western pharmaceuticals and cheap food on their domestic markets.
Global coordination mechanism on the prevention and control of NCDs
Annex 2 of the EB document 134/14 (p11-20) provides insight in the actual negotiations on the creation of a new global coordination mechanism to manage the global NCD burden. In par. 7 – 15 the different positions of the member states can be found. The EU and some other countries see a large role for an “international advisory group, comprised of public health and technical health experts in the field of NCDs “(par.8), as well as a “consultation segment with selected representatives of the private sector” (USA, par.10). Brazil, Iran and Pakistan object to the latter, and have reservations about the expert advisory group (par 7). The USA promotes a strong role for WHO and more in particular wants its Non-communicable Diseases and Mental Health cluster to be the secretariat and main coordinator of the global coordination mechanism, (par.14-15). Brazil, China and India and some African countries promote stronger involvement of member states and WHO regions in the coordination mechanism on NCDs (par 8. 11, 16).
Why is there such a push for WHO to be the main convenor in a multi-stakeholder global coordination mechanism on NCDs? Two answers come to my mind. First, Alison Katz elaborated in a recent article in detail the question whether NCDs are a true global health priority or rather a market opportunity determining priorities for WHO? Her central thesis is that while NCDs might be the main burden of disease in Europe, the Americas and a few emerging economies, this is not the case (yet) in most of Africa, South-East Asia and the Eastern Mediterranean. ”Very high levels of avoidable disease and premature death due to infectious diseases, maternal, perinatal and nutritional conditions persist in low income countries”. She recommends WHO to pay more attention to clean drinking water, sanitation and nutritious food as key determinants to overcome both infectious and non-infectious diseases instead of the exclusive, vertical, rather biomedical focus on NCDs and its risk factors. In her view, the NCD agenda is imposed on low income countries, as it’s lucrative for the pharmaceutical, food & and beverage industries, as well as for some NGOs, to develop commodities and expand markets for addressing chronic diseases (see for example the advertisement of ‘healthy products’ on the shelves of supermarkets for the new middle classes).
Second, the lessons from the Global Fund (to fight Aids, Tuberculosis and Malaria) and the GAVI alliance have taught WHO that it has to follow the conditions of the main funders, or otherwise these donors will create global health partnerships outside its control. WHO would thus rather convene and obtain funding for a partnership (the global coordinating mechanism) on NCDs within its own house instead of having to cooperate with a partnership outside its premises (which is now the case with the Global Fund and GAVI). The US, EU and some of its member states as well as the Bill and Melinda Gates Foundation are the biggest funders of WHO. WHO in 2012 received US$264 mln.as voluntary specified funds from the Gates Foundation which is more than the US Government’s voluntary specified contribution of US$208 mln. This ‘steering’ of the priorities of multilateral organisations by its donors is known as multi-bi financing.
What will happen next?
A new framework of engagement with non-state actors will be presented for discussion to the programme, budget and administrative committee (PBAC) of the Executive Board on 14-16 May 2014 (also not accessible to observers), and then presented to the 67th World Health assembly for consideration. A new proposal for the Global Coordinating Mechanism will also be presented to the WHA, based on the outcomes of the April consultation with member states. Despite the opposition by several lower and middle-income countries to the multi-stakeholder model proposed it is most likely that these policy proposals will be adopted as this is what the main donors want.
The simple reason is that so far there is little interest by emerging economies to fund WHO on a voluntary basis or even to plea for higher assessed (membership) contributions. It has been analysed by Devi Sridhar and colleagues that despite the growing influence by BRICS countries in global governance for health, this hasn’t translated into more funding commitments to WHO (or other multilateral health organisations) so far. Perhaps these countries have little faith in the autonomy of WHO as the global health authority and thus prefer to solve their issues on a regional basis? The same trend is also visible in other UN global governance regimes (such as on climate change).
At issue is thus WHO’s legitimacy. Having followed the WHO reform over the last years, it’s evident that the organisation’s reform has focused on managerial and organisational aspects so far. The main challenge, how to enhance the (democratic) legitimacy of WHO, has been dealt with in a very pragmatic way. The backdrop of the WHO reform was, of course, a severe economic crisis in the main donor countries (among the donors, only Bill Gates wasn’t affected by the crisis, but he’s in a league of his own).
