Global Aid Architecture for Health in Developing Countries Peter Berman Professor of the Practice of Global Health Systems and Economics September 22, 2014

Topics Actors The Scale-up in Funding Governance Current initiatives Discussion

Aid for Health  DAH = ODA + non-government external flows  US $5.6 billion in 1990, growing to more than $31 billion by 2013  7 Development Banks  30 Multilateral organizations  90 Global Health Programs  30 Bilaterals  Thousands of NGOs  Private philanthropy $5-6 billion/year by 2013

Plethora of Actors in Aid

MOH MOEC MOF PMO PRIVATE SECTORCIVIL SOCIETYLOCALGVT NACP CTU CCAIDS INT NGO PEPFAR Norad CIDA RNE GTZ Sida WB UNICEF UNAIDS WHO CF GFATM USAID NCTP HSSP GFCCP DAC CCM T-MAP 3/5 SWAP UNTG PRSP Isn’t Donor Collaboration Wonderful? Source: WHO: Mbewe

Accounting for DAH Tracking money is a useful way to describe scale, resource allocation, roles Familiar accounting issues: What is “health”? What are the best mutually exclusive allocation categories? Unpacking the flow of financing and avoiding double counting Linking to national financing

Who tracks DAH? OECD Development Assistance Committee (for ODA) Technical agencies: UNFPA, UNAIDS Academic researchers: IHME, LSHTM, NIDI Civil Society: One, Save the Children, others Collaborations: Countdown to 2015 National authorities: National Health Accounts National Health Strategy and MTEF

Source: IHME 2014

External Flows: By Source Source: IHME 2014

Source: Ravishankar et al, 2009 External Flows: By Channel Source: IHME 2014

15 Trends in ODA+ for MNH, CH, and R* (Countdown to 2015 estimates)

16 Ten Countdown countries received just under half of total ODA+ for maternal, newborn and child health in 2011 Source: Organisation for Economic Co-operation and Development’s Development Assistance Committee’s Creditor Reporting System Aid Activities Database

17 Seven Countdown countries received just over half of ODA+ to R* in 2011 (includes ODA for HIV/AIDS related programs) Source: Organisation for Economic Co-operation and Development’s Development Assistance Committee’s Creditor Reporting System Aid Activities Database

INTERNATIONAL AID ARCHITECTURE 18 Private Capital Debt Buy-back IFFIm Airline Tax GAVI Multilateral Banks UN Agencies ( WHO & others) Bilateral Donors UNITAID Global Fund Official Development Assistance International Philanthropy AMC Buy-downs, co- financing Global Health Partnerships Product Development Partnerships

DOMESTIC HEALTH SYSTEM ARCHITECTURE 19 Public ProvidersPrivate Providers Public Health & Community Health Services Individual Preventive Public Health Interventions Data, Health Education, Environmental Health Ministry Finance Ministry of Health Social Security Health Service Delivery Health FinancingPopulation Individual Health Interventions, Acute & Chronic Care Health Strategy Out-of-Pocket Payments Private Payments Insurance Out of Pocket Money Flow Government Money Flow Service Provision Public Providers

20 Private Capital Multilateral Banks UN Agencies ( WHO & others) Bilateral Agencies Official Development Assistance Public ProvidersPrivate Providers Public Health & Community Health Individual Preventive Public Health Interventions Data, Health Education, Environmental Health Ministry Finance Ministry of Health Social Security Health Service Delivery Health FinancingPopulation Individual Health Interventions, Acute & Chronic Care Health Strategy Out-of-Pocket Payments Private Payments Insurance Public Providers Debt Buy-back IFFIm Airline Tax GAVI UNITAID Global Fund International Philanthropy AMC Buy-downs, co- financing Global Health Partnerships

Donor contributions to medicines in Kenya

Governance Different global agencies have different governance structures WHO – World Health Assembly, member countries, one vote one country World Bank – Executive Board – Directors representing members with votes weighted by ownership of Bank’s capital Global Fund and GAVI – Board with members including governments, agencies, CSOs, private sector National Aid agencies – politicians, citizens Private Philanthropy and Corporations – owners

Questions Where did the decisions about current global health priorities (such as the MDGs) come from? Who should make decisions about global health priorities? Diseases Beneficiaries Health systems How should accountability for resource use and aid effectiveness be done?

