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# re: Accra High Level Forum – Accountability before aspiration? @ Monday, March 31, 2008 3:26 PM

Whyms and Buse have written an extremely timely and important set of questions which I hope will be picked up and addressed by those involved in the consultation process for HLF-3. On the specific question they raise about 'what is going on here' - i.e. why has the health-as-a-tracer-sector agenda been dropped - I don't think there's too much mystery.

First, the content of the Roundtables broadly mirrors the five key areas of the Paris Declaration (ownership, alignment, harmonisation, managing for results and accountability) – an outcome for which support was expressed in a June 2007 Steering Committee Meeting in Paris (where there was support for "alignment of the Roundtable content with the Paris Declaration").  

Second, the choice of content for the Roundtable also corresponds with the priorities of partner countries as expressed through mini 'exit' surveys organised by the WB at various meetings held from June-Sept 07 (see 'Summary of Partner Country Consultation on the Preparation of the Accra High Level Forum on Aid Effectiveness' on the HLF-3 site). Thus, monitoring had 40%, country ownership 38%, managing for results and accountability 33% a piece, role of CSOs 19%, and funding 17%. Health-as-a-tracer-sector received just 10% support- the same as fragile states and conflict countries.

Clearly, the health-as-a-tracer-sector idea has been dropped from the Accra agenda. The reasons for this are not difficult to determine, and it is possible to understand the rationale – i.e. that it is an idea that no longer reflects the priorities of partner countries. My guess is that this will also be the justification for the change in focus of the HLF agenda – expect to hear soothing phrases like ‘inclusive consultation’ and words such as ‘participatory’ and ‘representative’.

On the one hand this is a good thing: it is good that partners are consulted. But consultations also lend themselves to the dark art of agenda-setting. It is not sufficient to give ‘partners’ a list of options and then say ‘choose your favourite’; there must be a more accountable and iterative process than that. Many of us thought that we had that with the OECD; that the health-as-a-tracer idea had been discussed, shaped, re-shaped, and approved – in other words a ‘proper’, inclusive, decision-making process.

Of course, understanding the rationale for making a radical revision to the agenda of a high-level, international forum doesn't mean that the rationale is right. The HLF consultation process is ongoing and it is not too late to make sure that health is given a much higher profile than it currently has on the Accra agenda. Whyms and Buse have alerted us to the problems; if we want a different outcome, then it is up to all of us now to take these issues further.

Andrew Harmer    

Andrew Harmer

# Global Health Fund aka World Social Health Insurance @ Friday, April 11, 2008 2:49 PM

How very encouraging it is to read distinguished health development experts like Desmond Whyms and Kent Buse supporting the idea of expanding the mandate of the Global Fund to become a Global Health Fund.

My own thoughts about this originated from the turf battles between health development and medical relief experts. Having worked for a medical relief organisation during most of my professional life, I found it very difficult to understand why most health development experts attached such great importance to the sustainability of interventions supported with foreign assistance. [1]

Of course, sustainability matters. But why would sustainability have to rely on domestic resources, within a foreseeable future? Could sustainability not rely on a combination of domestic resources and sustained foreign assistance? Using the Global Fund as an example, I developed with Katharine Derderian and David Melody the concept of a 'World Health Insurance', which would provide sustained foreign assistance to low-income countries for all essential health expenditure. We used the US$35 per person per year expenditure level as recommended by the Commission on Macroeconomics and Health as the minimum target for all low-income countries. [2]

With Wim Van Damme and Marleen Temmerman, we described a practical paradox as an illustration of why the Global Fund should gradually become a Global Health Fund: the 'Medicines Without Doctors' paradox. As long as salaries of health workers are funded within the 'old' sustainability approach (aiming for domestic financial self-reliance), while medicines for AIDS treatment are funded within the 'new' sustainability approach (based on domestic financial resources and sustained foreign assistance), we will find situations in which the medicines are available, while the health workers are not. Of course, there are many similar paradoxes: like free healthcare for people living with AIDS in the same health centres where all other patients must pay user fees. [3]

I elaborated those ideas and arguments in my doctoral thesis. I think I illustrated the necessity and the feasibility of some kind of Global Health Fund, and I also tried to illustrate how a human rights approach to health supports a Global Health Fund. [4]

However, with Wim Van Damme, Brook Baker, Paul Zeitz and Ted Schrecker, we also warned for a too hasty transformation from the Global Fund into a Global Health Fund. A Global Health Fund would need at least US$24 billion to US$36 billion per year, only to bring public health expenditure levels in low-income countries to US$40 per person per year, and only if low-income countries would greatly increase their own contributions to healthcare. [5]

What seems urgently needed now is a serious discussion between the so-called 'Health 8', to clarify the future role of the Global Fund within the global health aid architecture. This should take place in 2008 and 2009, before the next replenishment of the Global Fund will be launched (2010).

