Aid Effectiveness for Health 2011

8/7/2019 Aid Effectiveness for Health 2011

1/40


2/40

ACTION FORGLOBAL H EALTH


3/40

3

CONTENTS

Executive Summary 4

Introduction 6

01 Coordinating health aid: Mission impossible? 8

02 No ownership without civil society 18

03 Managing for results should not mean financing by results 24

Appendix: Trends in health ODA: an update 30

Conclusion 36

Glossary 37

Bibliography 38

Acronyms

Acknowledgements

Action for Global Health would like to thank the many people who contributed to this report,including our consultants Madhusudan Sharma Subedi (Nepal), Elias Salvador Ainadine(Mozambique) and Roxana Mara Rodrguez (El Salvador), and all the civil society andgovernment representatives active in the health sector in Nepal, El Salvador and Mozambiquewho agreed to be interviewed during our fact-finding missions.

Thank you for your hard work every day to make aid effectiveness work.

This report was produced by Action for Global Health and written by Rebekah Webb,consultant.The editorial team consisted of six global health advocacy officers from the Action for GlobalHealth member organisations working in close cooperation with the whole Action for GlobalHealth network.

cover image: Firoz Ahman Firoz/ActionAid

image Lahcene Abib/Mdecins du Monde


4/40

AID

EFFECTIVENESS

FOR

HEALTH

:

:

EXEC

UTIVE

SU

M

M

ARY

ACTION FORGLOBAL H EALTH4

image NellFreemanforthe Alliance

Ensuring that development cooperation is

effective has never been more important as theinternational community seeks to reach theMillennium Development Goals (MDGs) in lessthan five years time. Realisation of the universalhuman right to health is inextricably linked to theeffectiveness of aid. In recent years, the EuropeanUnion (EU) has been committed to reforming itsexternal aid instruments according to theprinciples established by the Paris Declaration onAid Effectiveness (2005) and the Accra Agendafor Action (2008). However, in contradiction tothese efforts towards aid effectiveness, Europeandonors have at the same time allowed funding tohealth and other key social sectors to decreasesignificantly. Of the five largest economies inEurope, only the United Kingdom is currently ontrack to meet aid targets. As a result, total aid forhealth remains well below the levels that havebeen calculated as necessary to reach the healthMDGs.

Currently, the aid effectiveness agenda is havingunintended side-effects for civil society, healthoutcomes and the MDGs that are decidedly

unhealthy, both financially and practically. Threecentral problems require urgent attention:

Donor coordination and alignment

These principles have not always been applied inthe way that they were originally envisaged, andthe impact has not been as strong as it could havebeen. Existing coordination mechanisms arecomplex, time-consuming and often process-oriented instead of impact-oriented. Moreover,division of labour arguments have often beenused by donors in order to cut OfficialDevelopment Assistance (ODA) spending in

general and health aid in particular. Following the

implementation of the Division of Labour,European Commission (EC) health aid decreasedfrom 4.7% of total EC aid in 2005 to 1.3% in20081.

Ownership - Civil society, including Parliament, islargely excluded from health policy decision-making. Where mechanisms to include non-stateactors are in place, governments tend to hand-picka select group to engage. The principle ofownership is not being defined or operationalisedas it was originally intended, to the detriment of

health outcomes. European donors are not usingtheir weight adequately to insist on greaterinvolvement of civil society in the formulation ofnational health policy.

EXECUTIVESUMMARY

1 TheEU's Contribution to the Millennium DevelopmentGoals: Keepingthe Goals Alive, Alliance2015, 2010.


5/40

A

ID

E

F

F

E

C

TIV

E

N

E

S

S

FO

R

H

E

A

LTH

:

:

EXEC

UTIVE

SU

M

M

ARY

Managing for Results - Aid could have muchmore impact. Even where policies are strong,implementation is weak. Being able to draw astraight line from aid flows to a tangible, visible

improvement in the lives and rights of the poorestpeople is frustratingly challenging. Instead ofaddressing this from the perspective of recipients,managing for results is being misinterpreted asfinancing by results. Very little aid is actuallyfiltering down to the poor and results are not tiedto the MDGs. The ECs use of General BudgetSupport (GBS) has been ineffective in supportinghealth outcomes.

Due in large part to the global financial crisis,development budgets and health aid are likely tostagnate (in Germany) or be cut back (in France,Italy and Spain) in 2010 and 2011. Europeandonors need to urgently review their health ODAspending in light of the strong commitments madeon the global stage. In particular, they can ensurethat their investment in health yields visible and

tangible dividends by taking the following threeconcrete steps:

1. Improve health aid coordination through the useof an appropriate mix of funding mechanismstailored to country needs, local contexts andaligned to national health plans.

2. Directly support Community SystemsStrengthening (CSS) to enable civil society toparticipate meaningfully in the development andimplementation of all national health plans andrelated policies.

3. Ensure that managing for results is aligned withcountry efforts towards long-term goals,including Health Systems Strengthening (HSS),universal access to primary healthcare and theattainment of the MDGs.

5

image Corrie Wingagecourtesy of Interact WorldwideandBIG Lottery Fund



6/40


At the global level, aid to health, both in absoluteterms and as a share of total aid, has increasedover the past two decades. Development

assistance to health has risen from US$4.4 billionin 1990 to US$26.8 billion in 20102. However,compared with total aid disbursements, Europeandonors contribute relatively less to health thanother international donors. In 2008, the EU, itsMember States and other European donorsrepresented only 39% of health ODA, whileaccounting for 65% of global aid3.Ofthefivelargest economies in Europe, only the UK iscurrently on track to meet the ODA target of 0.7%of GNI and 0.1% to health aid, as recommended

by the World Health Organisation (WHO)4

. Year onyear, Europe represents a smaller share of theglobal health ODA. As a result, total aid for healthremains well below the levels that have beencalculated as necessary to reach the healthMDGs.

According to the latest estimations, an additionalUS$36-45 billion is required annually to meet thehealth MDGs5. These calculations, however, were

limited to low-income countries and under-ambitious with respect to the goal of universalaccess to HIV prevention, treatment and care, andthe removal of user fees. A truer estimate of thereal financing needs - accounting for theseadditional costs - is US$95 billion per year6.

More and better aid to the health sector equatesto more lives saved, greater equity and betterquality of life for people, and fewer people living inpoverty. Two of the major causes of poverty andreason for the lack of progress on the health

MDGs are discrimination and inequality. Withoutthe immediate implementation of the ParisDeclaration and the Accra Agenda for Action,it will be impossible to achieve the MDG targetson time.

INTRODUCTION

A cardinal objective of the aid effectiveness agendais to improve the lives and well-being of people and,in particular, the most vulnerable in society.

Dr Kwabena Duffour, Minister of Finance andEconomic Planning, Republic of Ghana

6 image Corrie Wingagecourtesy of Interact WorldwideandBIG Lottery Fund

5 Taskforce on InnovativeInternationalFinancing for Health Systems, MoreMoneyforHealthand More Healthfor Money, 2009.

6 B. K. Baker, CTL-for-Health/FTT-with-Health:Resource-Needs Estimates andan Assessmentof FundingModalities, AfGH/InternationalCivilSociety Support,2010. Theauthor usedsubsidiary estimateson targeted global health needstocalculatea moreglobal resource needsestimatefor 2009-2016.

2 Institutefor Health Metrics andEvaluation, FinancingGlobalHealth 2010.Availableat:

http://www.healthmetricsandevaluation.org/resources/policyreports/2010/financing_global_health_1110.html.

3 German Foundation for World Population andEuropeanParliamentaryForum onPopulation and Development, Mapping EuropeanDevelopment Aidand PopulationAssistance: Euro-mapping 2010.

4 For more information,pleasereferto theappendix inChapter3.

AID

EFFECT

IVENESS

FOR

HEALTH

:

:

IN

TRO

D

U

C

TIO

N


7/40

About this report

The aim of this report is to stimulate debate in thelead-up to the 4th High-Level Forum on AidEffectiveness, to be held in Busan, South Korea inDecember 2011. The report draws extensively onoriginal research developed by Action for GlobalHealth (AfGH), including fact-finding missions onaid effectiveness in four developing countries - El

Salvador, Mozambique, Tanzania and Uganda7 -and an online forum examining the impact of ODAon health. In the course of this research, AfGH hasbeen able to identify three central problems thatrequire urgent attention:

1. Donor coordination and alignment efforts todate are not improving health outcomes.

2. Civil society8, including Parliament, is largelyexcluded from health policy decision-making.

3. Managing for results is being misinterpreted as

financing by results.These three aspects of the aid effectivenessagenda are examined in depth in correspondingchapters of this report. In each case, AfGHexamines the specific commitments, theunderlying theory and actual progress madethrough the lens of the health sector. A review ofthe latest ODA health data is also included as anappendix to Chapter 3, to highlight the ominousforecast for health aid in four out of five of thelargest European economies.