You can’t help but wonder what the future position and legitimacy of the WHO will be in a more multipolar world.
Remco van de Pas
ITM Antwerp
After being 5 years at Wemos, I just started to work at the Institute of Tropical Medicine Antwerp as researcher in the public health unit, focusing on international health policies. I will nevertheless remain involved in the MMI Network as a Board member. This editorial was first published in the weekly ITM “International Health Policy” newsletter.
MMI Network: Geneva events
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67th World Health Assembly
Geneva, 19-24 May 2014
The agenda of this year’s World Health Assembly is again very long. You might consult the great WHO Watch website for an overview and preliminary analysis of key agenda items. As an organization in official relations with WHO, the Medicus Mundi International Network is invited to appoint representatives to the World Health Assembly and to make statements under items concerning technical issues. We will focus our activities on networking and advocacy related to key MMI projects, mainly:
- WHO watch
- Democratising Global Health Coalition on the WHO reform (DGH)
- Health workers for all and all for health workers (HW4All)
- Health Workforce Advocacy Initiative and its working group on migration
WHA: http://apps.who.int/gb/e/e_wha67.html
WHO Watch: http://www.ghwatch.org/who-watch/wha67
MMI projects: http://www.medicusmundi.org/en
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Network event:
Prevention and control of NCD in the face of free trade and market deregulation: How to preserve policy space for public health?
Side event to the World Health Assembly, Geneva, 20 May 2014
During this World Health Assembly, the Terms of Reference for the Global Coordination Mechanism on the Prevention and Control of NCDs, the Terms of Reference for the UN Interagency Task Force on the prevention and control of non-communicable diseases (NCDs) and a limited set of indicators for the WHO global action plan for the prevention and control of NCDs 2013-2020 will be considered.
Up to now, though, relatively limited attention is given to the potential impact of trade and investment treaties on health and the risk that these treaties will limit the possibilities of governments to prevent and control NCDs. Investor-State Dispute Settlement provisions and regulatory cooperation in trade and investment treaties make it difficult for governments to take preventive action and may even prevent governments to consider taking action.
In 2006, the 59th World Health Assembly adopted resolution WHA 59/26 on International Trade and Health. In a WHA side event organized by the MMI network (lead: Wemos), we want to draw again attention to this resolution and its implementation and discuss how it may be used by various actors for the prevention and control of NCDs.
First announcement: www.bit.ly/WHA67-NCDs
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Network event:
Working towards Health for All: What’s the count? And what role for civil society action? MMI mini-symposium and Annual Assembly
Geneva, 24 May 2014
The Annual Assembly of the Medicus Mundi International Network takes place in the week of the World Health Assembly in Geneva. As MMI is orienting on its network strategy for the coming 5 years, we intend to make use of having many partners close to us to invite them to a mini-symposium on key issues for the next years and the potential role of civil society – and the MMI Network – related to health systems, global health governance and determinants of health. Most documents for the Assembly documentation are available now.
Announcement: www.bit.ly/mmi-2014
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The next issue of the MMI Network News will focus on the annual reports of the MMI Network and its members.
International Health Policy: MMI Updates
Bits and pieces of news on international health policy: each “MMI update” is 140 characters or less – these are the rules of the game on Twitter. Just enough for a headline, eventually an author, a date, the source – and a link to the website where you find the full information. Have a look at some of our “tweets” published during the last month. As usual, it’s a bit much, so take it or leave it.
