- Improved Aid for Better Health – Recommendations from the Busan Health Working Group For the HLF-4 and beyond 29 September 2011
The Importance of Health Aid Good health is vital to human welfare and to continued economic and social development. Realisation of the universal human right to health is inextricably linked to the amount and the effectiveness of aid. Most aid recipient governments are doing their best to achieve universal access to health, but require external funding to fill gaps between funding needs and their own resources. For example, in Tanzania foreign aid represents nearly 40% of the health sector budget.1 Donors have been increasingly filling health sector funding gaps: Development assistance for health grew considerably over the last two decades, from $6 billion in 1990 to $22 billion in 20072. However, an additional US$36-45 billion is required annually to meet the health-related Millennium Development Goals (MDGs) by 20153. These include MDG 4: Reduce child mortality; MDG 5: Improve maternal health and achieve universal access to reproductive health; and MDG 6: Combat HIV/AIDS, malaria and other major diseases. Currently the bulk of the health funding is targeted at HIV/AIDS, Malaria and infectious disease control, although funding for HIV is currently decreasing4. Sectors such as family planning have seen a decline in funding levels, despite the increase in numbers of women with an unmet need for family planning.5 Moreover, additional funding is required for other key social sectors that impact on human health such as nutrition, water and sanitation, gender equality and primary education.
Aid Effectiveness in the Health Sector Health is at the forefront of the debate on what aid effectiveness means from a sector perspective. In the 1990s donors and governments created Sector-Wide Approaches (SWAps) to improve harmonization, predictability of aid and donor alignment behind national health programmes. In recognition of the need to address the growing complexities of aid programmes, in 2005 the international community endorsed the Paris Declaration on Aid Effectiveness, and the subsequent 2008 Accra Agenda for Action. In the health sector, efforts to promote donor coordination, alignment, and country ownership have resulted in a number of initiatives such as the International Health Partnership and related initiatives (IHP+)6. While donors have made efforts towards aid effectiveness in the health sector, several problems remain. The challenges are complex and include insufficient funding, weak links between investments and health outcomes, and a lack of strong political will to invest in the health sector by Ministries of Finance in aid recipient countries. These challenges have been compounded by increasing complexity in the number of external actors in the health sector and a proliferation of different financing mechanisms, resulting in high transaction costs for Ministries of Health. Insufficient attention to equity and financial sustainability are also persistent problems in the sector.
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Koenig, S. and R. Rosenquist. 2010. Institute for Health Metrics and Evaluation, 2011. 3 Taskforce on Innovative International Financing for Health Systems, 2009. 4 Kates et al. 2011. 5 OECD, QWIDS, accessed 6 September 2011. 6 Other examples of efforts to improve aid effectiveness in sectors that impact health outcomes include the Sanitation and Water for All partnership, and Comprehensive Africa Agriculture Development Programme. 2
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In light of this context, the Busan Health Working Group has developed a set of key recommendations for the Fourth High Level Forum on Aid About the Busan Health Working Group Effectiveness in Busan (HLF-4), to improve aid in the health sector and speed progress towards the healthThe Busan Health Working Group is a related MDGs and related sectors that influence health coordinating platform for civil society advocating for health to be recognized as an outcomes. The Working Group developed these integral issue in development, and highlighting recommendations based on documented evidence and lessons learned from the health sector to consultations with a wide variety of stakeholders inform aid effectiveness policy discussions at working in the health sector, including civil society and the High Level Forum on Aid Effectiveness in development partners in the global South and North. Busan. The recommendations consolidate the conclusions and Working Group members are Action Against outcomes of a number of important events in the health Hunger (ACF UK), Action for Global Health community during the last two years in preparation for European NGO network (AfGH), Asia Pacific 7 Busan . Alliance for Sexual and Reproductive Health The recommendations are meant to complement and reinforce the general Civil Society Organization (CSO) Positions as presented by BetterAid, the CSO Open Forum and other aid networks. The lessons learnt from a sector which has captured much of the attention from the donor community during the last decades should also help other sectors draw their own conclusions for a better and more effective use and implementation of development aid.
(APA), Communication for Development Centre, German Foundation for World Population (DSW), Global Health Advocates (GHA), members of the IHP+Civil Society Representatives; International Planned Parenthood Federation (IPPF), International HIV/AIDS Alliance,Population Action International (PAI), Save the Children International, SightSavers, Stop AIDSAlliance and WaterAid
Busan-Specific Recommendations In the immediate term, we urgently call for delegates reviewing experience in aid effectiveness at the HLF-4 to highlight lessons from the health sector by: • [Recommendation 1] Ensuring health is featured prominently in Busan, including by supporting the inclusion of the International Health Partnership and other Related Initiatives (IHP+) and Commission on Information and Accountability for the UN Secretary Generals Global Strategy for Women and Children’s Health as Building Blocks after Busan. Health should continue to be a tracer sector in the post-Busan governance and monitoring framework.