7



7 TheDSW/AfGHpolicy briefings on health aideffectivenessin El Salvador,Mozambique, Tanzania andUganda are currentlyavailable at:

http://www.euroresources.org/afgh.html.

8 Seeboxin Chapter 2 fora definitionof civilsociety.

A

ID

E

F

F

E

C

TIV

E

N

E

SS

F

O

R

H

E

A

LTH

:

:

IN

TRO

D

UC

TIO

N

7


8/40


Nowhere is the need for donor coordination moreevident than in health. Over the past two decades,the number of donors, financing and delivery

mechanisms in global health has grownexponentially. There are now more than 100 globalpartnerships in the health sector alone, with 80%of donors providing just 10% of total assistance9.Each of these donors has its own particular, andoften conflicting, method of aid delivery,monitoring and evaluation framework andtimeframe. The result is chaotic and expensive forthe intended beneficiaries, with Ministries ofHealth overwhelmed by the weight ofadministration required to manage donor

relationships and meet donor requirements10

.According to Dr Giridhari Sharma Paudel, DeputyDirector of the Family Planning Association ofNepal: There should be better coordination andcollaboration among international donors

The focus should be on the poor, marginalised

and under-served population.

To date, most of the debate around aid modalitieshas been about how touse them as a tool toincrease ownership. On the one hand, there has

been a progressive movement in the developmentfield as a whole from donor control towardsgovernment control, and away from project-basedaid to GBS. On the other hand, there has been astrong growth in the number of vertical initiativesand funds in response to health emergencies,particularly HIV/AIDS. Donors, however, appear tobe unaware of these initiatives and funds and ofhow different aid modalities and approaches caninteract with domestic power dynamics11. A betterunderstanding of the advantages and

disadvantages of each health aid mechanismneeds to be developed among all actors, includingcivil society and governments.

COORDINATION OFHEALTH AID: MISSIONIMPOSSIBLE?

The effectiveness of aid is reduced when there are too many duplicatinginitiatives, especially at country and sector levels. We will reduce thefragmentation of aid by improving the complementarity of donors effortsand the division of labour among donors, including through improvedallocation of resources within sectors, within countries, and acrosscountries. Accra Agenda for Action, 2008

8

9Development assistanceto a particularcountryis saidto be fragmentedwhenthereare more than 15 donorsbetweenthemproviding less than 10% of the

countrysprogrammableaid.

10 See for example,AfGH, Health Spendingin Mozambique:Impactof current aidstructuresand aid effectiveness,2011.

11L.WildandP.Domingo,Aidand accountabilityin health, what candonorsdodifferently?, Project Briefing,No. 46, ODI/WorldVision, September2010.

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

1



9/40

9

Source: Brook K. Baker, CTL-for-Health/FTT-with-Health: Resource-NeedsEstimates and an Assessment of Funding Modalities, AfGH/InternationalCivilSociety Support, 2010.

Mechanism

Table 1

PastPeformance

PriorityFocus

Country Ownership/Coordination/Harmonization

Global Fund

GAVI

World Bank

UNITAID

EC MDG Contracts

IHP+

Bilateral Aid

Joint HSS Platform

Proposed GlobalFund for Health

Strong: results-basedfunding, long-term

commitments, reducedvolatility, equity

Strong: long-termcommitment, low volatility,equity

Weak: poor performance-based funding,conditionalities and debt-based financing, notfocused on the poor

Strong: Market impact,secure sources of revenue,value for money, medium-term commitments

Mixed: Hasunderemphasized health

Weak: Only 4 compacts todate, has not been able toraise money

Mixed: Varies by donor interms of volatility, duration,

disbursement/commitmentratio, and conditionality

Just being piloted now

NA, but plans to use GlobalFund model

HIV, TB, malaria, HealthSystem Strengthening

(HSS)

Immunization and HSS

Health Finance, multi-sectoralism, health systems

Medicines and diagnosticsfor HIV, TB and malaria

HSS, general budgetsupport (in theory)

National health planningand financial accountability

Varies by country, UShistorically focused on

priority diseases; Europeandonors focus more on childand maternal health, andHSS

HSS for priority diseasesand positive synergies inregard to health systemsmore broadly

Comprehensive primaryhealth care, humanresources for health, and

HSS

Country-led but behind onharmonization

Country-led but behind onharmonization

Engages with Ministries ofFinance but behind onharmonization

N.A. in general but patentpool will make it easy toprocure affordablemedicines

Strong in theory, but mixed

Strong

Varies by country, generallyvery weak

Expected to be strong

Undeveloped at present;potential for reducedtransaction costs

9


10/40

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

1



A major impetus behind the aid effectivenessagenda has been to address the lack of globaloversight and organisation of overseas aid, andthe detrimental impact it is having on progresstowards the MDGs. One of the central aims is toensure that donors harmonise and align theirpolicies and aid modalities to suit governmentpriorities. The United Nations (UN) and related

agencies, including the World Health Organisation(WHO), are best placed to provide the necessaryharmonisation, coordination and leadership at aglobal level to deliver on human rightscommitments, but lack the required political andeconomic power to do so.

In Paris, signatories committed to work togetheron a range of concepts and tools, including jointactions and research, common procedures,comparative advantage, complementarity anddelegation. Most of the focus, particularly within

the EU, has been on the concept of division oflabour and reducing the number of donorsreporting on key sectors at a national level. InAccra, effort was made to bring the concept ofownership back into the harmonisation agenda,to place the role of recipients more centrally todetermine how they want donors to be active intheir countries, and to warn against applyingdivision of labour to the extent that the quality andquantity of aid diminishes.

The impact of European donorcoordination on health aid so far

Donors will respect developing countries

priorities, ensuring that new arrangements

on the division of labour will not result in

individual developing countries receiving less

aid.Accra Agenda for Action, 2008

In 2007, the European Union introduced avoluntary European Code of Conduct on theDivision of Labour in Development Policy. Theprimary principle of the Code is that EU donorsshould focus their activities on two sectors basedon their respective comparative advantages, andthese should receive the bulk of available funding.In addition to the two focal sectors, donors can

provide general budget support where conditionspermit and finance activities in other areas such assupport to civil society, research, oruniversity/school cooperation12.

The EU Division of Labour policy has not beengood for health. In practice, it has led to the ECstepping out of the health sector in a number ofcountries that are struggling to meet the healthMDGs, with serious consequences for progress.

This has been the case in both Tanzania andUganda, leaving the EU delegation without thenecessary human resources and health expertiseto oversee how aid is spent, as well as participatein health policy dialogue with the government andtrack performance, particularly with regard to newMDG contracts.

Meanwhile, in Mozambique, some Europeandonors seem to have used the policy to justifysignificant cuts in their aid budgets, instead ofapplying the principle of delegated cooperation13.

12 EU Codeof Conduct on Divisionof Labour in Development Policy, 2007.

13 Throughdelegated cooperationa donor hasthepowerto acton behalfof otherdonors concerningthe administrationof fundsand dialogue withthe partnergovernment. See:

http://europa.eu/legislation_summaries/development/general_development_framework/r13003_en.htm#KEY.


11/40

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

1

A European donor official described it as thesector-exit strategy14. Overall, following theimplementation of Division of Labour, EC healthaid was reduced from 4.7% of total EC aid in 2005to 1.3% in 200815. This is a clear example of howdonor alignment can lead to lower financialcommitment to health. As the Accra Agenda forAction makes clear, before embarking on the

concept of division of labour, donors need toscrutinise the impact this may have on the overallamount of aid going to the sector.

In line with aid effectiveness objectives, the

EU should channel two thirds of health ODA

through partner countries-owned

development programmes and 80% using

partner countries' procurement and public

financing management systems.

The EU Role in Global Health, 2010

Since 2005, many European bilateral donors,including Denmark, Germany, Ireland, theNetherlands, Sweden and the UK have joined theEC in raising the proportion of aid allocatedthrough GBS as a direct response to Paris andAccra Principles. The rationale behind GBS is thatit gives developing countries greater control overhow aid is used, as well as reduces theunpredictability of aid flows and transaction costs.Channelling funds directly through governmentsystems builds planning and budgeting capacityand strengthens public accountability

mechanisms. In terms of health, long-term andpredictable support is ideal since 80% of healthsystem expenditures are recurring costs. This isprovided GBS is actually used to increasedomestic funding to the health sector. GBS canalso have a positive impact on health and universalaccess goals, in that funding can be used forinfrastructure that benefits health in rural areas,such as roads and sanitation projects. Almost 50%of the 10th European Development Fund,equivalent to 11 billion, is to be disbursed in

this way.

