Setting a Developing Country Agenda for Global Health
(excerpts)
[In May 2008, the Global Economic Governance Program of Oxford University brought together a group of current and former health ministers and senior health officials from developing countries to discuss gaps and challenges they face in dealing with current global health financing and governance arrangements. This short report summarizes key points emerging from the meeting.
Over the course of the meeting, participants voiced their frustrations with the current state of health assistance. Already, within countries health policy-makers face strong incentives to prioritize clinical care and infectious diseases and to under-fund prevention and wider inter-sectoral health issues such as access for the poor to health services and maternal mortality. Crucially, national health strategies need to aim at stronger health systems. However, far from helping to correct this imbalance, at present, donors are exacerbating and magnifying it].
*1. Too many new initiatives: donors need to learn to `stay the course':*
At the international level, a constant deluge of new initiatives, focusing on specific diseases or issues makes it extremely difficult for governments to develop and implement sound national health plans for their countries. "Countries are being jostled from one initiative to another. We need to reverse the situation. It is the moral duty of international community to accept developing country leadership".
Donors shift attention from one issue to the next without working to build capacity or 'stay the course.' Too often donors want to 'plant their flag' and take credit for moving health forward. Often the same countries are involved in several such initiatives at any one time.
*Solutions?*
Containing donors' enthusiasm for launching new initiatives is difficult, but a few donors – the Gates Foundation and the Global Fund were mentioned – are beginning to recognize the need to support underlying health systems. In the face of powerful incentives for donors to pursue vertical strategies, one suggestion made was: "A step forward would be for a percentage of all donor funds going into initiatives, especially vertical program, to be earmarked for health systems development".
Another solution which improves the possibilities for a national health strategy is pooled or 'basket' funds in Ministries of Health which are seen as creating policy space for the ministry.
Debt relief has also been identified as assisting countries in moving towards self-sufficiency in financing health. "Nigeria finally got debt relief … that will not give you money, but what you are setting aside to service your debt is now available for local spending. In 2006, that money was set aside, but not just set aside, the Ministry of Health was given 21% of that money on top of the regular policy".
In addition, South-South cooperation with the emerging powers, such as between Mozambique and Brazil on HIV/AIDS, was seen as a positive way forward as well as providing an alternative to the traditional donors.
*2. National strategies are being weakened by parallel priorities and implementation directed by donors*
Too often donors find or direct their own ways of implementing initiatives in-country, thereby distracting from, weakening, and neglecting national health strategies and systems. The World Bank was cited by several Ministers as a very poor donor, dictating how money is used, how programs should be implemented, and how evaluation and monitoring should be undertaken. This has led some governments to choose not to take World Bank assistance. "Donors should not be Intrusive". "We want to work with them [the donors] not to be told what to do by them".
Even assistance which has been explicitly aimed at strengthening local capacity falls prey to the problems of donor over-direction. In some countries, capacity-building assistance directed by donors results in a plethora of workshops which draw key staff members away from the ministries where they are most needed.
Hiring of international consultants often provides undesired technical assistance. "Hiring highly paid consultants from outside, a lot of money goes back to those consultants. So why not use our own consultants, who are national, who are equally competent, who know the country well".
Much funding is used for technical assistance which is sometimes unwelcome. "From our assessment, it was only 40% of World Bank aid that has tangible benefit. The other 60% is in the form of technical assistance".
*Solutions?*
Negotiating with donors identifying leadership at the country level and a clear national strategy. "We understand the problem better than our partners and also we understand the priorities – where we need to put the resources". "We have a program. Whoever wants to help must swim with us in the program".
Sticking to the strategy and strong leadership can be undermined by the fear of donors walking away and moving resources to another country. For heavily donor-dependent countries this is a stark alternative. Reflecting on the refusal of PEPFAR to participate in the national approach agreed to by all other donors, one minister noted "We have never put our foot down. We fear. We are cowards."
Ministers of Health and senior advisors need to convince other ministries and sectors of the importance of investing in activities which impact health. Policies that have the most impact in terms of ensuring good health and preventing illness often lie outside the health sector. The domain of Ministries of Health is predominantly treatment, resulting in an under-emphasis on preventive activities at the country level.
Once governments have the space to set their own policies, participatory multi-stakeholder mechanisms can then be used to ensure that policies reflect the needs of the people. A particularly successful example of a participatory process for setting health priorities is the creation of a National Health Assembly:
"The Thai National Health Assembly brings together citizens from all parts of the country, civil society and parliamentarians to collectively decide on policies".
