Action For Global Health/ DSW
Fact-finding Visits 2010/2011
Outcomes
7 June 2011
Fact-finding team meeting stakeholders
Presentation Outline
1- Ownership and Civil Society/
Parliament Participation
2- Donor Coordination, aid
structures and their impact
on health spending
3- Managing for Results:
The role of aid forprogress towards the MDGs
and for universal access to primary
healthcare
1- True democratic ownership – 7 key steps
1. DEMOCRATIC OWNERSHIP: Recognize CSOs as true
partners and independent actors for development, not
sub-contractors/ entities of the govt
“Mass org.” in Vietnam: Prevent hand-picking of
participants by govt! – EC Delegation Vietnam.
2. SHARED RESPONSIBILITY among govt, donors and
CSOs FOR MEANINGFUL ENGAGEMENT of representative
diversity of non-state actors.
3. TRANSPARENCY AND CONTEXT-ADAPTED COMMUNICATION
IATI: Vietnam MoH suggestion: Sector ODA Database
Mozambique: government electronic state financial
administration system (E-SISTAFE) and ODAMOZ
Online discussion: “international aid programme meeting
point”; a platform for donor/CSO exchange of information.
1- True democratic ownership – 7 key steps
4. CAPACITY FOR DIALOGUE
CSOs: Pooled funding of EU donors for CSO capacity
building.
CSSM Moz, IDF Ug. – but: high admin. Costs.
Donors: Lack of Staff/ health expertise (
EC Tanz.)
5. REPRESENTATIVE ACTORS: CSO Platforms; Global
Fund’s CCM elections as best-practice
model
India CCM replication – A “Western Model?”
6. Representation at ALL LEVELS, not only fora or technical
WGs, but highest level policy-making instances.
Tz, Ug., Moz.: Health policy advisory committees
El Salvador: CISALUD
7. FOLLOW-UP: make recommendations binding!
El Salvador: CISALUD and National Health Forum
2- Health aid Coordination – Mission impossible?
• ACP countries: progress - middle-income countries:
lacks attention
• Often parallel coordination for HIV/AIDs and Health
• True govt leadership questionable (particularly: ACP
countries with high aid dependency)
• Process-oriented – funding commitments to health plans?
• Complexity and increased workload
SWAps: no option for India, Vietnam, El Salvad.
Donors with no presence in country increase complexity.
• Lack of meaningful engagement of Civil Society (all)
– lack of coordination of CSO projects (all)
• Process is too centralized – positive donor coordination at
local level:
El Salvador, RECODEL; Vietnam: EC health
coordination at province level.
How to make coordination possible: IHP+?
• International Health Partnership and related
initiatives (IHP+)
www.internationalhealthpartnership.net
• Eg. Related initiatives: Health Matrix Network =
a global partnership to address the lack of reliable
health information in developing countries.
• Over 50 members, including partner countries,
Civil Society and Development Partners
• IHP+ Principles: One Plan, One Budget, One
M&E
• Through Joint Assessment National Strategies,
Country Compact, Joint Financing Agreement.
How to make coordination possible: IHP+?
• IHP+ = opportunity for alignment of all donors and aid
modalities with National health policy.
Country Compact Mozambique – GAVI, USAID,
GFATM and CSOs signed on.
• IHP+ Validation leading to increased funding from
donors for health policies
HRH Policy Mozambique.
• Added value in some middle income countries with no
Health SWAp
Vietnam; El Salvador (clear interest from MoH).
• IHP+ seen as an additional burden in countries with
well-functioning SWAp
Tanzania.
• CSO participation in IHP+ processes deficient
Vice Health Minister El Salvador on IHP+: Where do I sign?
How about Division of Labour?
• EU Code of Conduct on Division of labour in
Development Policy – Principles:
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2007:0072:FIN:EN:PDF
• EU donors will focus their activities on two focal
sectors on the basis of their respective
comparative advantages
• Max. 3 donors per sector by 2010.
• Delegated cooperation/partnership:
If a given sector is considered strategic for the
partner country or the donor and financing gap:
funds to be delegated to another focal sector
donor.
How about Division of Labour?
• Division of Labour (DoL) often not a reality: focal
and non-focal sectors in all fact-finding
countries.
• DoL should not become a “sector exit strategy”
(High-level European DP representative in Moz.)
• Is DoL a donor or recipient country priority?
Strong govt call for harmonisation, not DoL.
El Salvador: 22 vertical programmes and 60
different disbursement systems. If harmonised,
could reduce health funding gap, while DoL is
likely to increase gap.
Best Aid Modality for reaching Health MDGs?
• European DPs interviewed in Mozambique:
“Trying to establish a ranking of best aid modalities
is artificial in itself as there is a need for both shortterm results and long-term impact of aid”.
• Country-context: General Budget Support (GBS)
not always best model - middle-income countries?
MoH in Vietnam: “Budget support is yet another
donor fashion – don’t finance by fashion, but by
needs and capacities!
[...] Japan’s targeted project or programme support
is very effective and aligned with our policies”
Best Aid modality for reaching the Health MDGs?
