DISSERTATION
(Re-)Fit For Purpose? The Ritual of Reform in Global Health Partnerships
My dissertation focuses on the politics of organizational reform in major multisectoral global health partnerships, such as the Global Polio Eradication Initiative and Roll Back Malaria. I investigate why these organizations appear to be locked in a never-end cycle of reform and restructuring. Partners consistently present reform efforts as attempts make the partnership "fit for purpose". But with rare exceptions, the changes that result are either superficial or accomplish the opposite of what reformers promised--for example, by creating more talk and bureaucracy rather than less. So why do most reforms fail? And why do organizations keep repeating the pattern?
I find that there is often a fundamental contradiction between what partners say they want from the organization or want in theory and what they want in day-to-day practice. For example, partners demand greater efficiency and efficacy, while also insisting on extensive voice opportunity and consensus decision-making. Or they expect the partnership to "orchestrate" partners’ activities and improve on-the-ground results, but then are unwilling to sacrifice their own autonomy to achieve coordination. Restructuring fails to address these contradictory priorities and so cannot truly make the partnership fit for purpose. Instead, it serve as a kind of ritual. By "performing" reform efforts, partners reaffirm their normative commitment to principles like efficiency, efficacy, and coordination. And they do it without disrupting the pragmatic realities of life in global governance organizations.
As rituals, reform efforts serve a clear purpose, even if they fail to make the organization more efficient and effective. But they are also costly in time, money, and energy. And over time, repeated reform efforts risk destabilizing a partnership because they reinforce a narrative of poor performance…when really, the organization’s returns are directly commensurate with partners’ investments in it. WHO and other UN agencies undergo similar ritual reform efforts, but apparently without suffering the same destabilizing consequences. This has important policy implications. Over the past 25 years, global health policymakers (particularly donors) have shown a preference for working through partnerships rather than the UN system, which they consider “dysfunctional”. My research suggests that partnerships come with their own forms of dysfunction; in the long run, they may prove less robust and resilient than traditional intergovernmental organizations. In an atmosphere of growing nationalism and isolationism, institutional resilience matters more than ever.
However, I also find that the dangers of ritual reform can be mitigated, or even reversed, under two conditions. First, partners must be on the same page when it comes to their priorities, contradictions and all. Second, those contradictions cannot be so severe that they undermine the partnership’s purpose and legitimacy. Based on these findings, I develop a set of recommendations for strengthening multisectoral partnerships and crafting more effective organizational reforms.
I find that there is often a fundamental contradiction between what partners say they want from the organization or want in theory and what they want in day-to-day practice. For example, partners demand greater efficiency and efficacy, while also insisting on extensive voice opportunity and consensus decision-making. Or they expect the partnership to "orchestrate" partners’ activities and improve on-the-ground results, but then are unwilling to sacrifice their own autonomy to achieve coordination. Restructuring fails to address these contradictory priorities and so cannot truly make the partnership fit for purpose. Instead, it serve as a kind of ritual. By "performing" reform efforts, partners reaffirm their normative commitment to principles like efficiency, efficacy, and coordination. And they do it without disrupting the pragmatic realities of life in global governance organizations.
As rituals, reform efforts serve a clear purpose, even if they fail to make the organization more efficient and effective. But they are also costly in time, money, and energy. And over time, repeated reform efforts risk destabilizing a partnership because they reinforce a narrative of poor performance…when really, the organization’s returns are directly commensurate with partners’ investments in it. WHO and other UN agencies undergo similar ritual reform efforts, but apparently without suffering the same destabilizing consequences. This has important policy implications. Over the past 25 years, global health policymakers (particularly donors) have shown a preference for working through partnerships rather than the UN system, which they consider “dysfunctional”. My research suggests that partnerships come with their own forms of dysfunction; in the long run, they may prove less robust and resilient than traditional intergovernmental organizations. In an atmosphere of growing nationalism and isolationism, institutional resilience matters more than ever.
However, I also find that the dangers of ritual reform can be mitigated, or even reversed, under two conditions. First, partners must be on the same page when it comes to their priorities, contradictions and all. Second, those contradictions cannot be so severe that they undermine the partnership’s purpose and legitimacy. Based on these findings, I develop a set of recommendations for strengthening multisectoral partnerships and crafting more effective organizational reforms.