Aid Effectiveness Recommendations In continuing to pursue aid effectiveness in Busan and beyond, we call urgent attention to the following challenges that are creating obstacles for the realisation of aid effectiveness in the health sector, and slowing progress towards reaching the health-related MDGs. A. Ownership and Participation One of the core principles of the Paris Declaration and Accra Agenda for Action is ownership. However, the principle of ‘ownership’ is not being defined or operationalised as it was originally intended. All too often, ownership is narrowly interpreted as ‘government’ ownership driven by Ministries of Finance,
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See the references section for materials from these events.
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which may have limited appreciation of the needs and priorities in the health sector8. CSOs, Parliamentarians, and academia and are often excluded from health policy decision making. In many cases, CSOs are not even aware of the major policy processes and mechanisms that have been put in place to enable their participation. Where mechanisms to include non-state actors are in place, governments tend to hand-pick a select group to engage with, and often fail to engage with local CSOs that represent marginalised and vulnerable groups. Lack of transparency also undermines CSO participation, and contributes to CSOs being unable to monitor funding intended to benefit the communities they represent. In health, democratic and fully inclusive country ownership requires that: •
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[Recommendation 2]: Bilateral and multilateral donors, and partner country government representatives involved in aid negotiations facilitate the meaningful engagement of parliamentarians and civil society, particularly those that represent the most marginalised and vulnerable groups. This implies ensuring their systematic and formalised representation at the early stages of planning and consultations related to any national development plans, health sector plans, budget support, and SWAps. [Recommendation 3]: Partner’s countries should promote an enabling environment by having legal frameworks in place that guarantee the space, transparency and conditions necessary for CSOs to meaningfully participate in decision-making.
Though they can still be improved, the IHP+ Joint Assessment of National Strategies (JANS) and Global Fund for HIV/AIDS, Tuberculosis and Malaria Country Coordinating Mechanisms (CCMs) are good examples of frameworks to foster broad stakeholder engagement in health planning, implementation and monitoring processes. B. Donor coordination and alignment The health sector provides a compelling example of the need for greater donor coordination. Over the past two decades, the number of donors, financing and delivery mechanisms in global health has grown exponentially. There are now more than 100 global partnerships in the health sector alone, with 80% of donors providing just 10% of total assistance9. Each of these donors has its own particular, and often conflicting, method of aid delivery, monitoring and evaluation framework and timeframe. The result is chaotic and expensive for the intended beneficiaries, with Ministries of Health being overwhelmed by the weight of administration required to manage donor relationships and meet donor requirements10. Efforts to address these challenges through improved donor coordination and alignment can also be problematic. To improve donor aid for better health outcomes, the Busan Health WG recommends that donors: •
[Recommendation 4]: Provide aid through a mix of modalities based on the country context11. In deciding where to use General Budget Support, donors should prioritize countries with strong and equitable and comprehensive national development and health strategies developed through inclusive processes. Donors should consider sector budget support and project support as a complement or even alternative to general budget support in countries where government commitment to the social sectors and particularly health is low, and where the needs of marginalised and vulnerable groups are often not prioritised in national policy and funding priorities.
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See Clarke and Ostrowski 2009 for recommendation to improve understanding between Ministries of Finance and Health. Development assistance is understood as fragmented when there are more than 15 donors between them providing less than 10% of the country’s programmable aid. 10 See for example, AfGH. 2011. Health Spending in Mozambique: Impact of Current Aid Structures and Aid Effectiveness. 11 In weighing options with country partners, donors should also take into account the quality of a country’s Public Finance Management systems, credible mechanisms for budget allocation and decision-making, transparency, and accountability over the use of funds. 9
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[Recommendation 5]: Increase donor coordination and alignment with country priorities in the health sector. The IHP+ may be used as a tool for aligning all aid modalities to a country’s health priorities, according to three core principles: one health plan, one budget and one M&E framework. Best practices and lessons learnt from IHP+ implementation at country level may be applied to aid effectiveness processes within other sectors.
Donor efforts to better coordinate through institutionalising ‘division of labour’ has in some cases resulted in cuts to Official Development Assistance (ODA) in general and health aid in particular. For example, following the implementation of the Division of Labour, European Commission (EC) health aid decreased from 4.7% of total EC aid in 2005 to 1.3% in 200812. •
[Recommendation 6]: Donors should use transparent criteria when applying Division of Labour to decisions regarding staying in or withdrawing from a partner country or sector. The decision should be agreed with aid recipient governments in consultation with CSO representatives. Donors should work together to ensure that development assistance to health, particularly services for the most marginalised and underserved groups will not decrease.
