Submission by Merlin
INQUIRY ON CO-ORDINATION FOR AID EFFECTIVENESS
ABOUT MERLIN
1. Merlin is the only UK specialist agency,
which responds worldwide with vital healthcare and medical relief
for vulnerable people caught up in natural disasters, conflict,
disease and health system collapse. Merlin's aim is to ensure
that vulnerable people who are excluded from exercising their
right to health have equitable access to appropriate and effective
healthcare.
2. This aim is inspired and underpinned
by the World Health Organisation (WHO) declaration[93]
that "the enjoyment of the highest attainable standard of
health is one of the fundamental rights of every human being without
discrimination of race, religion, political belief, economic or
social condition". In support of this aim, Merlin works in
partnership with global, national and local health agencies and
communities to strengthen health systems and build community resilience
to better prevent, mitigate and respond to health outcomes.
QUESTIONS OF
OWNERSHIP
3. Merlin's experience of the aid effectiveness
agenda is predominantly based on our experiences in fragile states
such as Burma, Sudan, Afghanistan and the Democratic Republic
of Congo. In these contexts making aid more effective continues
to be a challenge for partner countries and international donors
alike: much of the aid effectiveness agenda is predicated on a
mutual political willingness to make aid more effective, but in
countries such as Burma[94],
where international engagement is low and the regime unwilling
to assume responsibility for development strategies, there is
a need to consider what happens to ownership when countries are
not willing to provide for the people.
4. The health system receives the lowest
priority in Burma. According to the 2005 Human Development Report,
Burma had the lowest public health expenditure (as % of GDP) of
all 173 countries measured, with government expenditure standing
at 0.4%. Donor coordination around the three-diseases fund, a
humanitarian funding mechanism, demonstrates that working with
NGOs such as Merlin it is possible to support the health sector,
and align with existing national strategies to ensure that health
services and interventions are delivered in accordance with national
health priorities, but there remains insufficient levels of aid
to meet the needs of the population and in the main the current
political context means that Burma remains excluded from the processes
of the aid effectiveness agenda.
DONOR POLICY
ALIGNMENT
5. One of the greatest challenges in fragile
states centres on the capacity constraints of national policies
and systems; in the Democratic Republic of Congo little bilateral
or multilateral aid is aligned to national priorities owing in
part to the absence of the government's development strategy combined
with significant capacity constraints and shortages of technical
skills. Although the Ministry of Health is responsible, in principle,
for policy stewardship of the health system, in practice administration
and enforcement at central level is poor and the Ministry has
lost a considerable degree of its autonomy to decide, orient and
direct national and regional health policy. A shortage of national
managers capable of ensuring coordination in accordance with agreed
guidelines has resulted in poor coordination among donors operating
in the health sector. Furthermore the challenges posed by DRC
government budget estimates against actual donor disbursements
means that senior officials have poor information about what funding
will be available to implement national health policy, making
long term planning difficult.
6. One of the consequences of this situation
is the lack of policy coherence between donors in the health sector,
particularly in the east of the country; one of Merlin's greatest
challenges in DRC has been reconciling separate donor policies
within the same Province or even programme. Although the donor
community has endorsed the Paris Declaration and Good Humanitarian
Donorship principles in many cases this has yet to translate at
field level. The tendency for donors to split areas geographically
(even within a Province) can lead to policy and practical inconsistencies
and impact on people's ability to access health care: conflicting
donor policies vis-a"-vis cost recovery mechanisms
in Maniema Province in 2006 led to the implementation of user
fees in health facilities in one area, while neighbouring facilities
(supported by a different bilateral donor) introduced free health
care services. DFID has made a commitment to work towards promoting
policy coherence and within the context of health this is particularly
important; the failure of donors to agree on common approaches,
within the same sector and province, only serves to undermine
already weakened systems, increase inequities in health service
provision and further contribute to the pressures of Ministry
of Health staff.
ALIGNING BILATERAL
AID
7. Increasing the predictable nature of
aid disbursements is a central tenet of the aid effectiveness
agenda and critical to the development and strengthening of health
systems. Current donor funding mechanisms are often inadequate
in transitional contexts (that is, the transition from humanitarian
intervention to development) where populations remain highly vulnerable
and health needs are unmet. The risks of working with fragile
states needs to be better balanced by the long-term health and
political benefits of continued engagement. Donors expectations
must be realistic—in countries facing chronic under investment
in health systems health outcomes will not improve in the short
term, it is a long term process. Merlin believes that the current
short term approach to health funding undermines real progress.
8. In addition, the current plethora of
global health partnerships presents a highly fragmented approach
to improving health outcomes. Global and vertical funds must better
match national development strategies and systems. Merlin welcomes
DFID's work with global funds to ensure better impact without
cutting across national priorities and systems (DFID, 2006).
9. Centralised pooling mechanisms can serve
to reduce the volatility of disbursements (and direct aid according
to need rather than to strategic interest) although there are
lessons to be learned. USAID is been reluctant to commit to pooled
funding because of concerns about monitoring the effectiveness
of their contributions to the funds. In South Sudan the Multi
Donor Trust Fund, established in 2006, has yet to disburse funding
for health despite substantial commitments by donors and the government
of South Sudan. Significant debate surrounds the reasons for the
lack of progress of the MDTF, however the experience highlights
the fragility of new financing mechanisms in fragile states where
capacity is weak. The key purpose of the MDTF in health was to
support the newly established Ministry of Health to develop its
own capacity to carry out core management and coordination functions
and expand service delivery to meet the needs of returning and
resident populations. This key objective is some way from being
met.
REFERENCES
DFID (2006). DFID's medium term action plan
on aid effectiveness. Our response to the Paris Declaration.
February 2008
93 As reflected in the WHO constitution (1946), Alma
Ata Declaration (1976) and World Health Assembly (1998). Back
94
Burma is not a signatory to the Paris declaration. Back
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