Title: The Long and Tortured Road to Adequate and Sustained Donor Financing for Health
1The Long and Tortured Road to Adequate and
Sustained Donor Financing for Health
- Professor Brook K. Baker
- Northeastern U. School of Law, Program on Human
Rights and the Global Economy - Health GAP (Global Access Project)
- Joint Retreat of Civil Society Delegations
- Sept. 3, 2008
2Outline of Presentation
- Current global health spending domestic health
spending and development/donor assistance for
health. - Global health resource needs and financing gaps.
- Critical assessment of global health financing by
- World Bank
- PEPFAR
- Global Fund
- DfID, IHP
- Campaigning for adequate and sustained donor
financing for health what should we be doing?
3Health Spending in Developing Countries (92 of
Global Disease Burden) is Anemic
- Total health spending in developing countries in
2003 was 410 billion, roughly 12 of global
total and 5.7 of developing country GDP
(developing countries 84 of global population
and 92 of global disease burden). World Bank
Strategy for HNP Results 2007. - Most developing country health spending is out of
pocket (70 in low income countries 50 in
African countries) - Total health spending in Sub-Saharan Africa in
2005 was only 27 billion (11 population 24
disease burden). WB, Scaling Up Health Education
(2008).
4Health Spending by Region
5Most African Countries Fail to Meet their 15
Abuja Commitment
- At the end of 2007, only three African countries,
Botswana, Mauritius, and the Seychelles, were
meeting their 2001 Abuja Declaration commitment
to spend 15 of the governments self-funded
budget on health.
6(No Transcript)
7Would Meeting Abuja 15 Make a Difference?AU,
Health Financing in Africa 2006
8Do Poor African Countries Have Fiscal Space?AU,
Health Financing in Africa 2006
9Donor Assistance for Health is Even More Anemic
- Development/Donor Assistance for Health (DAH)
accounted for only 3 of total developing country
health spending in 2003. - However, DAH as a percentage of all official
development assistance grew from 4.6 in 1990 to
nearly 13 in 2005. - In Africa DAH accounts for 15 of health
spending, and 30 in 12 countries.
10High Dependence but Still Low FundingAU, Health
Financing in Africa 2006
11Donor Assistance for Health has Grown But is
Still Grossly Inadequate
- DAH rose from 6.8 billion in 2000 to
approximately 16.7 billion in 2006. - IHP Progress Rep.
- (2008)
- The mix of funding
- sources is changing
12Kaiser Estimates for 2006 DAH are Lower, but
Reveal Sub-Sector Spending
(13.75 billion)
13Percentage Growth in Sub-Sector Spending is
Highly Variable
14(No Transcript)
15Promises, Promises
- July 2005 at Gleneagles, the G-8 promised that
aid for all developing countries would increase
by approximately 50 billion a year by 2010, 25
billion extra would go to Africa. - Since DAH is only 13 of ODA, only an addition
3.25 billion per year would go to DAH and only a
portion of that for HRH. - First year, post Gleneagles, ODA actually
decreased by 5.1 (OECD, 3 April 2007). - Although donors make substantial aid commitments,
disbursements are consistently less.
162008 G-8 Commitments Hokkaido Toyako Summit
Leaders Declaration, 8 July 2008.
- We are firmly committed to working to fulfill
our commitments on ODA made at Gleneagles, and
reaffirmed at Heiligendamm, including increasing,
compared to 2004, with other donors, ODA to
Africa by US 25 billion a year by 2010. - G8 members are determined to honor in full their
specific commitments to fight infectious
diseases, namely malaria, tuberculosis, polio and
working towards the goal of universal access to
HIV/AIDS prevention, treatment and care by 2010. - We reiterate our commitment to continue efforts,
to work towards the goals of providing at least a
projected US 60 billion over 5 years, to fight
infectious diseases and strengthen health. - To achieve quantitative and qualitative
improvement of the health workforce, we must work
to help train a sufficient number of health
workers, including community health workers and
to assure an enabling environment for their
effective retention in developing countries.