In 2010, the European Court of Auditors carriedout a performance audit to assess whether the ECmanages its GBS programmes effectively16. Thereport recommended that the Commissionstrengthen its management of performance-related conditions for GBS, which should include a

clear and structured process for assessments anddisbursements. This echoes the recommendationsfrom the 2007 evaluation of EU health funding inSub-Saharan Africa that urged donors to promoteincreases in national health budgets through theuse of performance indicators, targeting suchincreases in GBS financing agreements17. Suchindicators should be based on internationallyagreed health targets, such as the 15% healthsector share target of the Abuja Declaration. Inaddition, the Court recommended that much more

is done to support the ability of civil society,including parliamentarians, academics and CivilSociety Organisation (CSOs), to hold governmentsto account on the budget. To this end, the reportcalled on the Commission to support specific, andtargeted, capacity-building initiatives.

11


14 Health Spending in Mozambique:The Impact of Current AidStructuresand AidEffectiveness,AfGH, 2011.

15 TheEU's Contribution to the Millennium Development Goals: Keepingthe Goals Alive, Alliance2015, 2010.

16 TheCommissions Managementof General Budget Support in ACP,LatinAmericanand Asian Countries,SpecialReportNo.11, EuropeanCourtof Auditors,2010.

17 Development Assistanceto health services in Sub-Saharan Africa,EuropeanCourt of Auditors,2008.


12/40

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

1



Providing funding directly to Ministries of Health inthe form of Sector Budget Support (SBS)overcomes some, but not all, of the challengesassociated with GBS. SBS combines use ofgovernment systems with donor preferences forhow money should be allocated, and offers clearadvantages over GBS in that Ministries of Healthdo not have to compete for their fair share. This

form of assistance can support theimplementation of reforms or actions to overcomebarriers to progress in the sector. In Uganda, forexample, the Danish Government has supportedthe development of the national health plan over anumber of years18. However, there is no guaranteethat funds will be used appropriately. Healthfunding can still get stuck at the level of central ordistrict authorities, as it has done in Nepal, holdingback efforts towards universal access19. Researchhas demonstrated that government-controlled

resources are slow to reach the local level andthen only in small amounts - as little as 20% -where health programming is most needed20.

In light of anxieties surrounding governmenthandling of funds, Global Health Initiatives (GHIs)have preferred to create and use their own aiddelivery systems. The rapid rise in the number ofthese initiatives has been one of the definingfeatures of the global health arena in recent years.The Global Fund to fight AIDS, Tuberculosis andMalaria (hereafter the Global Fund), the

Presidents Emergency Plan for AIDS Relief(PEPFAR), and the Global Alliance for Vaccinesand Immunisation (GAVI) are often the largestcontributors to health at the national level,dwarfing ministry budgets.

These vertical health funding mechanisms havebeen able to generate significant additionalfinancial resources for health and achieveimportant results in terms of lives saved, However,there are widespread concerns that they aredistorting partner country priorities by drawingresources away from basic health sector reforms,

contributing to the brain drain of governmenthealth workers, and using burdensome reportingrequirements and processes21. In El Salvador,there are as many as 22 vertical funds, with 60disbursement systems22. Meanwhile in Nepal,CSOs are very critical of donor behaviour. In aninterview with AfGH, Dr Bharat Pradhan, ExecutiveDirector of the Public Health Concern Trust, said:

Everybody in Nepal knows that most of the

health programmes are donor-driven. Most of

the programmes are vertical, and one can

easily see duplication of similar programmesin the same districts supported by different

donor organisations.

According to Janardan Thapa, a manager at theChild Welfare Scheme in Western Nepal:

Donors are not adequately familiar with the

local contexts, due to unavailability of valid

and adequate information. Therefore, there is

an over-generalisation of the problems by

donors. Donor priorities do not fit with the on-

the-ground reality and need more involvement

of communities. International agendas haveovershadowed local realities. In these cases,

CSOs are forced to reconcile local need and

donor preferences.

18 AfGH,HealthSpendingin Uganda. Theimpact of current aidstructuresand aideffectiveness,2010.

19 AfGH, Health aideffectivenessin Nepal: Paris, Accra, civilsocietyandthe poor, 2009.

20 B. Gauthier,PETS-QSDSin Sub-SaharanAfrica:A StocktakingStudy. HEC Montreal,2006. Availableat:http://siteresources.worldbank.org/INTPUBSERV/Resources/477250-1165937779670/Gauthier.PETS.QSDS.Africa.STOCKTAKING.7Sept06

.pdf.21 D. Sridhar & T.Tamashiro. Vertical Funds in the Health Sector:Lessonsfor Educationfrom the Global Fundand GAVI, 2009.

22 AfGH,HealthSpending in El Salvador.The impact of current aidstructures and aid effectiveness, 2011.


13/40

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

1

Vertical health funding mechanisms are beginningto adopt a more integral approach in order tocontribute to HSS and increase theimplementation of the Paris Declaration principles.Recent efforts made by the Global Fund in thatdirection, through the HSS funding window, theJoint Health Systems Funding Platform, andsupport for the Joint Assessment of National

Strategies (JANS), can be seen as positivedevelopments in that respect. PEPFAR hasrecently been integrated into the US Global HealthInitiative and is moving towards country ownershipand supporting national strategies. However, thepositive impact of these new approaches on HSSat country level still remains to be seen. Thechallenge is to make sure these developments donot lead to decreased investment in health.

Clearly, dependence on one aid modality to theexclusion of others is problematic for health

outcomes. Only a mix of these financingmechanisms allows for a careful adaptation to thecharacteristics, politics, drivers and constraints in aspecific country situation and sectors as well astargeted support to CSOs and Community-BasedOrganisations (CBOs), especially those workingwith marginalised and stigmatised populations,which often have limited or no access togovernment funding. Project-based aid, althoughlimited in aid effectiveness terms, can be useful toprovide policy and technical support and capacity-

building, to finance pilot interventions andinnovative programmes in health. In the case ofHIV/AIDS - which is highly stigmatised andinvolves life-long drug treatment - there mayalways be a need for vertical funding. An approachin which vertical interventions are integrated intohealth systems in a way that does not dilute theirimportance is an efficient way to respond to publichealth challenges.

Effective and inclusive aid coordination shouldensure that all aid modalities complement ratherthan conflict with one another. And importantly, as

Jose Davuca, Coordinator of the NationalAssociation of Nurses in Mozambique, describes,decisions around the use of aid modalities need tobe made by countries themselves, and not donors:

Donors should gradually let the Government

take the lead in developing the strategies and

defining priorities for the (health) sector. This

should, however, be based on an assessment

of the country in this area. All the donors

should be called to finance a strategy of the

sector which needs to be developed with the

involvement of all actors.

13

image DSW image Corrie Wingagecourtesy of Interact WorldwideandBIG Lottery Fund


14/40

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

1


image NellFreemanfor theAlliance

Abuja, donors and the I MF:Incompatible goals?

In Abuja in 2001, African governments committedto allocating 15% of their national budgets tohealth. Only a handful of countries have met thetarget. In Mozambique, Tanzania and Uganda, thepercentage allocation has in fact decreased in thepast year from 11-12% to 10%23. Moreover, incountries such as Tanzania, donor fundingincluding SBS is being included in the targetcalculations, artificially inflating the measure ofhow much governments are investing in theirhealth systems24. This is contrary to the intentionof the Abuja target to ensure greater governmentinvestment in HSS and ownership over healthspending. In Tanzania, the Government tends tosee the health sector in general as being takencare of by PEPFAR and the Global Fund, freeingthem to allocate GBS to other issues25. As a result,

gaps in funding programmes arise and publichealth problems persist.

Even where governments may wish to increasetheir health budgets, this may not be easilyreconciled with their plans for economic growth. Inmany countries, health sector budgets are not setaccording to health needs, but macro-economicpolicies. Large public expenditures financedthrough donor aid inflows are thought todestabilise the economy for a number of reasons.Traditional advice from the International Monetary

Fund (IMF) therefore specifically advisesgovernments to divert aid to reserves rather thanspend it26. In countries such as Tanzania, where theGovernment has pledged to manage the economyconservatively, health as a non-productive sectorhas been de-prioritised in favour of trade andinfrastructure. This trend in favour of cuttinggovernment expenditure is only likely to deepengiven the current global financial crisis.