COMMITTEE
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Martha Finnemore (chair); Michael Barnett; Henry Farrell; Suerie Moon
Horowitz Foundation for Social Policy George Washington University Embassy of Switzerland ThinkSwiss Program Brocher Foundation |
PEER-REVIEWED PUBLICATIONS
Pillinger, Mara, Ian Hurd & Michael Barnett. (2016) "How to Get Away with Cholera: The UN, Haiti, and International Law.” Perspectives on Politics 14(1): 70-86.
Pillinger, Mara (2015). “It’s Not Just For States Anymore: Legal Accountability for International Organizations under the Framework Convention on Global Health.” Global Health Governance 9(1):114-130.
Hennink M, Kiiti N, Pillinger M, Jayakaran R. (2012) “Defining Empowerment: Perspectives from International Development Organizations.” Development in Practice 22(2): 202-215.
Harris J, Pillinger M, Fromstein D, Gomez B, Garris I, Kanetsky P, Tebas P, Gross R. (2011) “Risk Factors for Medication Non Adherence in an HIV-Infected Population in the Dominican Republic.” AIDS and Behavior 15(7):1410-5.
Pillinger MH, Marjanovic N, Kim SY, Lee YC, Scher JU, Roper J, Abeles AM, Izmirly PI, Axelrod MJ, Pillinger MY, Tolani S, Dinsell V, Abramson SB, Blaser MJ. (2007) “Helicobacter pylori stimulates gastric epithelial cell MMP-1 secretion vis CagA-dependent and independent ERK activation”. Journal of Biological Chemistry 282(26):18722-31
Pillinger, Mara (2015). “It’s Not Just For States Anymore: Legal Accountability for International Organizations under the Framework Convention on Global Health.” Global Health Governance 9(1):114-130.
Hennink M, Kiiti N, Pillinger M, Jayakaran R. (2012) “Defining Empowerment: Perspectives from International Development Organizations.” Development in Practice 22(2): 202-215.
Harris J, Pillinger M, Fromstein D, Gomez B, Garris I, Kanetsky P, Tebas P, Gross R. (2011) “Risk Factors for Medication Non Adherence in an HIV-Infected Population in the Dominican Republic.” AIDS and Behavior 15(7):1410-5.
Pillinger MH, Marjanovic N, Kim SY, Lee YC, Scher JU, Roper J, Abeles AM, Izmirly PI, Axelrod MJ, Pillinger MY, Tolani S, Dinsell V, Abramson SB, Blaser MJ. (2007) “Helicobacter pylori stimulates gastric epithelial cell MMP-1 secretion vis CagA-dependent and independent ERK activation”. Journal of Biological Chemistry 282(26):18722-31
FORTHCOMING PUBLICATIONS
Pillinger, Mara. “Sustaining Partnerships: The GPEI Case.” In Andonova, Liliana B., Moira V. Faul, & Dario Piselli, eds. Partnerships for Sustainability: Pathways to Effectiveness. Routledge Press.
Pillinger, Mara. “Understanding the World Health Organization’s Response to COVID-19.” In Great Decisions 2021. Foreign Policy Association.
Kavanagh, Matthew M., Benjamin M. Meier, Mara Pillinger, Hanna Huffstetler, & Scott Burris. “Global Policy Surveillance: creating and using comparative national data on health law and policy.” American Journal of Public Health.
Kavanagh, Matthew M., Ellie Graeden, Mara Pillinger, Renu Singh, Stephanie Eaneff, Victoria Benaud, Taavi Erkkola, & Peter Ghys. “Understanding HIV-Related Law & Policy Environments Across Countries: Data to Improve the AIDS Response.” BMJ.
Pillinger, Mara. “Understanding the World Health Organization’s Response to COVID-19.” In Great Decisions 2021. Foreign Policy Association.
Kavanagh, Matthew M., Benjamin M. Meier, Mara Pillinger, Hanna Huffstetler, & Scott Burris. “Global Policy Surveillance: creating and using comparative national data on health law and policy.” American Journal of Public Health.
Kavanagh, Matthew M., Ellie Graeden, Mara Pillinger, Renu Singh, Stephanie Eaneff, Victoria Benaud, Taavi Erkkola, & Peter Ghys. “Understanding HIV-Related Law & Policy Environments Across Countries: Data to Improve the AIDS Response.” BMJ.
PRESENTATIONS (selected)
"Organizing Polio: Has Restructuring the Global Polio Eradication Initiative (GPEI) Improved Performance?" International Studies Association Annual Meeting. April 4, 2018. San Francisco, CA.
