Large donors are forcing the World Health Organization to reform

The current practice of large donors is forcing the World Health Organization and the World Bank to reflect on how to reform to remain more appealing to the wider set of stakeholders and interests at play, according to Devi Sridhar from the University of Oxford writing in this week's PLOS Medicine.

Sridhar argues that since the priorities of funding bodies largely dictate what health issues and diseases are studied, a major challenge in the governance of global health research funding is agenda-setting, which in turn is a consequence of a larger phenomenon—"multi-bi financing."

This term refers to the practice of donors choosing to route funding—earmarked for specific sectors, themes, countries, or regions—through multilateral agencies such as the World Health Organization and the World Bank and to the emergence of new multistakeholder initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance.

Sridhar says: "These new multistakeholder initiatives have five distinct characteristics: a wider set of stakeholders that include non-state institutions, narrower problem-based mandates, financing based on voluntary contributions, no country presence, and legitimacy based on effectiveness, not process."

Sridhar argues that the risk of multi-bi financing is that difficult choices about priority-setting in health will be made in the marketplace of global initiatives, rather than in the community that will have to live with those choices.

She says: "The shift to multi-bi financing likely reflects a desire by participating governments, and others, to control international agencies more tightly."

However, Sridhar adds: "one major impact of multi-bi financing has been to shine a clear light on how and where multilateral institutions, such as the World Bank and the World Health Organization, might do better."