The EC requires the majority of countries in receiptof budget support to have IMF agreements inplace. However, the impact of IMF macro-economic guidelines on health is significant.Health systems spending has been shown toincrease twice as fast in non-IMF borrowingcountries than in IMF-borrowing countries27. InUganda for example, ODA to the health sector

cannot be used if it exceeds the annual ceilingscommitted to by the Government28. Although theIMF claims that it has become more flexible, arecent report reveals that the institution continuesto recommend sector expenditure ceilings, bystating that establishing rules that put specificlimits on spending and borrowing can strengthenfiscal credibility and discipline29. Moreover, thereis no direct correlation between increasingeconomic growth and higher health spending. InNepal, although the national budget has tripled,

the budget for the Ministry of Health has onlydoubled30.

23 SeerespectiveAfGH reports on Health Spendingin Mozambique, Tanzania andUganda. Availableat:http://www.actionforglobalhealth.eu/index.php?id=10&no_cache=1.

24 AfGH,HealthSpending in Tanzania:The Impact of Current AidStructuresand AidEffectiveness, 2010.

25 Ibid.AfGH, Health Spendingin Tanzania:The Impact of Current AidStructuresandAid Effectiveness, 2010.

26 D. Stuckler, S. Basuand M. McKee, IMF andAid Displacement, in InternationalJournal of Health Services,Vol.41,No.1, pp 67-76, 2011. Seealso AfGH,The IMF,theGlobal Crisis and Human Resourcesfor Health: Still constraining policy space, 2010.

27 AfGH,The IMF,the Global Crisis and Human Resourcesfor Health: Stillconstraining

policy space, 2010.28 AfGH,HealthSpending in Uganda: Theimpact of current aid structuresand aideffectiveness, 2010.

29 IMF,BudgetInstitutionsand Fiscal Performance in Low-Income Countries,WorkingPaper.p. 13, March2010.

30 AfGH,Healthaid effectiveness in Nepal, 2009.


15/40

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

1

15

image Corrie Wingagecourtesy of InteractWorldwideandBIG Lottery Fund


31 Abebe Alebachew and Veronica Walford,Lessons from the JointAssessmentof NationalStrategy(JANS) Process in Ethiopia,2010.

32 Interviewwith Mr.Shanta LallMulmi,ExecutiveDirector, ResourceCentre for Primary Health Care,Nepal.

Best practices

A significant boost to donor coordination has alsobeen provided by the launch of the InternationalHealth Partnership and Related Initiatives (IHP+),particularly in connection with the JANS process,which has been used in to develop national healthstrategies in Ethiopia, Mozambique, Nepal andUganda. The aim of the IHP+ is to mobilise donorcountries and aid agencies around a singlecountry-led national health plan, guided by theprinciples of the Paris and Accra Declarations.Some of the positive health outcomes associatedwith IHP+ have been stronger country leadershipto drive donors in the right direction to supporttheir own national plans, better harmonisationbetween donors, and much stronger involvementof stakeholders, and specifically CSOs, in theplanning and implementing of national plans. InEthiopia, an evaluation of the process similarly

concluded that JANS is widely seen as improvingthe quality of the strategic plan, and has increasedthe buy-in and understanding of the resident andinternational partners as well as CSOs/NGOs.JANS provided a mechanism for the systematicengagement of CSOs that had not been active inhealth policy previously31.

In Nepal, one of the pioneer IHP+ countries,CSOs have also witnessed improvements in HSSand access to health for the most vulnerable as adirect result of participation in the decision-making

process at national level:

The budget allocated for health sector by the

Government of Nepal has increased. The

Government has made special service

provision for marginalised caste and ethnic

groups. Free health services at the primary

level is one of the good achievements.32


16/40


PARISDEC

LARATION19. Partner countries and donors

jointly commit to:Work together to establish mutuallyagreed frameworks that providereliable assessments of performance,transparency and accountability ofcountry systems (Indicator 2).

Joint Assessment of National Strategies (JANS), Ethiopia

Enhanced the quality and credibility of the national health strategy and system for implementation.

Increased donor alignment with national strategy and priorities and lowered transaction costs.

Provided more streamlined processes for getting funding approved (HSS platform).

The inclusive approach increased the buy-in and understanding of resident and internationalpartners as well as CSOs/NGOs.

32. Donors commit to:Implement, where feasible, commonarrangements at country level forplanning, funding (e.g. joint financialarrangements), disbursement,monitoring, evaluating and reportingto government on donor activities andaid flows. Increased useofprogramme-based aid modalities cancontribute to this effort(Indicator 9).

Development Partners Group for Health, Tanzania www.tzdpg.or.tz/dpghealth

A collection of 10+ bilateral and multilateral agencies supporting the healthsector in Tanzania.

Funds are provided through general budget support, the health basket, projects, and technicalassistance.

Operates a sophisticated troika system, ensuring that at least three donors are continuously takinga strong lead for health.

Strong transparency via website giving a comprehensive overview of all key policy documents andprocesses in the sector.

Budget Support Group, El Salvador

Brings together all four major donors in the country - Spanish Development Agency AECID, the EC,the Inter-American Development Bank and the World Bank.

Conducted a joint assessment of Public Expenditure and Financial Accountability (PEFA) in early2009.

Joint Assessment Framework Initiative, Uganda

The first donor joint assessment framework with the Government to support the improvement ofservices in four critical sectors education, health, water and roads via direct budget support overthree years.

The 11 Joint Budget Support Development Partners include: the African Development Bank, theEC, the World Bank, Belgium, Denmark, Germany, Ireland, the Netherlands, Norway, Sweden and theUK. Together, these donors contribute more than 80%of direct donor funding to Uganda.

Provides a set of well-defined and shared targets and actions by which performance can bemeasured.

Health sector performance indicators include a number of sexual and reproductive health-relatedindicators linked to MDG targets, and indicators on levels and distribution of qualified healthworkforce. These have been derived from the Government of Uganda's owntargets and reformcommitments, as expressed in sectoral policy papers and the national budget framework.

Aid effectiveness commitments Best practices

Table 2: Best practices in donor coordination


17/40

Developing countries will lead in determining

the optimal roles of donors in supporting their

development efforts at national, regional and

sectoral levels. Donors will respect developing

countries priorities, ensuring that new

arrangements on the division of labour will not

result in individual developing countries

receiving less aid.

Accra Agenda for Action, 2008

Primarily, donors need to increase their efforts oncoordination. More unified and comprehensivedonor report systems will allow governments tospend less time on reporting and more time onimproving management of ministries. However,donors should be wary of harmonising around onesingle method of aid delivery but use anappropriate mix of financing mechanisms, ensuringthat they are strongly aligned with nationally anddemocratically defined policy frameworks, plans

and financial systems.

This can be achieved through:

Enabling partner countries to choose between arange of aid modalities that are defined by thelocal context and not by donor and staticstandards.

Reserving budget support for countries with astrong commitment to health, including solid andinclusive national health plans andimplementation strategies. The IHP+ and JANS

process is a good method for judging this level ofcommitment.

Ensuring General Budget Support leads to HSSand CSS, fair access and achieving the right tohealth. This needs to be within the framework ofcoherent health strategic plans, using genderanalysis and planning as well as health-specificand gender-sensitive qualitative indicators, basedon internationally agreed targets, such as those inthe Millennium, Abuja, Cairo and BeijingDeclarations.

Using budget support policy dialogue to advocatefor domestic funding increases to reach theinternational targets mentioned above. To thatend, the relevant line ministries, such as theMinistry of Health, need to be included in dialoguewith the Ministry of Finance.

Strongly support IHP+ implementation at thecountry level, encouraging bilateral agencies andGHIs to increase their participation in nationalprocess and ensure that civil society ismeaningfully included. Europe should ensure thatIHP+ has a strong working plan and sufficientresources post-2012 in order to allow a fasterimplementation of aid effectiveness principles.

Fostering existing coordinating mechanisms, ifproven to be efficient, instead of creating newones. This is particularly relevant with IHP+ andthe new Health Systems Funding Platform.

Ensuring that money given through vertical fundsis cost-effective and does not have negativeexternalities on efforts to strengthen healthsystems, using country systems where possible inorder to limit fragmentation.