One way to harmonize donor approaches is through strengthening the European Union-United States dialogue on global health and aid effectiveness, including agreeing on a timeline for results and harmonising indicators and data collection in pilot countries. C. Managing for Results Aid should have a significant impact on country progress towards the health MDGs, universal access to primary healthcare and the right to health. Results-based financing programmes have the potential to ensure that aid brings better results, but their success depends heavily on program design and implementation. It is important to identify results indicators that reflect the specific needs, rights and social realities of intended beneficiaries. Reductions in aid due to poor performance or problems with data should not exacerbate inequities. One of the main risks of focusing on results is a de-prioritisation of interventions that bring changes over longer periods of time, such as health and community systems strengthening, behavioural change, preventative medicine, research and access to healthcare for stigmatised and marginalised populations. Impact should always be the focus and thus managing for results to achieve good long term development outcomes should not be confused with financing by results in the short term. In order to improve results in the health sector, the Busan Health WG recommends that donors and aid recipient governments: •
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[Recommendation 7]: Ensure that the indicators used to measure aid results are developed through a careful and inclusive process with intended project beneficiaries including civil society. Indicators should: measure progress/impact and not just output/activity performance; directly relate to national health plans; be locally defined and able to reflect internal diversity (social/demographic, economic); prioritize health-specific and gender-sensitive qualitative and quantitative indicators, reinforce agreed targets such as those in the MDGs, Abuja Declaration, Maputo Plan of Action, International Conference on Population and Development, Beijing Declaration, and Secretary General’s Global Strategy for Women and Children. [Recommendation 8]: To improve development results, strengthen linkages between health and other development sectors and increase policy coherence with non-development
Action for Global Health 2011A.
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sectors. In particular, they should encourage cross-sectoral cooperation and linkages between health, water, sanitation, nutrition and other relevant sectors, as well as coherence with trade policies, in order to effectively address the social determinants of health and reduce current burdens on healthcare systems. Integrating or linking programs within the health sector, such as reproductive health and HIV, can also improve health outcomes. [Recommendation 9]: Remove user fees for health services, to achieve universal health service coverage. Abolishing user fees reduces financial barriers to health services for the most vulnerable groups. However, increased access must not come at the expense of quality of care. Governments, donors, or other private sources (e.g. insurance) must fill any shortfalls in funding from the removal of user fees to support medical providers and facilities, and ensure availability of medical supplies. [Recommendation 10]: Accountability is considered to be the key for increasing equitable improvements in health outcomes but results are mixed regarding the implementation of the mutual accountability principle. All stakeholders need to strengthen individual mutual and public accountability to facilitate full participation in the improvement of health outcomes. Transparency, access to information, and an enabling environment for all stakeholders including civil society fosters accountability over the use of aid and government funds, which can contribute to better health outcomes.
References Action for Global Health and DSW. 2011. Concluding Notes and Recommendations from two joint stakeholder roundtable meetings on health aid effectiveness. Action for Global Health. 2011A. Aid Effectiveness for Health: Towards the 4th High Level Forum, Busan 2011. Action for Global Health. 2011B. Aid Effectiveness: Progress and the Status Quo of Democratic Ownership and Meaningful Civil Society Participation in the Health Sector. Clarke, G and and C Ostrowski. 2009. “Improving Ministry of Health and Ministry of Finance Relationships for Increased Health Funding.” Policy Brief. Global Health Initiative, Washington, DC: Woodrow Wilson International Center for Scholars. Dennis, S. 2009. Making Aid Effectiveness Work for Family Planning and Reproductive Health. Working Paper. Washington, DC: Population Action International. IHP+Results. 2011. 2010 Performance Report: Strengthening Accountability to Achieve the Health MDGs. London: Responsible Action UK. Institute for Health Metrics and Evaluation. 2011. Financing Global Health 2010: Development Assistance and Country Spending in Economic Uncertainty. Seattle: University of Washington. Koenig, S. and R. Rosenquist. 2010. Health Spending in Tanzania: The Impact of Current Aid Structures and Aid Effectiveness. Action for Global Health and DSW. For additional reports from fact-finding visits on the impact of aid on health spending in Uganda, El Salvador, Mozambique, India and Vietnam, see: http://www.euroresources.org/afgh.html. Task Team on Health as a Tracer Sector. 2011. Progress and Challenges in Aid Effectiveness: What Can We Learn from the Health Sector? Final Report. Paris: OECD Working Party on Aid Effectiveness. Taskforce on Innovative International Financing for Health Systems. 2009. More Money for Health and More Health for Money.
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