I sincerely hope these ideas will contribute to stimulating debates and strong leadership, which could save the lives of millions of people. The Accra High Level Forum would provide an excellent forum, indeed.

Gorik Ooms
gorik.ooms@scarlet.be

[1] Ooms G (2006) Health Development versus Medical Relief: The Illusion versus the Irrelevance of Sustainability. PloS Med 3(8): e345. Available: http://medicine.plosjournals.org/archive/1549-1676/3/8/pdf/10.1371_journal.pmed.0030345-S.pdf

[2] Ooms G, Derderian K, Melody D (2006) Do We Need a World Health Insurance to Realise the Right to Health? PLoS Med 3(12): e530. Available: http://medicine.plosjournals.org/archive/1549-1676/3/12/pdf/10.1371_journal.pmed.0030530-S.pdf  

[3] Ooms G, Van Damme W, Temmerman M (2007) Medicines Without Doctors: Why the Global Fund must Fund Salaries of Health Workers to Expand AIDS Treatment. PLoS Med. 4(4): e128. Available: http://medicine.plosjournals.org/archive/1549-1676/4/4/pdf/10.1371_journal.pmed.0040128-S.pdf  

[4] Ooms G (2008) The right to health and the sustainability of healthcare: Why a new global health aid paradigm is needed. Ghent: Academia Press. Available: http://www.icrh.org/files/academia-doctoraat%20Gorik%20Ooms_0.pdf

[5] Ooms G, Van Damme W, Baker B, Zeitz P, Schrecker T (2008) The ‘diagonal’ approach to Global Fund Financing: a cure for the broader malaise of health systems? Globalization and Health 2008, 4(6). Available: http://www.globalizationandhealth.com/content/pdf/1744-8603-4-6.pdf

Gorik Ooms

# re: Accra High Level Forum – Accountability before aspiration? @ Tuesday, April 15, 2008 2:28 PM

The points raised by Ooms and others on this topic are very welcome. Clearly the debate on the Global Health Partnerships is entering an important juncture, with the HLF in September, the IHP+ recently underway, and a growing realisation that we are running very short of time to make up lost ground on the health MDGs by 2015. If we are serious about the health MDGs and our commitments to deliver more aid in a more effective way to reach them, we need to start discussing and acting on some radical reforms to the so-called global health architecture.

Our blog was not intended to present estimates of the global quantum required to adequately resource a Global Fund for Health.  We are well aware there are others better placed and more able to do so than we are (and we are pleased that Ooms usefully provides references to work that he and his colleagues have carried out on the topic).  Our interest and focus is on how to bring coherence to the existing money going into vertical health programmes - and the accountability to deliver this coherence. The real value (architecturally speaking) of new and innovative partnerships and initiatives is when they replace others, and not merely add to the complexity and confusion.  There is still value, of course, in disease focus for raising funds, convening technical experts, and monitoring impact. What we want to draw attention to are the primarily political challenges, represented by the urgently needed process of dismantling and streamlining the current too-numerous and messy resourcing channels, and the many heterogeneous and unnecessary demands that they are placing on country health systems. Thus we are calling for more discussion on the architecture/structures (including those which will deliver meaningful accountability for commitments made), coupled with more realism of, and openness to, addressing the politics which underpins this architecture

Desmond Whyms

# Overcoming multiple divides? @ Wednesday, April 16, 2008 8:59 AM

This discussion about a Global Health Fund or a Global Fund for Health provides an excellent opportunity for a much-needed dialogue between AIDS activists and advocates for improved general healthcare. These ideas are also being discussed on the listserv of the International Treatment Preparedness Coalition (ITPC). I encouraged the participants of the ITPC discussions to check out this ODI blog. Likewise, I would invite the readers of this ODI blog to join the ITPC listserv:
internationaltreatmentpreparedness@yahoogroups.com. Or perhaps someone smarter than I am could create an aids-and-general-healthcare-dialogue discussion group?