Focusing on IHP+ implementation each time it issigned by a partner country in order to increasecoordination and meaningful participation from allactors including CSOs. Donors also need toensure that those countries that develop acountry compact and go through the JANS

process have fully-funded national plans.

Using clear, shared and transparent criteria whenapplying Division of Labour to processes ofdecision-making regarding staying in orwithdrawing from a partner country, to be agreedwith CSO representatives, the Government andparliamentarians. Those criteria must guaranteethat health sector funding remains at the samelevel and that there will not be a decrease infunds.

Building the capacity of domestic accountabilitystructures including national parliaments, nationalaudit institutions, the judiciary and civil society.

17

Recommendations

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

1


18/40


In 2011, a number of policy processes are

underway to explore the meaningful participationof civil society. The Organisation of EconomicCooperation and Development (OECD) Task Teamon Health as a Tracer Sector will report on CSOparticipation as part of the preparation for the 4thHigh-Level Forum on Aid Effectiveness in Busan.AfGH welcomes the fact that the EC is in theprocess of developing a Communication on themeaningful engagement of civil society indecision-making processes and drafting newguidelines on Policy Dialogue in the health sector,

including a chapter on inclusive leadership33

.However, the process of elaborating these policydocuments needs to become more transparentand participatory in and of itself to have anymeaning.

Why the voice of civil society is criticalin health policy dialogue

Civil society organisations (must be) fully

engaged so that the needs of the most

marginalised population are taken into

account- TTHATS 2009

The interface that civil society can play betweengovernments, donors and communities, alsoenables CSOs to support greater politicalengagement and advocate for rights to be

respected and reinforced. Civil societyparticipation can contribute to enhancinggovernment accountability and transparency whilstadvocating for equitable and pro-poor healthpolicies. Civil society can hold both donors andrecipient countries accountable for effectiveutilisation of development aid. Without the fullengagement of civil society, country health plansare unlikely to be effective.

A significant step towards recognising the value ofcivil society engagement in policy and decision-

making processes was taken during the 3rd High-Level Forum in Accra. It was acknowledged thatcivil society actors have a legitimate role to play inthe design and implementation of country healthplans and in holding all partners accountable fordelivering results and achieving improved healthoutcomes. Developing countries committed toengaging with their parliaments, citizens and CSOsin the preparation, implementation and monitoringof policies and plans via broad consultativeprocesses. Donors pledged to directly support this

process, by strengthening the capacity of bothdeveloping countries to exercise this leadershipand CSOs to play an active role as independentdevelopment actors in their own right34.

NO OWNERSHIPWITHOUT CIVILSOCIETY

Country ownership is key.Developing country governments willtake stronger leadership of their owndevelopment policies, and willengage with their parliaments andcitizens in shaping those policies.


18

33 Theaimof theGuidelineson Policy Dialogueon GlobalHealthis toprovide officialsand representativesof the EU withthe information andknowledge theyneed to establishregional, nationalor internationaldialogueand politicalnegotiations,whichrespectsand promotes the

valuesagreedby theEU andMemberStateson Global Health.34 AccraAgendafor Action, 2008.

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

2



19/40

19

Civil society is variously defined as the actorsthat form an interface between citizens and

their government, including registeredcharities, community groups, trade unions,

and faith-based organisations. Civil societyhas a long history of engagement in the health

sector, particularly in response to government

inaction. The 1978 Alma Ata Declaration wasa landmark for recognising peoplesparticipation in health systems as central to

primary healthcare and for acknowledging therole that organised social action plays in

securing health gains. In Sub-Saharan Africatoday, a significant proportion of healthcare -

40% in Tanzania - is delivered by civil society,including Non-Governmental Organisations

(NGOs) and Community BasedOrganisations (CBOs)38. Among the

important roles that civil society plays in health

systems is monitoring the responsiveness andquality of health services and negotiatingpublic health standards and approaches.

Civil Society Organisations (CSOs) canbuild informed public opinion on health

and shift social attitudes.

Moreover, their access to the mostmarginalised, vulnerable and difficult-to-reach

populations and communities - includingLesbian, Gay , Bisexual and Transgender

(LGBT) individuals, injecting drug users, and

migrants - means that CSOs have thepotential to make universal access a reality.There is considerable evidence that

community participation in programme designand decision-making could play a significant

role in meeting the MDGs39.

However, in practice, the Paris Declarationprinciple of ownership is all too often interpretednarrowly as government ownership, driven by thepriorities of the Ministry of Finance. Truedemocracies rely on the checks and balancesprovided by a variety of domestic accountabilitystakeholders, including parliaments, governmentalaudit institutions and civil society (the media,

interest groups and academia), to function. Thebasis for democratic ownership is that theinterests and voices of all citizens are included innational development strategies and that everyonebenefits from development results35. In the caseofhealth, the democratic and fully inclusive formationof a country health plan should be a first steptowards country ownership of the health agenda.

Current barriers to meaningfulengagement

Research by AfGH has revealed that considerableefforts are still needed at the country level toensure that the Accra commitments are turnedinto action36. The lack of engagement isparticularly evident with regard to government-ledcountry health sector teams where CSOs arefacing a number of challenges including beingprevented from involvement in national healthplanning and monitoring. In many cases, CSOs arenot even aware of the major policy processes andmechanisms that have been put in place to enablethis.

This is due principally to the following reasons:

Suspicion and mistrust towards CSOs withinministries: governments tend to prefer to workwith a hand-picked group of well-known NGOs,smaller in-country and community-basedorganisations not usually on the guest list toparticipate in annual consultations, despite theirstrong role in health provision37.

19

35 DAC Network on Gender Equality, Makingthe Linkages,2008.

36 Fora fullanalysisrefer to AFGHreports on Uganda, Tanzania,Nepal,Ethiopiaand Zambia. Available at:http://www.actionforglobalhealth.eu/index.php?id=10&no_cache=1.

37 Seefor exampleAfGH, Health Spendingin Uganda: Theimpact of

current aidstructuresand aideffectiveness,2010.38 F. Omaswa, Informal health workers: to be encouragedorcondemned?, Bulletinof the World Health Organisation,February2006.

39 S. Commins, Communityparticipationin Service DeliveryandAccountability, 2007. Seealso WHO,StrategicAlliances:The roleof civilsociety in health, 2001.

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

2


20/40

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

2


image MareikeLuppe/terre deshommes

Many officials within the Ministry of Health

are opposed to citizen participation in health

as it represents a threat to their status. They

do not have the slightest interest in following

the guidelines on working with

communities.40

CSOs are not regarded as legitimate actors: CSOpartners are relied upon to deliver services butas sub-contractors, have little or no room formutual influencing and accountability. This isparticularly the case for organisations that arenot engaged in service delivery and which focuson issues that are not considered to be a nationalpriority, such as womens rights, LGBT rights, orthe rights and networks of people living with HIV.

Severe restriction of CSO roles and activities: inZambia for example, according to proposedlegislation, all CSOs would have to operate underthree-year licences, making strategic planningand fundraising extremely challenging. Donorsare reluctant to question the introduction of suchlaws, perceiving them as a legitimate action by ademocratic government, even as progress onalignment and harmonisation are held back bypoor human rights records in these countries41. InMozambique, NGOs and networks feel that thereis much room for improvement:

CSO engagement can be strengthened by

increasing their involvement at all stages of

policies and strategic planning. This also

requires strengthening the monitoring of real

usage of the spaces created for civil society

participation since in most cases the degree

of CSOs engagement depends on the

openness of the person responsible on the

government side.42

Lack of transparency and of consultation of civilsociety and Parliament: the role of Parliament isoften limited to basic oversight of the budget. InUganda, Members of Parliament (MPs) only haveone month to scrutinize the budget and inMozambique and Zambia, health reports are notmade available to Parliament. As a result there isa low level of awareness and acceptance of the

MDG targets and aid effectiveness processesamong MPs.

Lack of funding for local CSOs capacity-building: CBOs and local NGOs on the frontlineof service delivery simply do not have time orresources to invest in building their financial andresource mobilisation capacity. This does notmean that they are incapable of using funds well.The EC in particular does not have a strong trackrecord in making its funds for advocacy easy forcivil society to access.

