5 Approaches and contexts
5.1 Knowledge-based policy
A strong knowledge base is essential for making good decisions with regard to innovation and willingness to take risks, and for setting the right goals and criteria for results.
One fundamental requirement for a results-based approach is systematic use of research-based knowledge to evaluate measures (for instance to determine which clinical programmes or measures are most effective and where incentives should be directed for greatest effect); another is continuous monitoring of the population’s health and the performance of the health service using good registration and information systems for health data. More generally, it is also important that the global political and technical debate on health issues is based on relevant and adequate knowledge.
This whole area is referred to as knowledge-based policy formulation. A successful strategic approach to global health involves choosing wisely between the many different channels available for achieving results on a set of priorities that range from concrete targets (for instance the Millennium Development Goals) to broad, long-term objectives (for instance the normative work of WHO). This requires knowledge-based policy formulation. This approach is fundamental to the Government’s global health policy.
There are several challenges in this context. Firstly, knowledge needs to be generated that answers the questions political decision-makers are seeking to address. Secondly, political decision-makers and institutions must make use of this knowledge. Thirdly, it is more difficult to develop knowledge about new, innovative solutions than about solutions that are well established and tested. It is also difficult to discontinue established services whose performance cannot be documented. Fourthly, not all actors base their arguments on research and evidence when solutions are being discussed.
Politics and knowledge
This last point underscores the close links between knowledge-based policies and political mobilisation for health. Many of the best arguments for gender equality and universal access to health services for groups that are vulnerable or discriminated against are health-related, although the Norwegian positions in these areas are at heart rights-based. At the same time, research should also identify the dilemmas and contradictions that arise in politics and in the interface between principles and values on the one hand, and the real world on the other. It will always be easier to find good arguments, also internationally, for policies that have a sound knowledge base. Not least, international recognition that research-based evidence should form the basis of health policy in itself helps to build consensus, since it provides a common platform for solutions that can be applied irrespective of regional, ideological and religious differences.
Innovation poses particular challenges for knowledge-based policy formulation. It will always be more difficult to support new and untried approaches with evidence. Inevitably, such approaches involve a higher level of risk. At the same time, we must have the courage to break new paths if we are to utilise our resources better and engage new donors and actors. Active use of up-to-date and relevant knowledge is the key that enables decision-makers to reduce risk and identify new approaches that can optimise results. The Government will continue its efforts in the area of global health research and innovation, and will emphasise the use of up-to-date research results in its policy formulation.
Performance management is a good example of an area that requires a close dialogue between research communities and decision-makers, and where knowledge-based policy formulation is absolutely essential. This approach requires the use of indicators that are both relevant and reliable. Systematic use of research-based knowledge and good information and implementation systems are decisive for providing reliable input for political decision-making processes, and are essential for good governance.
Willingness to take risks in the choice of solutions and forms of cooperation is a central part of the Government’s approach because this is a prerequisite for innovation. But the willingness to take risks too should be knowledge-based; as far as possible the factors that influence the risk profile should be identified, analysed, assessed, addressed and followed up in order to keep risk connected with target attainment at an acceptable level. Research can provide knowledge that extends beyond direct experience.
The global pattern of disease is changing, and we can expect significant changes over the next ten years. Effective solutions require an ability to identify and define developments at an early stage – not least to ensure an approach that emphasises preventive work. Here too, a sound knowledge-based policy is vital.
The Government contributes to knowledge production on global health by financing and actively supporting research, knowledge management, and the dissemination of research-based knowledge and best practices. Systematic work is being done to establish good systems for knowledge management and knowledge dissemination both nationally and internationally through the EU and WHO. One challenge is to ensure more, and more relevant, knowledge production that is targeted at the needs of the poorest countries.
The knowledge organisations of the Norwegian health authorities and various Norwegian research communities have a strong position as partners of WHO and other actors. For instance the network of WHO collaborating centres includes seven Norwegian institutions: the Norwegian Institute of Public Health, the Norwegian Centre for Integrated Care and Telemedicine under the Northern Norway Regional Health Authority (Tromsø), the National Institute of Occupational Health, the University of Bergen, the University of Tromsø, the University hospital of North Norway (Tromsø), and St. Olav’s Hospital (Trondheim University Hospital).