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Universal health coverage
Health systems strengthening
Health services, health financing
- Universal health coverage: time for an ambitious call for equity in health. Winnie_Byanyima
http://blogs.oxfam.org/en/blogs/14-04-11-universal-health-coverage-time-ambitious-call-equity-health - 7 things you should know about Universal Health Coverage. Robert Marten
http://www.rockefellerfoundation.org/blog/7-things-you-should-know-about-universal - Progress towards UHC in Brazil, Russia, India, China, South Africa (BRICS). Robert Marten et al. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960075-1/fulltext
- There’s a growing movement to achieve UHC. Where does your country stand? World Bank video
http://bit.ly/1jwpRco - From health systems to systems for health. Agnes Nanyonjo
http://e.itg.be/ihp/archives/health-systems-systems-health/ - Health Centre Committees: vehicle for social participation in east/southern African health systems. Loewenson et al. http://www.equinetafrica.org/bibl/docs/EQUINET%20HCC%20Diss%20paper%20101%20FINAL.pdf
- Toolkit for Performance Based Financing
http://bit.ly/Qf1J4i - PBF for implementation of national health strategies: a debate to be continued – Financing Health in Africa
http://bit.ly/1rMlQlz - The way forward – narrowing the knowledge gap in the WHO African Region to strengthen health systems
http://jrs.sagepub.com/content/early/2014/02/26/0141076813512818.full - The World Bank, the PFI hospital and the destruction of a nation’s healthcare system. Anna Marriott
http://bit.ly/1fEdfBm - Zooming out from healthcare to systems thinking. David Algoso
http://algoso.org/2014/04/06/zooming-out-from-healthcare-to-systems-thinking/ - Faith and health care in Africa: a complex reality. Jill Olivier
http://www.opendemocracy.net/openglobalrights/jill-olivier/faith-and-health-care-in-africa-complex-reality - Private health sector assessment in Tanzania. James White et al.
http://documents.worldbank.org/curated/en/2013/09/18273242/private-health-sector-assessment-tanzania
See also below:
Health beyond 2015
Twitter: #UHC
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Health policy and systems research
- People-centred science: strengthening the practice of health policy and systems research. Lucy Gilson
http://bit.ly/1ncQmoD - Implementation research toolkit: Address critical health system barriers. WHO brochure and materials
http://www.who.int/tdr/publications/topics/ir-toolkit/en/ - Implementation Research in Health: A Practical Guide” (Peters et al, 2013)
http://www.who.int/alliance-hpsr/resources/implementationresearchguide/en/ - Cohred is building a collection of research contract negotiation stories. Story to share?
http://www.cohred.org/frc - Early bird registration for the Third Global Symposium on Health Systems Reserach is open. Join us in Cape Town: http://hsr2014.healthsystemsresearch.org/registration-third-global-symposium-on-health-systems-research-2014-cape-town
- Right to health and global public health research: from tensions to synergy? Gorik Ooms and Rachel Hammonds
http://onlinelibrary.wiley.com/doi/10.1111/tmi.12287/abstract
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Human resources for health
Migration of health professionals
- Global consultation: towards a strategy on Human Resources for Health http://www.who.int/workforcealliance/media/news/2014/globalHRHconsultation/en/
with GHWA concept note: A global strategy on Human Resources for Health for post2015 (PDF)
http://bit.ly/1fVPP5f - Health professional mobility in a changing Europe. New dynamics, mobile individuals and diverse responses
http://goo.gl/wFwNgG - Transforming the Global Health Workforce. Marilyn A. DeLuca and Agnes Soucat (editors), 2013, PDF
https://archive.nyu.edu/handle/2451/31982 - Human Resources for Health at the World Health Assembly
http://www.who.int/workforcealliance/media/events/2014/hrh_67th_wha/en/ - Task-shifting and prioritization: Examining role and experiences of community health workers in Malawi. Smith et al.
http://www.human-resources-health.com/content/12/1/24/abstract - Eight facts about health workers and the brain drain. Martin Drewry
http://www.humanosphere.org/2014/04/ten-facts-health-workers-brain-drain/ - Celebrating Heroes in Health. World Health Workers Week statement
http://bit.ly/1j2wofb - World Health Worker Week
http://www.who.int/workforcealliance/media/news/2014/hww_2014/en/ - World Health Worker Week: Let us hope that those we celebrate still have a job next Monday…
https://interact.healthworkers4all.eu/pages/viewpage.action?pageId=3736512 - Keeping community health workers in Uganda motivated: challenges, facilitators, preferred program inputs. A Brunie
http://www.ghspjournal.org/content/2/1/103.full - Think Development in Poor Countries Will Reduce Migration? The Numbers Say Otherwise. Michael Clement
http://www.cgdev.org/blog/think-development-poor-countries-will-reduce-migration-numbers-say-otherwise - Emigration: an opportunity for Iranian physicians, a challenge for the government. F Shams/ A Shams
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960517-1/fulltext - What makes staff consider leaving the health service in Malawi? Wanangwa Chimwaza et al.