40 Interviewwith Dr Margarita Posada,CitizensAlliance Against HealthPrivatisation,El Salvador.

41 SeeAfGH, Zambia: Aideffectivenessin the health sector, 2009and AfGHEthiopia:Aid Effectiveness in the health

42 Interviewwith Helder White, ProgrammeDirector, MozambiqueNetworkofAIDSService Organisations.


21/40

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

2

Best practices

One of the key priorities of the new El SalvadoreanMinistry of Health during its first 100 days in officewas the establishment of a National Health Forum.The Forum, launched in May 2010, is designed tounify andstrengthen the civil society movement byacting as an open platform for all non-state actorsworking on health. Accordingto Dr. Adolfo AntonioVidal Cruz, National Co-Coordinator of the Alliancefor Sexual and Reproductive Health:

The current National Health Policy was

formulated on the basis of a broad consultative

process with various civil society organisations

at the National Health Forum and some of the

ideas were used to begin designing a proposal

for comprehensive health reform that is

currently underway in El Salvador.

Even though it was facilitated initially by theadministration, the Forum aims to be an independent

space to communicate CSO health concerns to theMinistry. Ren Alfredo Cataln, Vice-Chairman ofCommunity Health for the Community AdvisoryBoard in La Libertad, El Salvador is positive about itsimpact:

Overall, there have been some changes as we

are now working closely with health units

participating in the planning and provision of

health services and this is part of the new health

policy and its implementation. We have seen

increased interest of health authorities to learn

of the reality we live in communities, and we feelincluded and heard through the National Health

Forum.

At the international level, progress has also beenmade to increase the role and recognition of civilsociety as keyactors in policy and decision-makingprocesses, notably in relation to the structure of theGlobal Fund and more recently with GAVI. Thenational coordinatingmechanism of the Global Fundis considered by many CSOs - notwithstandingitslimitations - to be a best practice model for civilsociety and parliamentaryengagement43. TheCommunity Systems Strengthening Frameworkdeveloped by the Global Fund in collaboration withWHO, the Joint United Nations Programme on

HIV/AIDS (UNAIDS) and CSOs provides animportant guidance on howto support civil societycapacity-building activities and strengthencommunity systems. The progress made towardsmeaningful participation of civil society in thenational coordinating mechanisms should now bebuilt upon to support similar engagement in thefields of child, maternal, reproductive and broader

health.Another example of strongCSO participation in thehealth sector is the IHP+, where both northern andsouthern civil society is now represented on theglobal management structure. According toExecutive Director of the Resource Centre forPrimary Health Care ShantaLall Mulmi, the IHP+process in Nepal has definitely made it easier forCSOs to engage in national health policy. It has

acknowledged the role of CSOs in national and

regional policy processes.

In Mozambique, organisations such as HelpAgeInternational are also finding it easier to engage:

The IHP+ creates opportunities for CSOs to

access more information on the health sector

and to interact more (often and deeply) with

donors. These initiatives also have clearer

mechanisms for channelling the debate

between donors and civil society to the

government structures through the Ministry of

Health (via the Consultative Council).44

It has been shown that in countries where an IHP+

Compact is signed, civil society participation indecision-making process increases45.

In 2011, there are many opportunities for civil societyto be engaged with national processes. IHP+Compacts are already under development inBurkina Faso, Burundi, the Democratic Republic ofCongo, Djibouti, Niger and Togo, and will be signedby SierraLeone and Uganda. Malawi, Mali andRwanda are looking at implementing JANS.However, in order to be meaningfullyengaged innational health planning and budgeting, civil societyneeds practical and financial support.

21

43 AfGH,HealthSpending in Tanzania:The impact of current aid structuresandaid effectiveness, 2010.

44 Interviewwith RosaliaMutisse,ProjectOfficer,HelpAgeInternational,Mozambique.

45 Seenotes from the Third IHP+ Country Health Sector TeamsMeeting,December 9-10, 2010Brussels. Available at:http://www.internationalhealthpartnership.net/en/news/display/3rd_ihp_country

_teams_meeting.


22/40



Table 3: Best practices in increasing civil society ownership

PARISDEC

LARATION

ACCR

AAGENDAFORACTI

ON

14. Partner countries commit to:Exercise leadership in developing andimplementing their nationaldevelopment strategies throughbroad consultative processes.

Development Observatory, Mozambique

A consultative forum for monitoring the objectives, targets and actions specifically assigned to thepublic and private sector within the context of the Action Plan for the Reduction of Absolute Poverty- II(PARPA II) 2005-2009.

Composed of representatives of the Government, the donor community and Mozambican civilsociety.

Civil society is represented through a group called the G20, which includes churches, labour unions,networks of NGOs, the private sector and academics.

Recommendations from the Observatory arepart of the annual aid review.

14. Partner countries commit to:Take the lead in coordinating aid at alllevels in conjunction with other

development resources in dialoguewith donors and encouraging theparticipation of civil society and theprivate sector.

13. Donors will support efforts toincrease the capacity of all

development actorsparliaments,central and local governments,CSOs, research institutes, media andthe private sectorto take an activerole in dialogue on development policyand on the role of aid in contributing tocountries development objectives.

Health Policy Advisory Committee, Uganda

Meets on a regular basis in order to provide policy guidance to the sector.

Composed of representatives from the Ministry of Health and key donors.

CSOs and MPs are invited to annual health sector reviews in order to contribute to discussions onpast performance and future targets.

Civil Society Support Mechanism (CSSM), Mozambique http://www.australcowi.co.mz

A five-year pooled funding mechanism for CSO capacity-building.

Supported by DFID and IrishAid.

Designed to improve governance and accountability for ordinaryMozambican citizens throughstrengthening and diversifying the engagement of CSOs withmonitoring and advocacy on governance.

Civil Society Support website, Tanzania www.civilsocietysupport.net

Established by the EC andCanada with the contribution of all the major donors in the country.

Makes it possible to comparethe different funding opportunities for civil societymade available byeach donor, by sector and region.

Independent Development Fund, Uganda www.idf.co.ug

A grants-management fund chaired by Danish International Development Assistance (DANIDA),DFID, Swedish International Development Agency (Sida), TheNetherlands, the NGO Forum, theDevelopment Network of Indigenous Voluntary Assocations (DENIVA) and the Human Rights

Network Uganda. Designed to strengthen capacity of civil society to contribute to human rights, good governance andpoverty reduction efforts.

Open almost exclusively for proposals from national CSOsand CBOs; international NGOs can onlyapply as part of a consortium.

Country Coordinating Mechanism (CCM), Global Fund for AIDS, TB and Malaria, Nepal

Recognises theequal contribution of all stakeholders including civil society, private sector, theGovernment, donors, affected communitiesand academics in the development of proposals.

In Nepal, eight civil society members participate where they are ableto contribute to proposaldevelopment as well as monitoringand implementation of thegrant.

Representatives of affected populations share a table with high-level Government officials, somethingunheard of before.

National Health Forum, El Salvador

Designed as an open platform to unify the existing diversity and strengthen capacity of non-stateactors working on health.

An Organising Committee is in chargeof organising regional conferences, thematic roundtablesand establishing joint planning and monitoring systems for health sector policies, by prioritisingcommunity leadership.


23/40

Recommendations

23

Donors will support efforts to increase the

capacity of all development actors

parliaments, central and local governments,

CSOs, research institutes, media and the

private sectorto take an active role in

dialogue on development policy and on the

role of aid in contributing to countries

development objectives.


In order to ensure the meaningful participation ofcivil society and Parliament in health policy andprogramming, donors need to ensure that theownership principle is more comprehensivelydefined and is not considered to be in placewithout the involvement of all segments of civilsociety and national parliaments in policy-makingprocesses. Donors must step up efforts to ensurethe meaningful and systematic participation ofCSOs with wider diversity, especially womens andcommunity-based organisations that representmarginalised and vulnerable groups, in thedevelopment of national health plans.

In line with their commitments under the AccraAgenda for Action, donors can specificallycontribute to greater democratic ownership by:

Allocating sufficient aid to directly supportcommunity empowerment and CSS, in order toincrease communities awareness of existinghealth services, their participation in health

decision-making at local and district level, andsupport for their role as community healthcareproviders.

Allocating sufficient aid to strengthen civilsociety in developing countries by fundingadvocacy capacity-building, taking care thatfunding opportunities are well-disseminated,accessible and straightforward.

Using political dialogue to ensure governmentsinvolve a greater diversity of CSOs at all stagesof the decision-making and monitoring process.

Establishing transparency and accountabilitymechanisms to enable CSOs to understand andfollow up on consultation processes.

Actively supporting partnership-building amongst

all actors. More efforts need to be made in orderto improve and strengthen the relationshipbetween International NGOs (INGOs), localNGOs, CBOs, local authorities and MPs, in orderto ensure that these alliances contribute to truecountry ownership of development policies.

Agreeing to country-based measures to advancedemocratic ownership.