The G8 members will work towards increasing
health workforce coverage towards the WHO
threshold of 2.3 health workers per 1000 people,
initially in partnership with the African
countries where we are currently engaged and that
are experiencing a critical shortage of health
workers.
17Increased Donor Assistance for Health is Essential
- Massive increases in external assistance are
needed to finance MDG health goals. (WB, Health
Financing Revisited 2006) - World Bank estimates range between 25 billion
and 70 billion in additional aid, per year, to
meet MDG health goals. - These estimates may be far too low, especially
when HRH/HSS is included.
18Kiszewski A et al., Estimated global resources
needed to attain international malaria control
goals, 85 WHO Bulletin 623-630 (2007)
19Source Johns B et al, Estimated resource needs
to attain universal coverage of maternal and
newborn health services, 85 WHO Bulletin 256
(2007)
20Broader estimates re child and maternal health
are much higher
- Best Buys on child health (saving 6 million lives
in 42 countries with 90 of child mortality)
5.1 billion/year or 40.8 billion 2008-2015. - Full implementation globally 10.6/year.
- (Global Health Council 2008)
- Reproductive health (excluding HIV/AIDS) requires
approximately 136 billion additionally 2008-15. - Skilled maternal health and birth care requires
approximately 34 billion additionally 2008-15
(overall with figure above). - (Global Health Council 2008)
21Source Global Plan to Stop TB 2006-2015
22Source UNAIDS, Financial Resources Required to
Achieve Universal Access 2007
23Source WHO, Draft Resource Needs Estimates,
Human Resources for Health (2007)
24Scaling up Health Professional EducationGHWA
Scaling Up, Saving Lives (2008)
- If there are no changes in either the skill mix
of the health workforce or the way education and
training is delivered, it will cost about an
extra US26.4 billion, or an estimated US2.64
billion each year over a 10-year period (over and
above current growth in health expenditure) to
educate and train the 1.5 million extra health
workers that the World Health Organization (WHO)
has estimated are needed in the African Region. - The costs of employment would be additional to
this.
25Costs for Educating Health Workers and Doubling
Salaries (billions) WHO 2007
Total 75.4 548
26Earlier HRH/HSS Funding Needs Estimates (World
Health Report 2006, p. 13-14)
27Needed 70 billion/year for HRH/HSSWhere is it
coming from?
28Summary - Global Health Funding Needs,
Commitments, and Gaps Thru 2015
UK 12 billion?
29Recurrent Dilemmas in DAH
- Donor assistance for health aid is often
earmarked for specific purposes and burdened by
conditionalities. - Only 20 of all health aid goes to support the
governments overall program. - Over 50 is off budget and not available to
support the health system or to pay recurrent
public sector costs staff, infrastructure,
training, management, etc. - Donor health is unpredictable, short-term and
volatile, resulting in marginal improvements of
existing services rather than significant
scale-up and innovation.
30Recurrent Dilemmas in DAH
- Aid flows and donor requirements are poorly
harmonized with country priorities. - A great deal of DAH has been tied, requiring
purchase of donor commodities and technical
assistance/consultancies. - There are high overhead losses.
- There are losses to corruption and inefficiency
in recipient bureaucracies. - Donor health aid is often fungible, meaning that
countries can disinvest in health at the same
time that donors are investing, usually as a
result of IMF/ministry of finance macroeconomic
restraint policies and misguided government
spending priorities.
31World Bank HSS/HRH financing
- 1997-2007, the Bank had cumulative HSS/HRH
lending of 15 billion (12 billion in
disbursements). - The importance of Bank HSS/HRH financing has been
shrinking over time, though the Bank projected
significant increases in health lending for FY07
to nearly 2.4 billion. - The Bank does not specify how much of its DAH
goes to HRH. - Bank DAH financing has been quite volatile.