Current Initiatives Governance H4+1, H8 Diseases, health problems Roll back Malaria Stop TB Partnership for Maternal, Newborn, and Child Health …and more e.g. Health system strengthening Health Metrics Network Global Health Workforce Alliance Alliance for Health Policy and Systems Research Medicines Transparency Alliance …and more More than 170 different organizations and partnerships

Recent Initiatives to Support Health Systems WHO Maximizing Positive Synergies Collaborative Group High Level Task Force on Innovative International Financing for Health Systems …”Establish a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others to coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies”… …”Improve alignment of planning processes and resource allocations among Global Health Initiatives, and between Global Health Initiatives and country health systems”… International Health Partnership+ …” achieve better health results by mobilizing donor countries and other development partners around a single country-led national health strategy, guided by the principles of the Paris Declaration and the Accra Agenda for Action

Possible Components of a Joint Approach to HSS 1. Support for national health strategy development 2. Joint HSS processes – including Joint Assessment of National Strategies (JANS) for funding HSS components 3. Common monitoring framework using annual review processes for monitoring performance 4. Common funding/disbursement channels

RMNCH and on Advocacy: “neglected MDGs”, Countdown 2015, Women Deliver conferences, PMNCH partners meetings Mobilizing international momentum: G8 chaired by Canada in 2010 – the Muskoka initiative; UN Secy Genl’s Global Action Plan UN General Assembly MDG Summit 2010 Commitment -- $40+ Billion Commitments from both developed and developing countries: new donors, domestic commitments Commission on Information and Accountability ( ) ( New International Advisory Group for UNSG Newer initiatives: ENAP, APR, FP2020 Global and national accountability efforts This week – update at UN General Assembly

Non-communicable diseases 2012 events? Emerging global disease epidemics -- CVD, Diabetes, Cancer -- and risk factors – smoking, diet, exercise New technologies, new delivery challenges Many new stakeholders What happens after 2015? How much progress? Sustaining current commitments New commitments in the current global economy?

Post 2015 Sustainable Development Goals Longer, more open, consultative process “Open Working Group” reporting this week: Current proposal: 17 goals and 169 targets (MDGs, 8 goals and 21 targets) Goal 3. Ensure healthy lives and promote well-being for all at all ages 13 Targets – including some from MDGs and others What was effect of MDGs? What will be effect of SDGs?

Viewing the Global Health Architecture from the Country and Community National resources still eclipse external in most countries – sometimes by a huge margin. But the number of countries where aid is a third or more of health spending has risen dramatically. Larger and/or better governed countries may be better able to manage external health architecture Many countries have limited technical capacity at country level to coordinate multiple finance flows (Uganda received aid from over 40 different donors between , involving 648 different aid instruments and agreements, many separate missions, reports, studies, etc.) Countries also face internal governance issues – how well do governments represent communities?

Commitments are episodic and time bound. Try managing this… Aid Volatility

5 Principles of the Paris Declaration on Donor Harmonization Ownership: partner countries exercise authority over their development policies, strategies & national health systems when relying on aid Alignment: donors base their overall support on partner countries’ national health and development strategies and procedures Harmonisation: donors organise their multiple activities in ways that maximize their collective efficacy Managing for results: countries manage resources and improve decision making for results Mutual accountability: donor and developing countries will be mutually accountable for development results

Aid Skeptics There are significant voices who doubt the value of aid –e.g. William Easterly, Dambisa Moyo, Lant Pritchett Arguments? Dependency Crowds out private and domestic action -- distortion Limited and controversial evidence of effectiveness Technical aspects Weak capacities and self-interested behavior of donors and recipients Corruption In health, public goods and market failure arguments are still persuasive, but the scope of market failures in health may be narrower than many would like to accept

Concluding Thoughts We face the problems of success – unprecedented global attention to health – so far sustaining despite global economic crisis Numerous new organizational solutions – perceived by many as moderately successful Have the solutions also become a new problem? Can we improve enough to sustain or accelerate progress? Has the wave for health peaked? And what is your view about that?