"Pre-empting the Compatibility Problem: How Multisectoral Cooperation Can Undermine Pandemic Responses to and What To Do About It." Prince Mahidol Award Conference. January 29-February 3, 2018. Bangkok, Thailand.
“Legal Accountability for International Organizations?” Harvard Medical School Center for Global Health Delivery.
September 16, 2017. Cambridge, MA.
"WHO Answers to Whom?: The World Health Organization’s Multi-Stakeholder Problem & Its Implications for IR Theory." International Studies Association Annual Meeting. February 24, 2017. Baltimore, MD.
"Food & Drugs: Comparing Global Anti-Hunger & Anti-HIV Activist Campaigns". International Studies Association Annual Meeting. March 17, 2016. Atlanta, GA. Co-authored with Michelle Jurkovich.
"The Force of Ought: Norms and Coercive Power in International Bargaining". International Studies Association Northeast. November 6, 2015. Providence, RI.
“Excuses, Excuses: Sovereignty, Noncompliance and Rhetorical Coercion in Global Health Governance.” International Studies Association Annual Meeting. February 20, 2015. New Orleans, LA.
“Law and Irresponsibility: The UN Cholera Epidemic in Haiti.” International Studies Association Annual Meeting. March 28, 2014. Toronto, CA. Co-authored with Ian Hurd (presenter) & Michael Barnett.
“‘I Know It When I See It’: Empowerment from the Perspective of Development Organizations.” American Public Health Association Annual Meeting. November 9, 2009. Philadelphia, PA.
“The Intersection between Religion, Health and Empowerment.” African Religious Health Assets Program. July 13-16, 2009, Cape Town, South Africa. Co-authored with Kiiti N (presenter), Hennink M, Smith WM, Min D, & Jayakaran R.
“Risk Factors for Medication Non-Adherence in an HIV-Infected Population in the Dominican Republic.” International Association of Physicians in AIDS Care (IAPAC) 3rd International Conference on HIV Adherence. March 17-18, 2008. Jersey City, NJ. Co-authored with Harris J, Pillinger M, Gomez B, Garris I, Kanetsky P, Tebas P, & Gross R (presenter).
"Pre-empting the Compatibility Problem: How Multisectoral Cooperation Can Undermine Pandemic Responses to and What To Do About It." Prince Mahidol Award Conference. January 29-February 3, 2018. Bangkok, Thailand.
“Legal Accountability for International Organizations?” Harvard Medical School Center for Global Health Delivery.
September 16, 2017. Cambridge, MA.
"WHO Answers to Whom?: The World Health Organization’s Multi-Stakeholder Problem & Its Implications for IR Theory." International Studies Association Annual Meeting. February 24, 2017. Baltimore, MD.
"Food & Drugs: Comparing Global Anti-Hunger & Anti-HIV Activist Campaigns". International Studies Association Annual Meeting. March 17, 2016. Atlanta, GA. Co-authored with Michelle Jurkovich.
"The Force of Ought: Norms and Coercive Power in International Bargaining". International Studies Association Northeast. November 6, 2015. Providence, RI.
“Excuses, Excuses: Sovereignty, Noncompliance and Rhetorical Coercion in Global Health Governance.” International Studies Association Annual Meeting. February 20, 2015. New Orleans, LA.
“Law and Irresponsibility: The UN Cholera Epidemic in Haiti.” International Studies Association Annual Meeting. March 28, 2014. Toronto, CA. Co-authored with Ian Hurd (presenter) & Michael Barnett.
“‘I Know It When I See It’: Empowerment from the Perspective of Development Organizations.” American Public Health Association Annual Meeting. November 9, 2009. Philadelphia, PA.
“The Intersection between Religion, Health and Empowerment.” African Religious Health Assets Program. July 13-16, 2009, Cape Town, South Africa. Co-authored with Kiiti N (presenter), Hennink M, Smith WM, Min D, & Jayakaran R.
“Risk Factors for Medication Non-Adherence in an HIV-Infected Population in the Dominican Republic.” International Association of Physicians in AIDS Care (IAPAC) 3rd International Conference on HIV Adherence. March 17-18, 2008. Jersey City, NJ. Co-authored with Harris J, Pillinger M, Gomez B, Garris I, Kanetsky P, Tebas P, & Gross R (presenter).