The Research Council of Norway’s Programme for Global Health and Vaccination Research (GLOBVAC) is a cornerstone in Norwegian knowledge production in the field of global health. The programme has been successful in strengthening Norwegian research and research capacity in this area. The Research Council’s support for global health research have been extended (2012–2020), and expanded in scope, with emphasis on research on health systems and implementation research, and also on innovation, in addition to vaccination research. Both implementation research and research-based follow-up of measures over time are important means of assuring that new evidence is implemented and used.
A lack of or inadequate health statistics undermines the authorities’ ability to monitor the health situation, particularly in developing countries. Furthermore, inadequate statistics makes it harder for international organisations and other partners to provide relevant technical advice and financial support. Norwegian expertise is in demand internationally, for instance in the US and India. Several international initiatives are seeking to strengthen health statistics and information systems, such as the global Health Metrics Network. New technology, like mobile phones, opens up new approaches. Several Norwegian centres of expertise are engaged in international efforts through university-based networks in Asia and Africa. Norway is helping to strengthen health information systems in a number of countries, among them Mozambique, Tanzania, Malawi and India.
Boks 5.1 Commitment to global health research
Global health research is an area with political priority and it is discussed in the white paper on the climate for research, Klima for forskning (Norwegian only),1 the foreign policy white paper Interests, Responsibilities and Opportunities,2 which emphasises health and knowledge as a global public good, and the international development white paper Climate, Conflict and Capital,3 which emphasises capacity development in the South. The promotion of global health research as the foundation for knowledge-based policies is one of five priorities in the Norwegian WHO strategy for 2010–2013.
The primary goal of Norwegian investment in global health research is to develop new knowledge that can contribute to improving the health situation and living conditions in developing countries. It is also our goal to support capacity-building in these countries, as strong higher education and research institutions are essential for innovation, the expansion of effective health services and the development of national leadership. Norwegian research communities and institutions have won international recognition in areas like health statistics and tuberculosis research, and their activities and network-building have increased the internationalisation of Norwegian research and higher education.
Norway’s support for global health research is mainly channelled in the following ways:
As grants from the Ministry of Foreign Affairs and the Norwegian Agency for Development Cooperation (Norad) to international institutions – for instance to the Special Programme for Research and Training in Tropical Diseases and the Special Programme of Research, Development and Research Training in Human Reproduction under WHO, to public–private partnerships like the International AIDS Vaccine Initiative and the International Partnership for Microbicides, and to institutions working to strengthen the production and use of research-based knowledge as a basis for analysis and decision-making in global health (WHO, the Norwegian Knowledge Centre for the Health Services);
Through support for projects under the Research Council of Norway’s GLOBVAC programme in partnership with Norwegian research communities, often in collaboration with international partners and partners based in the South;
Through grants managed by the Norwegian Centre for International Cooperation in Education in partnership with Norwegian universities and institutions of higher education, and in collaboration with institutions based in the South. The 2009 reviews of the Norwegian Programme for Development, Research and Education and Norad’s Programme for Master Studies showed good results, and a new programme, the Norwegian Programme for Capacity Building in Higher Education and Research for Development, will start up in 2012; and
Through Norwegian participation in the EU’s Seventh Framework Programme (FP7) in the health area, where global health research is a priority area. FP7 also supports a common research effort involving clinical studies on HIV, malaria and tuberculosis in sub-Saharan Africa, which Norway participates in.
GLOBVAC, which was established in 2006, plays an important part in the Government’s efforts to promote women’s and children’s health. It has run two sub-programmes on global health and vaccination respectively. In the period 2003–2011, grants were awarded to more than 57 research projects, with a total value of NOK 400 million. GLOBVAC has supported basic research projects with a view to developing new and improved vaccines, clinical trials of vaccines, and research on health systems. An evaluation of GLOBVAC in 2009 was very positive, and the Government will therefore continue its support up to 2020, with emphasis on vaccination, health systems and implementation research and innovation.