Similarly, the National Human Rights Commission of India which holds public hearings on the access to health and has been used to hold state officials responsible for ensuring the health of their constituents.
"Unless the planning process becomes more broad-based, the priorities may not appropriately reflect the societal needs. This is problematic if governments progressively abdicate their responsibility for stewardship of the health system, with increasing economic liberalization".
*3. Too little transparency and information about aid activities: donors must learn to report fully to developing countries.*
Severe lack in donor accountability has resulted in little progress on improving health assistance. Donors seldom report fully on what they are doing.
"Donors talk a lot about transparency and accountability, but they themselves do not practice this".
Serious problems arise for planning when there is no accurate information provided to the government about the scope of donor activities.
There is a lack of transparency from donors about the quantity of aid flowing into the country and how it has been used. Part of the difficulty is that recent initiatives, such as PEPFAR and the Gates Foundation, disburse funds directly to NGOs. This makes it difficult for Ministries to plan their efforts as they do not know which NGOs are already receiving funds, and also the purpose of and region where the funds are being used.
An accounting for that part of aid which remains in donor countries is equally necessary. At the joint review with donors each year, recipient governments have no way to know if, or how much money, has actually reached their country. Donors often accuse developing countries of corruption and mismanagement of funds, yet developing country officials note that funds `leak' at the donor end of the equation.
Country experience highlights that information sharing also needs to extend into health research.
Moreover, the same donors adopt strategies which vary across countries: in some instances supporting health system development and in others undermining it. While in Tanzania the activities of PEPFAR and the PMI are governed by USAID which sits within the caucus of development partners, in Uganda PEPFAR and the PMI insist on remaining absolutely separate from other donors.
*Solutions?*
It would be very useful for recipient countries collectively to evaluate and compare donor activities and practices across different countries. While the Paris Declaration, and the principles of ownership and support for national development strategies take the right steps towards accountability, the problem lies in implementation. For example, no institutions monitor donor programs and practices at both the global and national level. "They [donors] like to monitor activities, but they do not like to be monitored and evaluated".
Donor coordination has been happening for years, but continues to lack a genuine respect for country ownership.
The World Health Organization has become dependent on donor funds and thus cannot serve to independently monitor donors. "The major international organizations are being distracted. They are looking for money because they are judged by the way they are mobilizing money. They are not guided by what has to be done".
WHO's limited budget, lack of mandate for primary research, sparse technical capacity and its need to derive its mandate from countries, does not allow it to take on such a political task. It is a bureaucratic institution controlled by certain donor countries. Several participants pointed to the key role of academia in serving as independent evaluators of donors providing information on current practices. However, even the most reputable universities are heavily dependent on donor funds, and thus cannot be seen to be objective and impartial. The challenge of maintaining the independence of researchers and academic institutions in the face of vast concentration of funding from the same donor(s) is a tough one.
Countries could come together to 'name and shame' the major violators of the Paris Declaration. "What happens is there is an exploitation of weaknesses in countries. If the donors see that in country A there has strong leadership, and direction on what they should do, they are not going to mess around. They go to another country where they can do things differently and that country will accept. We need to get a grouping of countries with one voice, that say 'if you want to deal with us let us be together, and what we have to achieve is the country's benefit, not the donor's A, B or C". "We need to provide a 'collective defense' for developing countries".
A possibility is grouping the 68 countries failing to meet MDGs four and five to consult one other and coordinate before major meetings. Also, civil society needs to help bolster the capacity of countries to form such coalitions.
*To monitor progress on global health goals, d*onors and recipients could each nominate two representatives to sit on a taskforce, chaired by an academic.
*To set ethical standards for health assistance, *a universal code of conduct on health assistance that is based not just on efficiency, but on ethics could also help; such a code would progress best if it can be taken to the highest levels of the UN.
To proceed with either of these initiatives, further analysis is needed to provide an evidence-base for what kinds of donor assistance are most effective, to provide tracking of grants from commitment to actual impact on-the-ground, to provide information on the quantity of donor financing in-country, and provide further documentation on the case for health.
*Participants*
Brazil, Nigeria*, *Indonesia, Uganda, Nepal, Tanzania, Kenya, Ecuador,
India, Egypt, Mozambique, Thailand, Indonesia. (Minister of Health)
For the Oxford Working Group*:*
*Rajaie Batniji, Harold Jaffe, Devi Sridhar *and* Ngaire Woods. *
Further updates will be available at www.globaleconomicgovernance.org along with video of a public panel featuring the Working Group. Please direct queries to the Global Economic Governance Programme.
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geg@univ.ox.ac.uk