House of Commons - Strengthening Health Systems in Developing Countries

Strengthening Health Systems in Developing Countries - International Development Committee Contents

2 DFID's health systems work

Expenditure

7. Almost one-quarter of DFID's total project budget in 2014-15 is allocated to health, making it DFID's largest area of spending.[16] The UK is one of the few donors to have increased official development assistance (ODA) on health as a proportion of gross national income in recent years, reaching the WHO recommendation of 0.1 per cent in 2011.[17] DFID was the third largest donor of ODA for health in 2012, behind only the United States Agency for International Development (USAID) and the Bill and Melinda Gates Foundation.[18]

8. Much of DFID's health expenditure is channelled via international multilateral organisations. DFID's bilateral expenditure (aid to a specific country) on health was £907 million in 2013, while it provided £387 million to the GAVI Alliance (GAVI), £543 million to the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), £53 million to UNITAID and £166 million to the WHO in 201314.[19] In total, UK ODA for health is roughly evenly split between multilateral and bilateral channels.[20]

9. DFID estimates that it spent £360 million on supporting health systems and £10 million on health systems research in 2013-14. In total, this accounted for around 34 per cent of total bilateral health spending, excluding core contributions to multilateral agencies. This was slightly lower than the 41 per cent estimated for 2008-09, though expenditure in absolute terms has risen substantially over the period.[21] DFID noted that these figures are likely to be substantial underestimates; programmes primarily focused on one particular disease or population group often have a significant health systems component.[22] Other estimates are lower: Action for Global Health suggested 14 per cent, based on the incomplete data on DFID's Development Tracker website; while Save the Children estimated that 21 per cent goes on direct systems strengthening.[23] Regardless, the actual figure is likely to fall below the WHO recommendation of spending 50 per cent of health international assistance funds on HSS.[24]

10. DFID's support for HSS includes technical assistance to governments and health providers, policy advice via a network of health advisers and direct funding to governments through both general and sector-specific budget support.[25] Financial aid, which includes budget support, has accounted for a decreasing proportion of DFID's bilateral HSS expenditure in recent years: it accounted for 42 per cent in 2012-13, compared with 66 per cent in 2008-09. Over the same period, the proportions used for technical assistance and, in particular, the delivery of bilateral aid through other organisations, have grown. In 201213, 36 per cent of DFID's bilateral HSS expenditure was channelled through multilaterals, NGOs or other third-party organisations.[26]

Bilateral programmes

11. DFID has a longstanding reputation as an effective promoter of sustainable investment in health.[27]However, it stands accused of undermining this reputation by focusing on vertical programmes and targeting short-term improvements in health outcomes, to the detriment of health systems.[28] For example, GRM Futures Group International, a consultancy, wrote:

NICE International told us that a "target-driven mentality" is "perhaps the greatest obstacle to DFID fulfilling its role in HSS globally", arguing that it resulted in important, but difficult to quantify, elements of HSS such as institutional reform, audit and decision-making processes being "under-valued and under-funded".[30]

12. DFID disputed this analysis, pointing to independent reviews which found that it had generally avoided a narrowing of activities onto the immediately measurable.[31] Dr Andrew Cassels, former Director of Strategy, WHO, told us that, though it was less inclined than in the past to talk about HSS, DFID retains an admirable focus on system strengthening in its bilateral programmes.[32] System strengthening is fundamental to the improvement of health outcomes. It is also the route to self-sufficiency for developing countries. We commend DFID for its strong focus on health system strengthening in its bilateral programmes. It is important that health outcome targets do not have the unintended consequence of reducing this focus. We recommend DFID review its health targets to ensure that they are compatible with achieving its system strengthening objectives.

International partners

MULTILATERALS

13. We heard concerns that multilaterals such as the Global Fund and GAVI, which receive a large amount of funding from DFID, show insufficient regard to HSS. This was partly because they were set up to tackle specific diseases, a task they had performed highly effectively, rather than to strengthen health systems.[33] However, Angela Spilsbury, DFID's senior health adviser in Ethiopia, told us that recent years have "seen a really large shift, with GAVI and the Global Fund moving towards a much more health systems approach".[34] The Global Fund's new funding model was praised in evidence, and Lynne Featherstone MP, Parliamentary Under-Secretary of State at DFID (the Minister), welcomed GAVI's HSS expenditure target.[35]

14. The multilaterals argued that disease-specific programmes are often effective vehicles for HSS. The Global Fund told us that while its interventions "may be born out of the need to respond to a particular disease […] they support the creation or development of key building blocks which serve the larger health system". Dr Michael Johnson, that organisation's Head of Technical Advice and Partnerships, described this as a "collateral effect".[36] The Global Fund aims, in partnership with other organisations, to "leverage" disease-specific programmes to have wider benefits at minimal additional cost.[37] For example, the Global Fund has financed the development of open-source health information software for Tanzania which, though designed for tracking AIDS, is now used across many diseases.[38] GAVI said that immunisation, by providing a point of contact between populations and health workers, gives an opportunity to deliver other services such as family planning.[39] Others cautioned against relying on "trickle-down effects", noting that vertical programmes could even act against the creation of sustainable health services, particularly where they compete with systems for scarce resources.[40]

