Trojan Multilateralism: Global Cooperation in Health
| Author | Ngaire Woods,Devi Sridhar |
| Published date | 01 November 2013 |
| Date | 01 November 2013 |
| DOI | http://doi.org/10.1111/1758-5899.12066 |
Trojan Multilateralism: Global Cooperation
in Health
Devi Sridhar
Global Public Health Unit, Edinburgh University and Blavatnik School of
Government, Oxford University
Ngaire Woods
Blavatnik School of Government, Oxford University
Abstract
This article argues that recent global health cooperation has been marked by two trends. First, there has been a highly
successful proliferation of vertical funds to fight specific diseases. These are characterized by narrower problem-based
mandates; multistakeholder governance; voluntary and discretionary funding; no in-country presence for the delivery of
assistance; and an output-based legitimacy (based on effectiveness, not process). The rise of new initiatives with these
characteristics has dovetailed with an increase in the funding of international organizations. However, the latter has
not necessarily strengthened multilateralism. Instead, rapid increases in discretionary earmarked funding to the WHO
and World Bank, which we call Trojan multilateralism, has replicated features of the vertical funds. With what conse-
quences for international cooperation? Using principal–agent theory, we find a mixed picture. International organiza-
tions are being redirected by specific incentives. However, two constraints on bilateral control are not shifting. There is
a persistent asymmetry of information between the WHO or the World Bank and individual member states, which gives
the former a degree of autonomy. Equally, there are persistent obstacles to tightening bilateral monitoring of multilat-
eral action. We conclude that the positive lessons to be drawn from vertical initiatives need to be balanced by the risks
posed from a convergence of vertical initiatives and Trojan multilateralism
Policy Implications
•Donor governments are rightly attracted by the model of vertical funds that can deliver clearly measurable out-
comes and do not require long-term funding commitments.
•However, they must now properly identify the ways in which these funds rely upon wider elements of global
health cooperation (including global regulation, monitoring and crisis management) and ensure that their funding
is aimed at both sets of goals.
•Senior management in international organizations need to use their autonomy; they should demonstrate more
robustly and make the case for how and why governments should support ‘core’global cooperation rather than
being lured yet further into the shorter-term, issue-specific interventions.
•Countries in receipt of the new global health funding need to identify and express more strongly their own health
priorities, and to build health strategies that prioritize the building of their own effective health systems.
International cooperation in global health seemed to
increase markedly during the decades up to 2010 (IHME,
2010). Widespread popular concerns about HIV/AIDS,
maternal mortality and the H1N1 (or avian flu) pandem-
ics brought more money and new mechanisms of deliv-
ery into global health. New ‘vertical’initiatives in health
proliferated, offering a powerful complement to tradi-
tional multilateralism. Focused on narrow goals, mobiliz-
ing a variety of stakeholders and delivering through a
light management structure, the Global Fund and the
GAVI Alliance (formerly the Global Alliance for Vaccines
and Immunization) demonstrate what vertical funds can
do. Meanwhile, the multilateral infrastructure of global
health cooperation –delivered by the WHO and the
World Bank –has also enjoyed an increase in its funding.
On the face of it, then, global health cooperation has
enjoyed a couple of decades of strengthening. However,
there is another possibility. It could be that the new and
successful vertical initiatives have created a model that is
tempting powerful states to import new and greater con-
Global Policy (2013) 4:4 doi: 10.1111/1758-5899.12066 ©2013 University of Durham and John Wiley & Sons, Ltd.
Global Policy Volume 4 . Issue 4 . November 2013 325
Research Article
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