• Many GBS donors also provide SBS - recognise the
limitations of the GBS in ensuring funds for
frontline service delivery
Tanzania
• GBS fails to address culturally sensitive issues –
HIV/AIDs, SRHR, Civil Society
Ug., India, Vietnam
• Biggest Health donor USAID/ PEPFAR: despite
recent reforms towards HSS, claims for traceability:
MoH Vietnam: “They want their money to be known
as their money”.
Uganda: USAID funding
agreements with districts for health workers pay
• EU-US dialogue: IHP+ as opportunity for alignment,
not necessarily Budget Support.
GBS and Health as an Investment
• Health considered “non-productive” instead of an
investment
Tanzania: New PRSP allocates 10% less
funding to health than in 2008/9 – growth: +14%.
Ug., Tz., Moz.: Share of health sector in national
budget stagnated at 9-12% during the last 3 years about 40% of the health budget = external funding.
Domestic share: 6-8%.
• Per Capita spending:
Uganda: USD 10 (2008/9).
Tanzania: USD 14 in 2010/11 (estimates).
Mozambique: USD 18 in 2008.
• Health funding gap of ca. 25% in ACP countries
Tanz. PHC programme: ca. 50% funding gap in 2010.
El Salvador: Health reform needs of EUR 100 million
Mozambique rural hospital: 2 of 3 nurses for 45.000 people
Hospital Laboratory Mozambique - Scarcity of equipment
How to promote domestic investments in health
• Ensure that Ministry of Health and health
accountability stakeholders (Parliamentary
Health Committees, CSOs) are to donor policy
dialogue processes involving the government.
• Avoid fungibility – use Abuja Declaration and
WHO/ PAHO per capita spending targets as GBS
indicators in order to increase domestic funding for
health.
• Avoid economic conditionality: the EU should act
within the governing bodies of the Bretton Woods
institutions to ensure fiscal space is granted to
the social sectors in general and the health
sector in particular
Ugandan MoF.
Vertical Funding for health – Example GFATM
• GFATM creation as “neutral” funding entity for three
“disease emergencies”: became single biggest
external source of funding to health in many
countries
Uganda, Tanzania: over 50%
• Global Fund put on budget both in Tanzania and
Mozambique = only about 50% disbursed in some
years – accountability problems
• On-budget GFATM funding led to distortion of
domestic funding to health - mainly HIV/AIDs
funding
• MoH decided to put it off budget again in 2009 –
caused drop in govt health expenditure: 13% - 11%.
Vertical Funding for health – Future of GFTAM
• Diseases approach: Suitable for middle-income countries?
El Salvador, where HIV/AIDs rate under 1%, and
75% of diseases are non-communicable.
Vietnam: 62% of morbidity to non-communicable
diseases.
India: TB on the rise; HIV and Malaria: high.
• Funding gap for HIV/AIDS – especially for preventionprevails – Not enough investment in health in general!
• Impact of recent GFATM reforms not yet visible at country
level – reform of structures needed (HQ decisions)
• Future? DPs/ govt: GFATM should not engage in HSS due to
lack of country presence. Added value of GFTAM in rapid
procurement vs. cumbersome govt. systems.
HIV/AIDs Awareness-raising in Mozambique
Project Support for health
Complementarity: CSO projects as “labs of
experience” and “models of intervention”
online discussion
Ug., Tz.: 40% of health services provided by
CSOs – key role in service delivery and expertise in
reaching the most marginalized.
Vietnam: EC evaluation: CSO health projects
scored best in terms of results, even though their
impact may not be as extensive as BS
Moz: NGOs call for more funding for integrated
and community-based approaches to health,
complementing govt and private sector services.
3. Managing for Results – Not financing BY Results!
• GBS and progress indicators. Progress, not process
Moz. Global Fund scorecard evaluation: Low health
scores despite immense progress
• Funding by performance, not impact: Ex: number of
condoms distributed instead of number of teenager using
condoms. Final aim to change behaviours or to tick boxes?
• Same risk for Cash-on-Delivery: Social sectors receiving
less funding for producing less results – can you weigh lives
against scorecards?
• New results-based financing initiatives in the health
sector: may undermine country ownership and health
systems strengthening.
Iniciativa Mesoamericana,
El Salvador: criticized for top-down disease-approach.
How can we trust the results?
Weaknesses in national reporting systems.
Ug.: Different data sources; cut-off points in time
between departments within MoH
DPs in Tanzania/ Ug. confirm OECD and CoA findings:
“Performance monitoring in the health sector faces problems
of reliability and timeliness of health information”.
Lack of health expertise on donor side (eg. EC Ug, Tz)
Ug.: Over-reporting at district health centre level.
Vietnam: Vaccination rates over-reported/ optimistic.
EU Del. Ug. and Moz. CSSM representative: “A need for
donor support for CSO shadow reports”.
Support social auditing at community level – El Salv.
El Salvador: Need for unified health information system
Thank you for your attention!
Contact: Sibylle Koenig
– sibylle.koenig@dsw-brussels.org –
Action for Global Health:
www.actionforglobalhealth.eu
DSW Brussels:
www.dsw-brussels.org
DSW resources:
www.euroresources.org