The Mid-Term-Review of the 10th EDF

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					Action For Global Health/ DSW
 Fact-finding Visits 2010/2011
                    7 June 2011
Fact-finding team meeting stakeholders
 Presentation Outline

1- Ownership and Civil Society/
   Parliament Participation
2- Donor Coordination, aid
   structures and their impact
   on health spending
3- Managing for Results:
   The role of aid forprogress towards the MDGs
   and for universal access to primary
1- True democratic ownership – 7 key steps

 1. DEMOCRATIC OWNERSHIP: Recognize CSOs as true
     partners and independent actors for development, not
     sub-contractors/ entities of the govt
        “Mass org.” in Vietnam: Prevent hand-picking of
     participants by govt! – EC Delegation Vietnam.
 2. SHARED RESPONSIBILITY among govt, donors and
    CSOs FOR MEANINGFUL ENGAGEMENT of representative
    diversity of non-state actors.
        IATI: Vietnam MoH suggestion: Sector ODA Database
        Mozambique: government electronic state financial
    administration system (E-SISTAFE) and ODAMOZ
        Online discussion: “international aid programme meeting
    point”; a platform for donor/CSO exchange of information.
1- True democratic ownership – 7 key steps

    CSOs: Pooled funding of EU donors for CSO capacity
    building.     CSSM Moz, IDF Ug. – but: high admin. Costs.
    Donors: Lack of Staff/ health expertise (     EC Tanz.)
   Fund’s CCM elections as best-practice
   model         India CCM replication – A “Western Model?”
6. Representation at ALL LEVELS, not only fora or technical
   WGs, but highest level policy-making instances.
         Tz, Ug., Moz.: Health policy advisory committees
          El Salvador: CISALUD
7. FOLLOW-UP: make recommendations binding!
        El Salvador: CISALUD and National Health Forum
2- Health aid Coordination – Mission impossible?

 • ACP countries: progress - middle-income countries:
   lacks attention
 • Often parallel coordination for HIV/AIDs and Health
 • True govt leadership questionable (particularly: ACP
   countries with high aid dependency)
 • Process-oriented – funding commitments to health plans?
 • Complexity and increased workload
         SWAps: no option for India, Vietnam, El Salvad.
   Donors with no presence in country increase complexity.
 • Lack of meaningful engagement of Civil Society (all)
   – lack of coordination of CSO projects (all)
 • Process is too centralized – positive donor coordination at
   local level:    El Salvador, RECODEL; Vietnam: EC health
   coordination at province level.
How to make coordination possible: IHP+?

• International Health Partnership and related
  initiatives (IHP+)
• Eg. Related initiatives: Health Matrix Network =
  a global partnership to address the lack of reliable
  health information in developing countries.
• Over 50 members, including partner countries,
  Civil Society and Development Partners
• IHP+ Principles: One Plan, One Budget, One
• Through Joint Assessment National Strategies,
  Country Compact, Joint Financing Agreement.
How to make coordination possible: IHP+?

 • IHP+ = opportunity for alignment of all donors and aid
   modalities with National health policy.
      Country Compact Mozambique – GAVI, USAID,
   GFATM and CSOs signed on.
 • IHP+ Validation leading to increased funding from
   donors for health policies  HRH Policy Mozambique.
 • Added value in some middle income countries with no
   Health SWAp
       Vietnam; El Salvador (clear interest from MoH).
 • IHP+ seen as an additional burden in countries with
   well-functioning SWAp    Tanzania.
 • CSO participation in IHP+ processes deficient
Vice Health Minister El Salvador on IHP+: Where do I sign?
How about Division of Labour?

  • EU Code of Conduct on Division of labour in
    Development Policy – Principles:

  • EU donors will focus their activities on two focal
    sectors on the basis of their respective
    comparative advantages
  • Max. 3 donors per sector by 2010.
  • Delegated cooperation/partnership:
    If a given sector is considered strategic for the
    partner country or the donor and financing gap:
    funds to be delegated to another focal sector
How about Division of Labour?

 • Division of Labour (DoL) often not a reality: focal
   and non-focal sectors in all fact-finding

 • DoL should not become a “sector exit strategy”
   (High-level European DP representative in Moz.)

 • Is DoL a donor or recipient country priority?
   Strong govt call for harmonisation, not DoL.
         El Salvador: 22 vertical programmes and 60
   different disbursement systems. If harmonised,
   could reduce health funding gap, while DoL is
   likely to increase gap.
Best Aid Modality for reaching Health MDGs?

 • European DPs interviewed in Mozambique:
   “Trying to establish a ranking of best aid modalities
   is artificial in itself as there is a need for both short-
   term results and long-term impact of aid”.

 • Country-context: General Budget Support (GBS)
   not always best model - middle-income countries?
       MoH in Vietnam: “Budget support is yet another
   donor fashion – don’t finance by fashion, but by
   needs and capacities!
   [...] Japan’s targeted project or programme support
   is very effective and aligned with our policies”
Best Aid modality for reaching the Health MDGs?

