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The Long and Tortured Road to Adequate and Sustained Donor Financing for Health

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Title: The Long and Tortured Road to Adequate and Sustained Donor Financing for Health


1
The 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

2
Outline 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?

3
Health 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).

4
Health Spending by Region
5
Most 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
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7
Would Meeting Abuja 15 Make a Difference?AU,
Health Financing in Africa 2006
8
Do Poor African Countries Have Fiscal Space?AU,
Health Financing in Africa 2006
9
Donor 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.

10
High Dependence but Still Low FundingAU, Health
Financing in Africa 2006
11
Donor 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

12
Kaiser Estimates for 2006 DAH are Lower, but
Reveal Sub-Sector Spending
(13.75 billion)
13
Percentage Growth in Sub-Sector Spending is
Highly Variable
14
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15
Promises, 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.

16
2008 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.

17
Increased 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.

18
Kiszewski A et al., Estimated global resources
needed to attain international malaria control
goals, 85 WHO Bulletin 623-630 (2007)
19
Source Johns B et al, Estimated resource needs
to attain universal coverage of maternal and
newborn health services, 85 WHO Bulletin 256
(2007)
20
Broader 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)

21
Source Global Plan to Stop TB 2006-2015
22
Source UNAIDS, Financial Resources Required to
Achieve Universal Access 2007
23
Source WHO, Draft Resource Needs Estimates,
Human Resources for Health (2007)
24
Scaling 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.

25
Costs for Educating Health Workers and Doubling
Salaries (billions) WHO 2007
Total 75.4 548
26
Earlier HRH/HSS Funding Needs Estimates (World
Health Report 2006, p. 13-14)
27
Needed 70 billion/year for HRH/HSSWhere is it
coming from?
28
Summary - Global Health Funding Needs,
Commitments, and Gaps Thru 2015
UK 12 billion?
29
Recurrent 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.

30
Recurrent 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.

31
World 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.

32
World Bank, Approach Paper Evaluation of the
World Banks Assistance for Health, Nutrition,
and Population (Independent Evaluation Group,
2007)
33
Bank 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

34
World 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.

35
Lack 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.

36
Fiscal 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.

37
Macroeconomic 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.

38
Loans 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.

39
PEPFAR 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.

40
PEPFAR 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.

41
U.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).

42
PEPFARs 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.

43
PEPFAR 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).

44
In 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.

45
Global 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.

46
Additional 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.

47
Global 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.

48
Overall Health System Spending 35
49
Global Fund Spending Now at 1 billion/year
(est. 220 million on HRH)
50
GF 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!

51
Global 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.

52
Round 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

53
Findings 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.

54
Examples 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.

55
Current GF HSS Strategy
56
Summary 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

57
GAVI
  • 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.

58
UK 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.

59
UKs 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.

60
More 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)

61
DfIDs 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.

62
International 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.

63
Global 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

64
New 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

65
DAH 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.
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