32World Bank, Approach Paper Evaluation of the
World Banks Assistance for Health, Nutrition,
and Population (Independent Evaluation Group,
2007)
33Bank MAP (AIDS) Financing for System
Strengthening 2001-06
- Ministries of Health 22 million/805 million
(13,181 staff trained) 2.6 - Civil Society Organizations 55 million/805
million (47,439 staff trained) 6.8 - Other ministries 55 million/805 million (74,793
staff trained) 6.8 - Other organizations, e.g., ex-pat consultants,
244 million/ 805 million 30
34World Bank has Troubling Assumptions about DAH
- Large increases in donor funding for health,
much of it for recurrent spending, raise
important questions about the ability of
countries to absorb these funds, the
predictability and maturity of these funds, and
the ability of countries to sustain services once
donor funding stops.
35Lack of Absorptive Capacity
- Lack of absorptive capacity has been raised
every step of the way. - But, developing countries inability to plan and
implement health reforms can be ameliorated by
donors paying for capacity development and
supporting recurrent health managements costs. - Harmonization and alignment of aid, reduction in
conditionalities, and improved coordination can
help eliminate absorptive capacity bottlenecks.
36Fiscal Sustainability
- A countrys capacity to accommodate expenditures
financed with aid within the domestic budget
constraint in a reasonable period of time, while
maintaining sustainable levels of debt to GDP and
debt service to exports. (WB, Health Financing
Revisited, p. 139). - According to the World Bank, donor aid is fickle
and therefore countries ultimately need to be
able to rely on their own meager resources. - If this understanding of sustainability persists,
expanding and improving human resources for
health and reaching MDG health goals will remain
not only elusive, but illusionary. - The solution to sustainability is adequate,
long-term, and predictable DAH from bilateral and
multilateral donors.
37Macroeconomic Stability
- Bank focuses on maintaining sound macroeconomic
and fiscal policy and country competitiveness. - This translates into public sector fiscal
restraint, low inflation targets, and
investor-friendly economic environment. In case
of conflict, macroeconomic stability trumps
HSS/HRH.
38Loans not Grants
- Virtually all Bank HSS funding will be via IDA
concessionary loans. - Loans today create the debt crisis of tomorrow.
- Loans for infrastructure development may make
some sense, but loans for recurrent costs make
almost no sense.
39PEPFAR Report on Workforce Capacity and HIV/AIDS
(2006)
- PEPFARs Stated Focus
- Support for policy reform to promote
task-shifting from physicians and nurses to
community health workers - Development of information systems and Human
resources assessments - Training support for health workers, including
community health workers - Retention strategies and
- Twinning partnerships.
- Note No real focus on expanding HRH.
40PEPFAR HRH/HSS Spending 2008 Annual Report to
Congress The Power of Partnerships PEPFAR
- FY 07, 638 million was spent on capacity
building in the public and private health sectors
(in FY 06 350 million). - Networks 133,758,635
- Human resources 195,186,583
- Local organization capacity development
128,129,771 - Training 181,387,958
- FY 08, PEPFAR plans salary support for 110,000
HCWs.
41U.S. Restrictions on Payment of Recurrent Costs
- However, the USG has policy restraints on payment
of recurrent costs, e.g., salaries in the public
sector. - Occasionally, it works around these restrictions
via public sector salary support or more commonly
by creating non-governmental outsourcing
mechanisms to hire, train, and deploy health
providers on a contract basis to public-sector
health centers (Kenya).
42PEPFARs Retention Strategies
- Incentives such as housing allowances, hardship
allowance, transportation allowances, and
educational stipends for their children, medical
insurance or refunds for medical expenses, - Salary increments for good performance,
scholarship opportunities, and a supportive work
environment.
43PEPFAR is heavily focused on in-service training
- From FYs 04-07, PEPFAR spent 281 million
supporting training and retraining for nearly 2.6
million health workers. - There are plans for training/retraining 2.8
million health workers in FY 08, especially on
task-shifting (cost 309 million). - PEPFAR has provided limited support for
pre-service training (1 million per focus
country FY 07, 3 million per focus country FY 08
but 6 million or 3 of country budget FY 09).