The EC has announced the adoption of theCommunication on the meaningful engagement ofcivil society and the new Health Sector PolicyDialogue guidelines. In this context, the EU shouldsend out a strong message to all developmentactors and take the lead by making public how civilsociety and Parliament have been meaningfullyengaged in these policy developments.

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

2


24/40


Managing for results is a key theme in both theParis Declaration and the Accra Agenda forAction. The aim is to ensure that all aid is directedtowards its fundamental goal: the attainment ofthe MDGs and other core commitments, such as

universal access to primary healthcare and theright to health. Until now, this aspect of the aideffectiveness agenda has tended to be taken forgranted by the international community. However,in the context of increasing pressure on donors toaccount for spending on ODA to theirconstituencies, securing value for money is nowat the top of the agenda of the 4th High-LevelForum in Busan.

It remains all too easy for even the mostscrupulous of donors to spend aid that makes no

tangible difference to the lives of the worldspoorest people. A lack of robust statistical systemsand monitoring frameworks at the country levelmakes accountability extremely challenging.Donors and governments are increasinglymeasuring the impact of their programmes andtaking steps to increase the results focus of healthsector plans. However, the Paris DeclarationEvaluation Report found that progress had beenvery slow at the national level. Hence in Accra, itwas emphasised that statistical and informationsystems in developing countries needed to be

strengthened. According to the OECD Task Teamon Health as a Tracer Sector, in many countriesthe results orientation of health sector strategies

MANAGING FOR RESULTSSHOULD NOT MEANFINANCING BY RESULTS

We will be judged by the impactsthat our collective efforts haveon the lives of poor people.


24 image BrunoFert//Mdecins du Monde

and programmes needs to be stronger46. Inparticular, there is a danger that the new focus onvalue for money and managing for results willdivert attention from the broader country contextof providing health services for all which is

particularly important for the most marginalisedand stigmatised groups in society.

In 2008, Alliance 2015 reported that less than25% of EC funds within budget supportprogrammes were being tied to achieving theMDGs, and only 50% tied to results47. A significantopportunity for the EU to assess how well it hasachieved concrete results has been the recentMid-Term Review of the MDGs by the EC. Thepublication of this report is eagerly awaited.

46 OECD,Aid forBetter Health: Whatare welearningabout what worksandwhat dowe stillhaveto do?InterimReport from theTaskTeam onHealth asaTracerSector,Working Partyon AidEffectiveness,2009.

47 Alliance2015, TheEUs contribution to the Millennium Development Goals.Poverty Eradication: FromRhetoricto Results?,2008.

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

3


25/40

25

Why aid is critical to the attainment ofthe MDGs and universal access toprimary healthcare

If we can invest the necessary energy and

resources, we will see major improvements.

But we must act now to save lives, to achieve

the MDGs, and to ensure our increasing

investments are not lost.

UN Secretary-General Ban Ki-moon

Notwithstanding the challenges around provingcause and effect, there is considerable evidencethat much of the progress made towards theMDGs to date - particularly in the areas of healthand education - can be attributed to aid48. One ofthe reasons for the lack of strong progress onMDG 5 is related to the fact that sexual andreproductive health is still suffering from a largefunding shortfall49 and is still neglected or denied

in many countries50. While trade, technicalassistance and migration policies have a role toplay, the need to fill the yawning funding gap isurgent. If managed well, aid can strengthencountries with poor governance, since it can beused to strengthen domestic accountabilitysystems and build the capacity of countries tomeet their development goals51.

Progress in reaching the MDGs on health is beingseverely constrained by the absence of fullyfunded and functioning health systems52. For

example, in Uganda, the current Health SectorStrategic Plan (HSSP III) has only one quarter ofthe financing it needs to meet the health needs ofthe population. El Salvadors new Health ReformPlan has a funding gap of US$100 million and inTanzania, the primary healthcare programmeneeds an additional 6 billion. In Nepal, goodpolicies are not being implemented because of alack of resources: We have not been able toimplement the concept of Free Health Services

properly. The human resources, infrastructure,

medical supplies for such provisions are still

inadequate53. Moreover, the current economicclimate means there are very limited options opento developing countries seeking to increase theirincome.

In 2011, there are two opportunities tosubstantially increase aid to health: the ECs 1Billion MDG Initiative and the proposed CurrencyTransaction Levy/Financial Transaction Tax,currently on the table for discussion during theFrench Presidency of the G20. Governments andCSOs need to jointly work on the ongoingimprovement of aid architecture to ensure new

funding will be spent in the most effective waypossible.

The limitations of results-basedfinancing

Results-based financing for health, sometimesreferred to as managing for development results,is commonly understood to mean that the paymentof aid is conditional on the achievement of certainresults54. Thiscan takethe form ofa cashpayment or non-monetary transfer made to anational or sub-national government, manager,provider, payer or consumer of health servicesafter pre-defined results have been attained andverified55. Performance-based aid is used bymultilateral agencies such as the Global Fund,GAVI and the World Bank, as well as PEPFAR.

25


49 http://www.euroresources.org/fileadmin/user_upload/Euromapping/EM2010/Euromapping2010_LoRes.pdf.

50 Morethan 350,000women dieannuallyfrom complications during

pregnancyor childbirth, almost allof them 99%in developingcountries.UN, MDG 5 Factsheet,2010. Available at:http://www.un.org/millenniumgoals/pdf/MDG_FS_5_EN_new.pdf.

51 L. Wild and P. Domingo, Aidand accountabilityin health: Keythemes andrecommendations, Project Briefing,No. 44,ODI/WorldVision, September2010.

52 WHO, Investingin ourcommonfuture: Joint ActionPlanforWomen's andChildren'sHealth.Draft for consultation, 2010. Available at:http://www.who.int/pmnch/topics/maternal/201006_jap_pamphlet/en/index.html.

53 Interviewwith Dr Bharat Pradhan,ExecutiveDirector of Public HealthConcern Trust,Nepal.


55 See www.rbfhealth.org.

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

3


26/40

AID

EFF

ECTIVENESS

FOR

HEALTH

:

:

C

H

APTER

3


The Meso-American Health Initiative 2015, fundedin part by the Gates Foundation and the SpanishGovernment, uses results-based financing as itsbasis. In this modality, governments have toprovide a substantial matching contribution to thishealth programme, of which 50% will bereimbursed upon the achievement of jointlyagreed targets for policy reform, quality and

coverage of health services56. Similarly, in Europe,MDG Contracting is being introduced by the EC asa way to reward performance against MDGindicators. The MDG contract is for six years, withat least 70% of funds provided as a fixed tranche,and up to 30% as a variable tranche that is onlypaid out when specific targets are reached. If thereare concerns, up to 15% of the allocation can bewithheld57.

Who decides what a result is?

While numerous country case studies have shownthat a results-based approach has indeed createdeffective incentives for countries to reach theirdevelopment targets, it has not always had an onlypositive effect on development. Mozambique, forexample, is seen as being a bad performer,according to the Global Funds Aid EffectivenessScorecard. Consequently, the Global Fund has, onnumerous occasions, halted or reduceddisbursements to the country, which resulted inserious aid effectiveness problems, includinggreater unpredictability of aid flows. Moreover,

other development partners in Mozambique statethat, contrary to the Global Funds evaluations, thehealth sector in particular had developed in anextraordinarily rapid and progressive mannerduring the last decade, considering that all of thecountrys health infrastructure and services hadbeen devastated during the recent civil war. CSOsactive in the health sector in Mozambique supportthe view that progress is being made, as JoseDavuca, Coordinator of the National Association ofNurses explains:

Access to primary healthcare is improving

throughout the country which contributes to

the achievement of the MDGs. However, a lot

more needs to be done in the area of

infrastructure, personnel and the provision of

medicines. This is particular important in the

remote areas, where communities still have to

walk long distances to reach a hospital or

health centre. For instance, less than 40% ofthe Mozambican population has full access to

primary healthcare.

The Mozambican case highlights that the ParisPrinciple of managing for results should not beconfused with financing by results, in other words,results-based management of aid should take intoaccount the progress made by developingcountries towards achieving their developmentgoals. This is especially true for fragile states,which should receive particular attention and

assistance for rebuilding their social sectors,before tying aid to sector performance.

Furthermore, an essential prerequisite for effectiveresults-based financing is the existence of arobust health information and managementsystem, which is still not the case in manydeveloping countries, including middle-incomecountries such as El Salvador. In suchcircumstances, incentives might induce recipientsto exaggerate results or falsify reports to receivepayment. Sometimes, however, incentives can do

more harm than good. In Tanzania, for example,health workers receiving a bonus for carrying outcertain vaccination programmes consequentlyneglected other health services they had beenresponsible for58.