http://www.human-resources-health.com/content/12/1/17/abstract
Twitter: #HRH, #healthworkers #healthworkerscount, #3GFHRH
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Access to medicines and vaccination
Medical research and development
Communicable diseases and diseases control
- WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health
http://www.who.int/mediacentre/news/releases/2014/amr-report/en/ - World Malaria Day 2014: WHO helps countries assess feasibility of eliminating malaria
http://www.who.int/mediacentre/news/notes/2014/world-malaria-day/en/ - Managing malaria in times of change. Fatoumata Nafo-Traoré
http://globalhealth.thelancet.com/2014/04/25/managing-malaria-times-change - Malaria Day: We know what it takes to stop malaria. Now we must work to make that knowledge universal.
http://bit.ly/1l2VdZp - 2nd Global Malaria Action Plan: GMAP2
http://tinyurl.com/mbpr6kj - WHO issues its first hepatitis C treatment guidelines
http://www.who.int/mediacentre/news/releases/2014/hepatitis-guidelines/en/ - WHO calls for access to drugs for hepatitis C. Sarah Boseley
http://www.theguardian.com/society/sarah-boseley-global-health/2014/apr/09/hepatitis-c-pharmaceuticals-industry - World Health Day, 7 April 2014: Small bite, big threat. Vector-borne diseases
http://www.who.int/campaigns/world-health-day/2014/en/ - World TB Day 2014: Reach the 3 million
http://www.who.int/campaigns/tb-day/2014/en/ - Tuberculosis 2014
http://www.thelancet.com/tuberculosis2014 - TB control needs a systems-thinking approach that puts patients at the centre of design strategies
http://ow.ly/uTgQy - World TB Day 2014: finding the missing 3 million. Nick Herbert et al.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960422-0/fulltext
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Prevention and control of NCDs
Disabilities, Mental Health, Care
- Wemos on the WHO public consultation of draft Sugar Guidelines: intake for adults and children:
http://www.wemos.nl/files/Documenten%20Informatief/Bestanden%20voor%20Voeding/recomm_WHOcons_sugar_March2014.pdf - Mental health and wellbeing in children and adolescents. Lancet editorial
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960587-0/fulltext
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Equity and human right to health
Social, political, economic determinants of health
Poverty and social protection
- When is redistribution popular? Social conflict and the politics of inequality
http://www.odi.org.uk/publications/8186-redistribution-popular-social-conflict-politics-inequality#.U1jz4JtPvCs.twitter - Tax-free poverty reduction? Niels Keijzer and Timo Mahn
http://www.thebrokeronline.eu/en/Blogs/Global-development-blog/Tax-free-poverty-reduction - Water and sanitation: addressing inequalities. Lancet editorial
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960665-6/fulltext - The effect of illicit financial flows on time to reach the fourth MDG in Sub-Saharan Africa. Bernadette O’Hare et al.
http://jrs.sagepub.com/content/107/4/148.full - Tuberculosis and the social determinants of health
http://nccdh.ca/resources/entry/public-health-speaks-tuberculosis-and-the-social-determinants-of-health#sthash.GBq06XUg.dpuf
Twitter: #SDH, #HIAP
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Global health governance and policy
- A manifesto for planetary health. Schuftan et al.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960710-8/fulltext
related to http://t.co/1p0wFlfXdw - Lancet Commission on health governance: withdraw your recommendations, come up with better ones! David McCoy
http://bit.ly/Rbq3nr - Commission on Global health governance: just another report? De Vos et al.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960674-7/fulltext
and authors’ reply
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960676-0/fulltext - The multiple meanings of global health governance: a call for conceptual clarity. K Lee, A Kamradt-Scott
http://www.globalizationandhealth.com/content/10/1/28/abstract - International Health Regulations (2005): taking stock. Isabelle Nuttall
http://www.who.int/bulletin/volumes/92/5/14-138990/en/ - Chinese health foreign aid and policy: beyond medical aid. Guanyang Zou et al.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960713-3/fulltext - Why global health should embrace the global precariat. Kristof Decoster
http://e.itg.be/ihp/archives/global-health-embrace-global-precariat - Governance for health, wellbeing and sustainability – what is at stake. Commentary by Ilona Kickbusch (PDF)
http://ped.sagepub.com/content/21/1_suppl/83.full.pdf - Power: The nexus of global health diplomacy? Robert Marten et al.
http://www.ghd-net.org/sites/default/files/marten%20hanefeld%20smith_power%20%281%29.pdf - When will the global health community confront the political economy of ‘country ownership’? SM Topp et al.
http://e.itg.be/ihp/archives/global-health-community-confront-political-economy-country-ownership - What could research on national policies on global health reveal about global health governance? C.M. Jones
http://bit.ly/1udGwqC - African perspectives in global health diplomacy. Rene Loewenson et al.
http://bit.ly/1jobYh2 - Is global health about gizmos or people? Julia E. Robinson
http://bit.ly/1qmLVHe - Making sense of global health data. Alan Whiteside
http://e.itg.be/ihp/archives/making-sense-data/ - What is the World Health Summit for?