In recent years, Norwegian institutions of research and higher education have increased their commitment to global health, for instance through the Norwegian Forum for Global Health Research, which arranges annual conferences and promotes internationalisation and network-building. It has a membership of more than 370 researchers.
5.2 Consensus-building and mobilisation
It is vital to mobilise broad political support for common goals at the international level. Norway intends to actively promote international accountability and help to mobilise broad, strong global consensus on cooperation to address national health needs. The most important arenas for such activities are the various meeting places for heads of state and government, including the UN system, and especially WHO.
Safeguarding the right to health at all levels of society requires political will. Global health efforts therefore depend on political mobilisation and prioritisation at national level. At the same time, global health issues by definition transcend boundaries, and health is a global public good. To meet the challenges and achieve results it is therefore necessary to mobilise political will at international level also.
Effective follow-up of cross-border health challenges requires broad agreement. Health issues relate to areas where agreement may be hard to reach, and where fundamental human rights may clash with religious and cultural norms. On the more practical level, too, methods and approaches need to be coordinated if goals are to be reached. Above all, the ability to agree on and achieve global targets is important, as exemplified by the UN Millennium Development Goals and the related efforts. Another example is pandemic preparedness and response. This is where global health policy provides greatest added value as a supplement to national and inter-governmental health cooperation.
The fundamental starting point for Norway’s global health policy is the individual’s right to health as enshrined in the Universal Declaration on Human Rights, and the principle of universal access to health services. Although these principles are recognised internationally, implementing them in national and local policies is often controversial, particularly when it comes to the rights of women and vulnerable groups. Protecting these rights and translating them into concrete action involves a constant struggle. This political struggle is largely fought in global forums, and in parallel at the local level by civil society and NGOs. The campaigns against discrimination and criminalisation of vulnerable groups like homosexuals in connection with prevention and treatment of HIV/AIDS is one example of how political mobilisation at the global level and activism by NGOs at local and regional level can work in tandem.
The need to mobilise resources is a further reason to emphasise political work at global level. It has been estimated that achieving the goal of rich countries giving 0.7 % of their GNI in aid and poor countries allocating 15 % of their national budgets to health would double per capita spending on global health, from USD 25 to USD 50. However, this goal is far from realisation. Securing sufficient and long-term financing is crucial for achieving the health-related MDGs, and for further progress after 2015. The financing of global health is under pressure as a consequence of the financial crisis 2009–2011. The impact of the global financial crisis underlines the importance of increasing effectiveness, promoting innovative financing, increasing predictability and sources of finance, stimulating developing countries to increase their health budgets, and intensifying efforts against corruption in the health sector. Innovative financing models aimed at mobilising resources and new forms of public–private cooperation have contributed significantly to the political mobilisation for global health.
In 2010, the G8 countries committed themselves to providing at least USD 5 billion in the five-year period 2010–2014 for women’s and children’s health. The members of the African Union have committed themselves to allocating at least 15 % of their national budgets to health by 2015. The most wide-ranging demonstration of mobilisation for women’s and children’s health to date was in september 2010, when heads of state and government, the private sector, civil society and the UN system, led by Secretary-General Ban Ki-Moon, launched the Global Strategy for Women’s and Children’s Health.
Norway will actively promote health issues and seek allies in international forums. UN high-level meetings, which bring together a large number of heads of state and government are important arenas that set the pace for the rest of the UN system. G8 and G20 meetings, which also involve ministers of finance, also have an important role to play. The initiative on Foreign Policy and Global Health is building alliances across established groups. WHO and the World Health Assembly are crucial bodies. The EU and other regional forums are also significant arenas.