44In PEPFAR Evaluation, Institute of Medicines
HRH/HSS-related Recommendations
- Must transition to an emphasis on long-term
strategic planning and capacity building for a
sustainable response. - Must address Building workforce capacity by
increasing its support and including the
education of new health care workers in addition
to AIDS-related training for existing health care
workers. - Note PEPFAR II has committed to training
140,000 (new?) health workers 2009-13.
45Global Funds Conflicted HSS Mandate (Sources
Global Fund Progress Report 2007, Drager et al
2006)
- Mandated to support priority disease programming
so as to strengthen health systems and human
resource capacity. - Has walked a tightrope between supporting
immediate measures addressing priority diseases
and supporting long-term measures for increasing
in-country capacity for scale-up. - The systematic, long-term development of
fundamental health infrastructure is beyond the
mandate and resources of the Global Fund.
46Additional Strategic HSS Guidance
- Global Fund has adopted five strategic guidance
points for HRH - Scale-up of workforce planning
- Synergize across priority programs
- Simplify services and task shift
- Secure health and safety of health workers
- Foster collaboration.
47Global Fund has had a modest impact on Human
Resources
- Approximately 22 of the Global Funds portfolio
Rounds 2-6 were devoted to human resources and
training.
48Overall Health System Spending 35
49Global Fund Spending Now at 1 billion/year
(est. 220 million on HRH)
50GF Size and Resource Mobilization Are Growing
- Demand for Global Fund could increase to between
6 and 8 billion per year by 2010 - This would represents a tripling in size compared
to 2006 (x 2.2 compared to expected 2007 income) - The Second Voluntary Replenishment Conference
held in Berlin in 2007 raised US 9.7 billion for
expanded activities during the period 2008-2010
roughly half of what might be needed. - Note demand creation remains a BIG problem!
51Global Fund HRH/HSS Conditionalities
- The Global Fund has used evolving guidelines re
HRH/HSS and has only permitted separate HSS
proposals in Round 5. - Global Fund initially required evidence of
sustainability e.g., the ability to service
recurrent expenditures in HRH/HSS proposals, a
requirement it had not imposed in other areas,
but has now dropped. - Global Fund still requires recipients to
demonstrate a link between HRH/HSS spending and
impact on target disease populations.
52Round 7 TRP HSS Critique
- Out of 2.8 billion approved in Round 7, only
363 million was targeted toward HSS. - Proposed HSS actions focused too much on
addressing obstacles to delivery of health
services, and not enough on planning, financing
and building health systems in the first place. - HSS technical assistance has been problematic
53Findings from Other StudiesGlobal Fund HSS/HRH
- Weaknesses in HSS application guidance
applicants are unsure abut the precise scope of
permitted HSS proposals. - Focus is on in-service training
- By the end of 2006, the GF supported training and
retraining of 3.6 million HCWs. - Limited recruitment of new HRH
- The bulk of professional staff recruitment
proposals are at the program management level. - Staff are often hired only for project duration.
- Some proposals provide for salary support, but
the bulk of proposals provide other incentives,
especially for assignments in rural settings.
54Examples of Global Fund HRH Activities
- Global Fund has helped support innovative
Emergency Human Resource Strategy in Malawi
adding 40 million to the 100 million provided
by DfID. - Global Fund is supporting the training and
appointment of 30,000 community health workers in
Ethiopia. - Global Fund is supporting salary support for
essential health service workers in Cambodia.
55Current GF HSS Strategy
56Summary of Current GF HSS Approach
- Broad flexibility regarding eligible HSS
proposals - No budget ceiling
- No priority list of interventions, but wont fund
large infrastructure projects or vaccine research - Commitment to TRP flexibility and HSS expertise
- Involvement of HSS stakeholders in CCM proposal
development - Attempts to coordinate better TA on HSS proposals
57GAVI
- GAVI expects to raise and spend 1.2 billion in
2008 on childhood immunization and related health
systems improvements. - Countries identify and address health system
bottlenecks to increase and sustain high
immunization coverage and thereafter can apply
for funding. - GAVI has commitment 500 million over five years,
focusing on health workforce, supply/distribution/
maintenance, organization and management.