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960578-X/fulltext - Financing Global Health 2013: Transition in an Age of Austerity. IHME
http://www.healthmetricsandevaluation.org/publications/policy-report/financing-global-health-2013-transition-age-austerity - Who finances global health? Cool interactive visualization tool by IHME
http://ihmeuw.org/1t85 - The cure for global poverty: Health
http://www.humanosphere.org/2014/03/the-cure-for-global-poverty-health/ - Time to move from pruning trees in global health to forest management. Dave Algos
http://www.humanosphere.org/2014/03/time-to-move-from-pruning-trees-in-global-health-to-forest-management - What have economists ever done for global health? Richard Horton
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960491-8/fulltext - Back to the fuzzy future in global health. A remarkably “tough one” by Tom Paulson
http://www.humanosphere.org/2014/03/back-fuzzy-future-global-health
Twitter: #globalhealth #healthgovernance
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World Health Organization
WHO reform and financing
- Preliminary WHA67 journal with tentative programme of work, technical briefings and side events (NGO events missing)
http://apps.who.int/gb/e/e_wha67.html - Human Resources for Health at the World Health Assembly
http://www.who.int/workforcealliance/media/events/2014/hrh_67th_wha/en/ - No consensus on draft WHO policy on non-state actors. Alexandra Bhattacharya
http://lists.keionline.org/pipermail/ip-health_lists.keionline.org/2014-April/003950.html - see also: Editorial and Network News above.
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Health beyond 2015
MDGs and SDGs
- How can health remain central post2015 in a sustainable development paradigm? Peter S Hill et al.
http://www.globalizationandhealth.com/content/10/1/18/abstract - Working Document for 5-9 May Session of OWG on SDGs Updated focus areas including health (pdf) http://sustainabledevelopment.un.org/content/documents/3686Workingdoc.pdf
- …and related comments by Beyond2015
http://bit.ly/1iLen0R - Beyond2015 “Think Piece” on the post2015 agenda (PDF)
http://www.beyond2015.org/sites/default/files/B2015%20Pretoria%202.0%20Narrative%20Think%20Piece%20VPVC.pdf - Framework for the Future. Ending poverty in a generation. Save the Children proposal for post2015 framework
http://www.savethechildren.org.uk/resources/online-library/framework-future - Human rights and equality post2015: ‘red flag’ CSO petition
http://bit.ly/1dpsIUO
Twitter: #health2015 #post2015 #globalhealth
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Development, aid and international institutions
- Aid to developing countries in 2013. OECD figures on official development assistance (ODA)
http://www.oecd.org/development/aid-to-developing-countries-rebounds-in-2013-to-reach-an-all-time-high.htm - How silver-tongued multinationals can win trust in development circles. Jonathan Glennie
http://www.theguardian.com/global-development/poverty-matters/2014/apr/29/multinationals-business-global-development-regulation - Aid effectiveness in the health sector beyond 2015. IHP / Civil Society Consultative Group, April 2014 (pdf)
http://bit.ly/1mlt6rC - Shaping the architecture of global development cooperation. Heiner Janus et al.
http://www.thebrokeronline.eu/en/Blogs/Post-2015-shaping-a-global-agenda/Shaping-the-architecture-of-global-development-cooperation - Is ‘voluntourism’ the new colonialism? Kerry Stewart
http://www.abc.net.au/radionational/programs/encounter/5341384 - Does Health Aid Reach the Poor? Victoria Fan
http://www.cgdev.org/blog/does-health-aid-reach-poor - How to … make bad NGOs better. Paul Callan et al.
http://www.theguardian.com/global-development-professionals-network/2014/mar/19/four-ideas-development-organisations-ngos?CMP=twt_gu
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