At the risk of turning this into a comment that is too long for most people to read, I copied and pasted below a discussion between Paula Akugizibwe of the AIDS and Rights Alliance for Southern Africa (ARASA) and myself, see below.

This being written, I do understand Whyms' and Buse's focus "on how to bring coherence to the existing money going into vertical health programmes - and the accountability to deliver this coherence", while presenting "estimates of the global quantum required to adequately resource a Global Fund for Health" was not their intention. However, I do believe that, in this case, 'size matters'.

Most of the turf battles I witnessed (and been part of) in this field - medical relief versus health development, AIDS treatment versus AIDS prevention, AIDS treatment versus Health Systems, vertical versus horizontal - are caused by too little pies and too many people trying to get their piece of it. This creates a trap. On the one hand, if we call for a US$30 billion per year Global Health Fund 'and not a penny less than that', we will scare away the persons who could take such decisions. On the other hand, if we call for the Global Fund to become a Global Health Fund, without creating the prospect of a much bigger Fund, we scare away all the AIDS activists, who legitimately fear that the AIDS money for which they have fought hard will be used for something else.

Our best hope to overcome this divide is to hold governments of high-income countries and governments of low-income countries to account for commitments that they have made.

African governments promised to spend 15 percent of their budgets on health. That's a crucial promise. However, it needs to be completed. First of all, it should be 15 percent of their budgets excluding foreign assistance. It's too 'easy' to achieve this target with massive amounts of 'on budget' foreign assistance. Second, it should be 15 percent of at least 20 percent of GDP. Some low-income countries have government revenue of 20 percent of GDP or more; others have government revenue of only 10 percent of GDP. If governments of low-income countries are serious about realising the right to health (and the right to education, and so on), they should aim for domestic government revenue of at least 20 percent of GDP. 15 percent of 20 percent of GDP is 3 percent of GDP, while 15 percent of 10 percent of GDP is only 1.5 percent of GDP. 3 percent of GDP is what governments of low-income countries should account for.

High-income countries promised to allocate 0.7 percent of GDP to foreign assistance. If we expect low-income countries to allocate 15 percent of government revenue to health, we should demand the same from high-income countries foreign assistance budgets. That would make 0.1 percent of GDP.

Combined - 3 percent of GDP from low-income countries, plus 0.1 percent of GDP from high-income countries - should be enough to make a huge step forwards, and to settle the divide between AIDS activists and advocates for improved general healthcare for once and for all. According to my own estimates, it would increase domestic funds for healthcare in all low-income countries excluding India (which is on its way to become a lower-middle-income country) from US$7.5 billion to US$15 billion. Global health aid to these countries would increase from US$10 billion to US$30 billion. Together, that would make US$45 billion for 1.1 billion people (or the 'bottom billion', as Paul Collier calls them), or US$40 per person per year (coming from US$16 per person per year). That should be enough to overcome the divide.

And it requires nothing else than governments living up to promises already made.

Take care,

Gorik

P.S. The following is copied and pasted from the ITPC discussions  

-----Original Message-----
From: Paula Akugizibwe
Sent: 14 April 2008 09:18
Subject: ITPC Re: Africans Betrayed by Own Finance Ministers?


This is all so depressing. African governments don't want to spend adequately on health. IMF policies wouldn't let most of them spend adequately even they wanted to. PEPFAR can spend on health, but only on the terms and conditions of some dangerous moralist agendas - and of course, they can't tell us exactly how much they're spending. The IHP was developed at an unfathomable distance from the people to whom it matters most. WHO AFRO is a bastion of bureaucratic inefficiency. Most of the major players on the African health landscape seem to be caught up in stupid bureaucracy, self-serving politics and/or sheer arrogance; while our continent continues to play regular host to the world's most deadly epidemics. Cause and effect? Probably... One thing is clear – many of most influential people charged with improving health conditions on our continent don't really give a damn about their charge; and unless we start making them direct targets of strong advocacy campaigns, all our ambitious health targets will just remain meaningless figures on meaningless pieces of paper waved around by meaningless leaders. AU health ministers are meeting in Geneva on May 17 and the agenda includes a report on the progress of implementation of Abuja outcomes. Health ministers may not be directly responsible for national budgets but they certainly don't seem to be fighting hard enough for an adequate share for health. I think there should be a lot of noise in the lead-up to this meeting...