58UK DfIDs Global Health StrategyCrisp, Global
Health Partnerships The UK contribution to
health in developing countries 2007 DfID,
Working together for better health 2007
- 2005-06, DfID spent 481.4 million bilaterally
and 173.6 million multilaterally on global
health aid. - In 2007 it spent close to 800 million on global
health. It has committed to doubling its aid
budget between 2008-13. - DfID has committed 55 million over six years to
support recruitment, training and retention of
health workers in Malawi. - DfID is focused on sexual and reproductive
health it donated 100 million to UNFPA in Oct.
2007. - 50 of DfIDs aid is for basic health services.
59UKs HRH/HSS Focus
- On April 17, 2008, the US and UK announced a
partnership to increase number of health workers
in Ethiopia, Kenya, Mozambique and Zambia. - UK committed to spending 420 million on health,
including health workforce over three years - US planned to invest at least 1.2 billion over
five years to health workforce development. - On June 2, 2008, DfID announced it would spent 6
billion over 7 years to improve health services
and systems in developing countries to fight
HIV/AIDS through closer integration of AIDS, TB,
malaria, and SRHR, including maternal and child
health services.
60More from UK Achieving Universal Access (June
2008)
- In addition to the 6 billion, the UK announced
in September 2007 that it would provide 1
billion to the Global Fund between 2008 and 2015. - It committed 200 million over three years to
expand social protection programmes, which will
help ensure that more Orphans and Vulnerable
Children have access to better child nutrition,
health and education. - The UK will provide 2.134 billion over three
years (2008-11) to the IDA15 the International
Development Association replenishment (December
2007)
61DfIDs Global Health Strategy
- DfID is focusing on country-ownership,
longer-term aid, direct budget support, and
health system planning and strengthening,
including educating and training an expanded
health workforce and mitigating the brain drain. - DfID is also focused on improving the
effectiveness and coherence of international
funding for health via IHP.
62International Health Partnership-Plus A New
Focus on Coordination, ?
- UNAIDS, UNFPA, UNICEF, WHO, World Bank UK,
Norway, France, Germany, Italy, Netherlands
European Commission, GAVI, GFATM Gates
Foundation - Focused on providing better coordination among
donors improving health systems, supporting the
development and implementation of health plans. - First-wave, focus countries Benin, Burkina
Faso, Burundi, Ethiopia, Ghana, Kenya,
Madagascar, Mali, Mozambique, Niger, Zambia,
Cambodia, Nepal. - The first compact signed in Ethiopia on Aug. 28,
contains no explicit promises concerning
increased DAH.
63Global Campaign for the Health MDGs and other
Initiatives
- The Partnership for Maternal, Newborn Child
Health - more resources will be raised
- World Bank will coordinate through IDA
- Norway-Led Initiative Deliver Now for Women
Children (formerly Global Business Plan) - Focus countries India, Pakistan, Ethiopia
(Nigeria?) - UNICEF/Canada and others Catalytic Initiative to
Save a Million Lives - Focus countries Benin, Ethiopia, Ghana,
Liberia, Mali, Mozambique, Tanzania, Afghanistan,
Cambodia, Pakistan - Germany/France, Providing for Health Initiative
- Supports social health-protection systems
64New Commitments for HSS and support of primary
and child and maternal health
- Norway has pledged 1 billion to childhood
immunization through 2015 - The Netherlands has pledged 125 euros over three
years - Canada 105 million over 5 years, matched by
UNICEF
65DAH Faces Competition from Food and Fuel Shocks
and Other Priority Needs
- Since 2005, food prices have risen by 83 and oil
by even more over 300 since 2003 (from 30
barrel to 140). - FAO has estimated that the costs of a revitalized
global food policy is between 20-30 billion a
year - up from 3.4 billion in 2004. - These shocks will have adverse effects on
inflation, government spending, and currency
reserves in net importing countries and will lead
to tighter macroeconomic constraints from the
IMF. 72 countries will experience severe shocks
as a result of the combined effects of oil and
food prices. (IMF June 2008). - Poor countries have compelling and legitimate
needs in education, infrastructure, and economic
development, costing 10s of billions/year.