  • Many GBS donors also provide SBS - recognise the
    limitations of the GBS in ensuring funds for
    frontline service delivery  Tanzania
  • GBS fails to address culturally sensitive issues –
    HIV/AIDs, SRHR, Civil Society      Ug., India, Vietnam
  • Biggest Health donor USAID/ PEPFAR: despite
    recent reforms towards HSS, claims for traceability:
    MoH Vietnam: “They want their money to be known
    as their money”.    Uganda: USAID funding
    agreements with districts for health workers pay
  • EU-US dialogue: IHP+ as opportunity for alignment,
    not necessarily Budget Support.
GBS and Health as an Investment
 • Health considered “non-productive” instead of an
   investment        Tanzania: New PRSP allocates 10% less
   funding to health than in 2008/9 – growth: +14%.
      Ug., Tz., Moz.: Share of health sector in national
   budget stagnated at 9-12% during the last 3 years -
   about 40% of the health budget = external funding.
   Domestic share: 6-8%.
 • Per Capita spending:      Uganda: USD 10 (2008/9).
       Tanzania: USD 14 in 2010/11 (estimates).
       Mozambique: USD 18 in 2008.
 • Health funding gap of ca. 25% in ACP countries
       Tanz. PHC programme: ca. 50% funding gap in 2010.
       El Salvador: Health reform needs of EUR 100 million
Mozambique rural hospital: 2 of 3 nurses for 45.000 people
Hospital Laboratory Mozambique - Scarcity of equipment
How to promote domestic investments in health
• Ensure that Ministry of Health and health
  accountability stakeholders (Parliamentary
  Health Committees, CSOs) are to donor policy
  dialogue processes involving the government.
• Avoid fungibility – use Abuja Declaration and
  WHO/ PAHO per capita spending targets as GBS
  indicators in order to increase domestic funding for
• Avoid economic conditionality: the EU should act
  within the governing bodies of the Bretton Woods
  institutions to ensure fiscal space is granted to
  the social sectors in general and the health
  sector in particular       Ugandan MoF.
Vertical Funding for health – Example GFATM

  • GFATM creation as “neutral” funding entity for three
    “disease emergencies”: became single biggest
    external source of funding to health in many
    countries    Uganda, Tanzania: over 50%
  • Global Fund put on budget both in Tanzania and
    Mozambique = only about 50% disbursed in some
    years – accountability problems
  • On-budget GFATM funding led to distortion of
    domestic funding to health - mainly HIV/AIDs
  • MoH decided to put it off budget again in 2009 –
    caused drop in govt health expenditure: 13% - 11%.
Vertical Funding for health – Future of GFTAM
• Diseases approach: Suitable for middle-income countries?
       El Salvador, where HIV/AIDs rate under 1%, and
  75% of diseases are non-communicable.
       Vietnam: 62% of morbidity to non-communicable
       India: TB on the rise; HIV and Malaria: high.
• Funding gap for HIV/AIDS – especially for prevention-
  prevails – Not enough investment in health in general!
• Impact of recent GFATM reforms not yet visible at country
  level – reform of structures needed (HQ decisions)

• Future? DPs/ govt: GFATM should not engage in HSS due to
  lack of country presence. Added value of GFTAM in rapid
  procurement vs. cumbersome govt. systems.
HIV/AIDs Awareness-raising in Mozambique
Project Support for health

    Complementarity: CSO projects as “labs of
    experience” and “models of intervention”
       online discussion

        Ug., Tz.: 40% of health services provided by
    CSOs – key role in service delivery and expertise in
    reaching the most marginalized.

        Vietnam: EC evaluation: CSO health projects
    scored best in terms of results, even though their
    impact may not be as extensive as BS

        Moz: NGOs call for more funding for integrated
    and community-based approaches to health,
    complementing govt and private sector services.
3. Managing for Results – Not financing BY Results!

 • GBS and progress indicators. Progress, not process
       Moz. Global Fund scorecard evaluation: Low health
   scores despite immense progress

 • Funding by performance, not impact: Ex: number of
   condoms distributed instead of number of teenager using
   condoms. Final aim to change behaviours or to tick boxes?

 • Same risk for Cash-on-Delivery: Social sectors receiving
   less funding for producing less results – can you weigh lives
   against scorecards?

 • New results-based financing initiatives in the health
   sector: may undermine country ownership and health
   systems strengthening.         Iniciativa Mesoamericana,
   El Salvador: criticized for top-down disease-approach.
How can we trust the results?
 Weaknesses in national reporting systems.
     Ug.: Different data sources; cut-off points in time
 between departments within MoH
     DPs in Tanzania/ Ug. confirm OECD and CoA findings:
 “Performance monitoring in the health sector faces problems
 of reliability and timeliness of health information”.
      Lack of health expertise on donor side (eg. EC Ug, Tz)
    Ug.: Over-reporting at district health centre level.
 Vietnam: Vaccination rates over-reported/ optimistic.
    EU Del. Ug. and Moz. CSSM representative: “A need for
 donor support for CSO shadow reports”.
    Support social auditing at community level – El Salv.
El Salvador: Need for unified health information system
Thank you for your attention!
             Contact: Sibylle Koenig
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