56 AfGHHealth spendingin El Salvador:the impact of current aid structuresand aid effectiveness, 2011.

57 DSW, June2008. Budget support consequences for sexual andreproductivehealth.

58 AfGHUK, Results-basedFinancing: Making surethe UKsaid for healthdelivers morehealth for the money, 2011.


27/40

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

3

Best practices

Increased international attention to managing fordevelopment results has moved monitoring andevaluation away from its previously narrow focuson inputs and outputs to the achievement ofoutcomes and impacts. A case that stands out inthis regard is the recently adopted MalawiHIV/AIDS Monitoring and Evaluation (M&E)system, defined around a four-tiered resultspyramid of indicators on input, output, outcomeand impact. The design of the M&E systemincluded a number of innovative aspects based onmanaging for results principles.

All phases from strategic planning throughimplementation to completion and beyond wereaccompanied by dialogue on results for partnercountries, development agencies and otherstakeholders, through regular consultations. TheM&E system was strongly aligned with a results-

oriented National HIV/AIDS Strategy, conceivedwithin the framework of international conventionsand agreements. The results reporting systemwas set up as a simple, cost-effective, and user-friendly tool.

A newly designed Activities Reporting System wasproduced, following extensive consultation anddistrict-level input, and a specific curriculum wasdeveloped to train grassroots organisationsinvolved in the system. Results information is usedfor management learning and decision-making, as

well as for reporting and accountability. Data arepromptly distributed to stakeholders, thus enablingM&E results to be utilised for decision-making,reporting and accountability59.

27

image MareikeLuppe/terre des hommes


59 M. Goergenset al,Malawi:A National HIV/AIDS MonitoringandEvaluation System, in:Managingfor Development Results Principles in Action:Source book on emerging goodpractice, 1st Edition,2006. Availableat:http://www.mfdr.org/Sourcebook/1stEdition/6-3Malawi-A-National-HIV-AIDS.pdf.


28/40



PARIS

DECLARATION

AC

CRAAGENDAFORACTION

44. Partner countries commit to:Endeavour to establish results-

oriented reporting and assessmentframeworks that monitor progressagainst key dimensions of thenational and sector developmentstrategies (Indicator 11).

National HIV/AIDS Monitoring & Evaluation System, Malawi

Focus on managing for, not by, results, by arranging resources to achieve outcomes.The M&E system is itself a tool to allow the National AIDS Commission to manage fordevelopment results in the future.

All phases from strategic planning through implementation to completion and beyond were accompanied by dialogue on results for partner countries, development agencies, and

other stakeholders via regular consultations. The results reporting system was set up as a simple, cost-effective, and user-friendly tool.Data are promptly distributed to stakeholders, thus enabling M&E results to be utilised fordecision-making, reporting and accountability.

Inclusion of human rights and gender assessments in

health sector review, Uganda

Mid-term review of the health strategy involved Ugandan CSOs and Ministry of Health.

Supported by the UN Special Rapporteur on the Right to Health missions.

Public accountability and ownership of the national health strategy strengthened by meansof broad stakeholder engagement.

49. Donors commit to:Provide timely, transparent andcomprehensive information on aidflows so as to enable partnerauthorities to presentcomprehensive budget reports totheir legislatures and citizens.

National HIV/AIDS Monitoring & Evaluation System, Malawi

A publicly accessible unified online development cooperation database.

All donors and NGOs are asked to indicate and regularly update the programmes they areimplementing in the country.

Currently provides access to information on all bilateral, multilateral and South-South aidflows, in future will include decentralised cooperation and technical assistance.

23a) Developing countries willstrengthen the quality of policydesign, implementation andassessment by improving informationsystems, including, as appropriate,

disaggregating data by sex, regionand socio-economic status.

23b) Developing countries anddonors will work to develop cost-effective results managementinstruments to assess the impact ofdevelopment policies and adjustthem as necessary. We will bettercoordinate and link the varioussources of information, includingnational statistical systems,

budgeting, planning, monitoring andcountry-led evaluations of policyperformance.

Data disaggregation, Nepal

The Ministry of Health and Population is piloting a data collection system using data fromhospitals and health facilities.

Data is disaggregated according to sex, age, caste, ethnicity and regional identity.

Results will show which groups benefit most from abolition of user fees and other policies.

African Community of Practice on Managing for Development Results (AfCoP-MfDR)

The AfCoPprovides an innovativemethod to strengthen capacities required to achieve andaccount for development results.

Over 1,000 members from 37 Africancountries sharing experiences, networking and buildingstronglearning relationships between practitioners in Africaand aroundthe world.

Members strive to maketheirorganisations more results-oriented, effective and accountable toensure that thelives of their fellow citizens are improved.

Web-platform is a keyforum forthecommunity to askquestions, exchange experiencesand toensure sustained dialogue.

Table 4: Best practices in managing for results


29/40

Recommendations

Developing countries and donors will work to

develop cost-effective results management

instruments to assess the impact of

development policies and adjust them as

necessary. We will better coordinate and link

the various sources of information, including

national statistical systems, budgeting,

planning, monitoring and country-led

evaluations of policy performance.


Aid must have a real impact on country progresstowards the health MDGs and universal access toprimary healthcare and the right to health. Results-based financing programmes should be designedby taking into account the specific context andsocial realities of each beneficiary country,ensuring that reductions in aid due to poorperformance do not exacerbate inequities indeveloping countries.

To this end, donors should consider taking thefollowing actions:

Ensure that managing for results is linked toprogress and not just results performance. This isespecially relevant to the long-term process ofHSS, health promotion and behaviour change,research and access to healthcare forstigmatised and marginalised populations.Managing for results should not be confusedwith financing by results.

Ensure that the indicators used to measureresults are country-specific and directly relatedto national health plans. In order to be able tomeasure progress towards these indicators,countries need to be supported in their efforts toimprove their data collection, disaggregated bysex, age and income information and publicfinancial management systems.

In conformity with the 2010 EU Plan of Action onGender Equality and Women's Empowerment inDevelopment, integrate gender perspectives intonational health plans, annual and multi-annualplanning and budget cycles, including genderindicators in health monitoring systems.

Work on policy dialogue to ensure thatinterventions showing scientific evidence of theirimpact are included in national health plans.

Promote the linkages between disease-specificprogrammes and other health initiatives, such as,for instance, reproductive health and familyplanning programmes and efforts to scale up thehealth workforce.

Provide technical and financial support todeveloping countries by means of long-term,sustainable financing mechanisms that makeuniversal access to primary healthcare possible.

29

A

ID

E

F

F

E

C

TIV

EN

E

S

S

F

O

R

H

E

A

LTH

:

:

C

H

APTER

3


30/40


APPENDIX:TRENDS IN HEALTH ODA:AN UPDATE

It is not possible to talk about the quality of aidwithout examining the quantity of aid beingdelivered. This appendix aims to give a snapshot ofthe quantity of aid from the five AfGH Europeandonor countries to developing countries and toevaluate their performance with regard to ODA andhealth ODA.

The data contained in this appendix is taken from areport commissioned by AfGH to accuratelycalculate real aid transfers from the five AfGHcountries60. The main findings are summarised intable 5 of this appendix.

30

Methodology

In order to calculate ODA and health ODA as apercentage of total ODA, AfGH does not includeexpenses that do not make a difference to thelives of people living in recipient countries, such asadministrative costs, the expense of housingrefugees during their first year of asylum in thedonor country, or debt that is written off from acountry's balance sheet. All of these items areallowed to be classified as ODA according toOECD Development Assistance Committee (DACguidelines), but do not represent real investmentsto build up the services and conditions required forhuman development in developing countries.Furthermore, the current practice of including debtrelief in aid figures creates artificial bubbles inofficial ODA statistics. The concept of realresource transfers represents a more realisticmeasure of overall donor efforts. In this way itbecomes possible to accurately compare andevaluate the true ODA contribution of the fivecountries. A detailed description of the

methodology applied is available on the AfGHwebsite61.

60 Performance of EconomicallyPrivileged Countriesas Donors - Estimate ofODATransfersto Developing Countriesand Contributionsfor Health Promotionregarding RelevantFinancing Mechanisms in the period 2007 to 2009.TheCasesof: France,Germany, Italy, Spain and the United Kingdom of GreatBritainand Northern Ireland,by Joachim Rueppel in cooperation withSieglinde Mauderand Birgi

Documents

Aid Effectiveness for Health 2011