PHA-Exch> Setting a Developing Country Agenda for Global Health.

[Claudio Schuftan]

**
*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.

Email: geg at univ.ox.ac.uk
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