Paula Akugizibwe
AIDS and Rights Alliance for Southern Africa

Westminster House, 4th Floor
122 Longmarket Street
Cape Town, 8001
South Africa


-----Original Message-----
From: Gorik Ooms
Sent: 15 April 2008 09:32
Subject: RE: ITPC Re: Africans Betrayed by Own Finance Ministers?


Dear Paula,

It is depressing, I agree. However, we should not despair. I'm not suggesting that turning the Global Fund into a Global Health Fund will be the magic bullet that will solve all problems. However, it could contribute
to a solution for most of the points you raised.

1. 'African governments don't want to spend adequately on health'. For upper-middle-income countries, the Global Fund has started a policy of demanding 'counterpart efforts'. I think this could be broadened to all recipient countries. For example: all countries that by 2015 are not allocating the equivalent of 3 percent of their Gross Domestic Product on health (excluding grants) will no longer receive funding to governmental structures. Only civil society organisations would receive funds.

2. 'IMF policies wouldn't let most of them spend adequately even if they wanted to.' True, but this entire policy is based on the argument that foreign assistance is not reliable in the long run. If all high-income countries would agree (or be pressured into agreeing) to allocate the equivalent of 0.1 percent of their Gross Domestic Product into a Global Health Fund, forever, the argument would no longer be valid.

3. 'PEPFAR can spend on health, but only in terms and conditions of some dangerous moralist agendas.' We don't have those problems with Global Fund grants, and we should not have them with Global Health Fund grants. Proposals are judged on their technical merits, in accordance with scientific evidence. No moralist agendas (and also important, no other political strings attached).

4. 'The IHP was developed at an unfathomable distance from the people to whom it matters most.' The IHP would become a platform to provide technical assistance, to help health ministries elaborate the best strategies. But the real decisions would be taken in 'Country Coordination Mechanism' and the board of the Global (Health) Fund, which include civil society. Far from perfect, I agree, but it's a start and progress is being made.

5. 'WHO AFRO is a bastion of bureaucratic inefficiency.' Well, a Global Health Fund wouldn't change that. Unless we consider that WHO in general is constantly caught between a rock and a hard place; between the obligation to promote the most cost-effective solutions for inadequate resources and the obligation to try and increase the resources available.

On your main point, we do agree: change will not come from people like me sitting behind a PC in Belgium; change will come from strong advocacy, on the ground, around the world.

Take care,

Gorik

Gorik Ooms

# The aid story in 2008. What’s next? @ Wednesday, April 16, 2008 2:42 PM

2008 is turning into another of those milestone years for aid. A cluster of high level meetings are focusing international attention on the challenges around effective development assistance. This presents familiar challenges: how to scale-up, align and

Overseas Development Institute (ODI) Blog

# re: Accra High Level Forum – Accountability before aspiration? @ Tuesday, May 06, 2008 8:01 AM

Two suggestions in this article concern me:

a) that because health aid flows are complex they should radically "harmonised" and "aligned"

b) because the Fund has been successful it should be expanded to cover other health problems.

But isn't the Fund's success a result of the fact that its actions have not had to be "harmonised" with any other agenda and that it has been free to focus on a few, very specific problems? There is a real risk here of unintentionally diluting and diverting one of the few great international development initiatives of recent years.

Francis Bacon
http://thatsthewaythemoneygoes.blogspot.com/

Francis Bacon

# re: Accra High Level Forum – Accountability before aspiration? @ Wednesday, May 07, 2008 7:26 AM

Accountability, transparency and the lack of global coordination and strategic direction in global health remains one of the key governance challenges. We are of the firm opinion that a regular high level forum is needed with great urgency and that it should be established under the auspices of the WHO.  The WHO has the constitutional mandate to address global health issues in general and not only the governance of WHO itself -therefore the overall coordination of global health action should be the task of the World Health Assembly (WHA).  In a recent comment in The Lancet we propose such a mechanism: the establishment of a Committee C of the WHA. Its meetings should include the major stakeholders in global health – international agencies, philanthropic organisations, multi-country health initiatives, as well as representation from major civil society groups, particularly those who legitimately represent the most vulnerable populations. We believe that such a mechanism would fulfil a number of challenges faced by the current fragmentation of the global heath; in particular it would enhance transparency and accountability. (Creating a committee C of the World Health Assembly
Gaudenz Silberschmidt, Don Matheson, Ilona Kickbusch
The Lancet - Vol. 371, Issue 9623, 3 May 2008, Pages 1483-1486)

Ilona Kickbusch