Political mobilisation is not only a question of international collaboration, but also of national policies in individual countries. Achieving the current international goals will largely depend on factors that are the responsibility of individual countries. Our bilateral relations with other countries are therefore import arenas for political mobilisation – both to win support for Norwegian positions in global forums and to encourage the inclusion of global goals in national policies. Accountability is a vital objective in this context. Good governance is a key factor for addressing health problems, particularly at country level, and accountability is a key challenge here. Weak institutions and decision-making processes without sufficient support lead to low-quality services and low cost-effectiveness. Corruption is a common problem, and has a double negative effect since it on the one hand skews and hinders decision-making processes, and on the other steals meagre resources. These problems are found in all parts of the world, and not only in the context of development cooperation. Efforts to increase accountability in governance include promoting implementation of international norms and follow-up of commitments, active dialogue to influence national authorities, and, not least, high standards in all channels for Norwegian funds.
The diversity of arenas and partners presents both opportunities and challenges for consensus-building and mobilisation. Most countries, for instance, deal with the organisations in the UN system individually rather than as a group. At national level, the approach to the UN is often sector-based, and responsibility for this work decentralised to the authorities in the sector concerned. It is therefore difficult to maintain consistent and predictable political leadership. Problems can also arise in coordination within and between ministries – with different ministries following up different aspects of related complex issues in multilateral forums. Norway’s work to address this challenge in terms of Norwegian policy is the subject of an annual report on policy coherence to the Storting (cf. the Ministry of Foreign Affairs’ budget proposition).
5.3 Innovation, results and predictability
In its foreign and development policy, Norway is working actively to identify niches where we can make a difference, and where Norwegian funding and Norwegian efforts will make an effective contribution. In global health cooperation, Norway will actively promote regular reviews to identify the most effective ways of organising cooperation and the development of new instruments, including instruments that require a willingness to take risks. These efforts are results-driven. Emphasis should be given to innovation and willingness to take risks, especially in relation to established mechanisms and organisations. This is essential if Norway is to be a predictable, credible actor that demonstrates leadership, engages in dialogues and is prepared to take responsibility when changes have to be made in established cooperation forums.
Innovation and results
WHO estimates that as much as 20–40 % of global health spending is wasted because of inefficient use of resources. «More health for the money» is therefore an important goal in a situation where the lack of resources is a considerable bottleneck for global development in the health area.
The lessons learned from global health efforts over the past few decades show that the ability and will to try new forms of cooperation is a key factor for achieving good results. Global health is one of the areas that have seen the most innovation in the past decade. For example, we have seen widespread mobilisation and engagement of non-governmental actors who have taken on greater responsibility in this field, and considerable use of non-aid funding.
Innovation and willingness to take risks depend on political will to evaluate, develop and try out existing and new financial mechanisms and organisational models. Norway has shown that it is able and willing to innovate and take risks by contributing to the establishment of new results-based partnership like GAVI that are owned by other actors than just states. The international drug purchase facility UNITAID is also based on an innovative model for financing, which relies on both national taxes and conventional aid.
The limitations of the UN system, for instance when it comes to including partners other than states in governing bodies, have been a contributing factor to the establishment of new financial mechanisms with narrower, closely targeted mandates to combat communicable diseases, like GAVI in the field of vaccines, the Global Fund and UNITAID. These mechanisms have been established under the assumption that they conform to the normative roles and functions of the UN, and on the assumption that they produce good, measurable results right down to individual level in terms of the number of vaccinations, delivery of pharmaceuticals and treatment of HIV/AIDS, malaria and tuberculosis. They have also been in the forefront of the development of new results-based approaches for financing, and have therefore become attractive as channels for results-oriented aid.
The last decades have seen greater willingness among private actors to invest in efforts to combat diseases that particularly affect the poorest countries, a prime example being the Gates Foundation. The pharmaceuticals industry, including manufacturers of vaccines, has increased its engagement through various schemes. The pharmaceuticals industry in the South is growing, and there is a rapid development of new models for cooperation on research, development and procurement of medicines and vaccines. This has produced results. For instance products have quickly become available for developing countries and prices have been reduced due to stronger and widespread competition. These efforts have drawn on the expertise, credibility and experience of the UN system, with WHO and UNICEF at the forefront. Furthermore, the World Bank with its financial expertise and country experience is playing an important part as bridge builder and guarantor to ensure that the funds are managed effectively.
Technological progress is a key factor for development, in the health services as in every other area. For example, increased use of mobile phones and information technology is improving access to vital health services and enabling more cost-effective use of the health workforce where this is a scarce resource.
Norway is actively engaged in, and is a driving force in, the global coordination of this work, for example in connection with the establishment of a common platform for financing of health systems in low-income countries, where GAVI, the Global Fund and the World Bank are key partners.
Long-term financing of national health systems is important to ensure access to health services. The International Development Association (IDA), the World Bank’s fund for the poorest countries, has such a long-term perspective. The development and financing of evidence-based models for health finance adapted to local conditions is crucial for developing more sustainable health services in all countries.
Results-based financing is an example of an innovative approach to improving the supply and quality of services. Together with the UK, Norway supports the Health Results Innovation Trust Fund under the World Bank for testing, evaluating and developing models for results-based financing in relation to both supply and demand, with emphasis on access to and use of services for women, children and vulnerable groups. One of the goals is that activities financed by the fund should increase knowledge about opportunities and challenges, and the impact – both positive and negative – of various forms of results-based financing. Our cooperation with the World Bank, including support for the fund, will continue.
Innovation in health services also implies a willingness to introduce new measures before they have been fully evaluated, where this is justified. However, it is also important that innovation is based on sound, realistic assessments. For instance, the acquisition of new technology can be cost-effective if the decision is based on good and realistic assessments, and the equipment is suitable in terms of competence, implementation capacity and needs. Ineffective use of new technology or the acquisition of inappropriate technology may in the worst cases reduce the effectiveness of health systems. Risk management is therefore crucial to the practical implementation of innovation, as is the systematic development of a knowledge base through follow-up research and documentation of effects and benefits, possible side effects and costs. This underlines the close connection between technological and organisational innovation, and the importance of knowledge-based and comprehensive decision-making processes (cf. chapter 5.1).
It is strongly emphasised that integrity must be maintained wherever Norwegian funds are used. International organisations and schemes that receive Norwegian funds are expected to have in place and be able to document good preventive measures, control systems and sanctions that ensure zero tolerance for financial irregularities. If the management of funds is not satisfactory, Norway will address this in an appropriate manner at the system level, or directly in connection with the management of individual projects involving Norwegian funds.
Predictability and credibility
There is no contradiction between engagement in flexible and non-traditional organisations with sector-specific goals such as GAVI, and at the same time being a predictable long-term partner and contributor to the UN system, whose goals are normative and more general, and where it is not as easy to measure performance directly, and other approaches are therefore needed. Credibility, expertise and predictability all require long-term commitment – in political, technical and financial terms – not least in relation to the UN. Focus on results also entails a willingness to pursue long-term goals.
Norwegian efforts will be based on consistent and long-term promotion of fundamental rights, an approach that gives Norway a recognisable and credible profile over time. The right to health is a fundamental individual right, and a goal in itself. Thus Norway’s profile as a credible and predictable actor in global health policy is primarily related to our rights-based approach to global health.
Taking a rights-perspective in global health efforts is also an important departure point for achieving results in other areas. The efforts to improve the position of women are a good example of this, as both a goal in itself and a means of achieving other goals. The underprivileged position of women in many societies is one of the greatest obstacles to the fulfilment of the Millennium Development Goals in general, and particularly when it comes to reducing maternal and child mortality. Investment in women’s health and education, and strengthening women’s political and economic influence is a groundbreaking strategy for achieving the MDGs, in addition to the efforts to realise the specific health targets for women and mothers.
Global health challenges by nature transcend borders, and must therefore be addressed through a common understanding of basic standards for delivery of services at individual level, regardless of citizenship, ethnicity and other dividing lines. This especially applies to the principle of universal access to health services, which is crucial for ensuring that health systems are designed to reach all groups.