15. We also heard concerns about the breadth of HSS-focused work by multilaterals. Dr Andrew Cassels argued that system interventions by the Global Fund and GAVI tend to be narrowly linked to their target health outcomes, providing inputs to a system without strengthening its operation.[41] Dr Julian Lob-Levyt, former CEO, GAVI, and former Chief Health Adviser, DFID, stressed that failing to acknowledge these narrow interests risked broad HSS being given insufficient attention.[42] The Independent Commission for Aid Impact (ICAI) noted that while GAVI had developed and maintained an effective vaccine distribution system in Kenya, this was not connected to wider health system reform.[43] Furthermore, Kara Hanson, Professor of Health System Economics, London School of Hygiene and Tropical Medicine, questioned whether these multilaterals have the requisite expertise to manage HSS programmes.[44] As they typically do not have permanent incountry representatives, they can also encounter problems in local coordination and identifying priority areas for improvement.[45]

OTHER DONORS

16. We were told that other major health sector donors have tended to "focus on quite narrow, short term results".[46] In our recent inquiry on recovery and development in Sierra Leone and Liberia, we received evidence that child mortality rates had fallen faster in Liberia, where USAID had taken a largely vertical approach, than in Sierra Leone, where DFID had concentrated on HSS.[47] However, Paul Wafer, Head of Sierra Leone and Liberia, DFID, expressed concern that USAID's approach was not sustainable or affordable in the long run.[48]

17. The Bill and Melinda Gates Foundation (Gates) is a major player in health development. It made total grants of $3.4 billion in 2012 and is now the largest contributor of voluntary funds to the WHO, outstripping all national governments.[49] Gates had a reputation of being focused on vertical interventions, and in the development of new technologies such as vaccines in particular, to the exclusion of HSS. This approach influenced the direction taken by other organisations, including the WHO.[50] We were told, by both Gates and DFID, that Gates now takes an increasingly system-centric approach.[51]

GAP-FILLING AND COORDINATION

18. Professor Kara Hanson told us that Gates sees its role as a "gap filler", specialising in areas where it has expertise, such as technology, and leaving other work to other organisations.[52] Similarly, we were told that GAVI's immunisation work "opens the space for others to come in on health systems".[53] The Minister acknowledged that DFID subscribes to this approach, explaining that it maps gaps in provision, stepping in or aside as necessary depending on which organisation has the comparative advantage.[54] However, it is not clear how this approach would work in countries where DFID does not have a bilateral programme.[55] DFID has reduced its portfolio of country programmes from 43 to 28 since 2010, meaning UK aid is increasingly delivered by multilaterals.[56]

19. Despite some significant moves in the right direction, we are not convinced that DFID's main international partners give the development of health systems the same priority as DFID does. To some extent, this is understandable; multilaterals such as the Global Fund and GAVI were set up to tackle particular diseases, tasks they have performed with great distinction. But DFID now has fewer bilateral programmes and relies on multilaterals to manage an evergreater proportion of its expenditure, often without in-country representatives. We recommend that DFID conduct a detailed assessment, by country, of the extent to which existing funding arrangements enable its health systems strengthening objectives to be met.

20. We also heard concerns about coordination between multiple donors in countries "pushing in different directions with different sets of priorities".[57] The International Rescue Committee used the example of South Kivu province in the Democratic Republic of Congo, where USAID, DFID, the Swiss Development Corporation and Cordaid were providing inefficient, duplicative assistance in overlapping geographical areas and local authorities were reluctant to reveal funding arrangements through fear of losing support.[58] As a result, the same activity was sometimes being financed several times.[59]

21. Poor coordination is a particular problem where there are separate funding flows for individual conditions, resulting in inefficient parallel systems such as "labs for TB built side-by-side with labs for AIDS".[60] Similarly, poor coordination between programmes could mean that the achievement of rapid results in one area is achieved at the expense of another; for example, health workers might be attracted from one programme to another through incentive payments.[61]

22. DFID has been a force for improved coordination, often through assisting governments in taking greater ownership of system strengthening efforts in their own countries.[62] For example, we heard particular praise for the Health Pooled Funds in South Sudan and Mozambique, Development Partners for Health in Kenya and the Health Transition Fund in Zimbabwe.[63]

23. DFID stressed that its influence on coordination is dependent on the approach taken by governments and other donors. For example, in Kenya, where DFID does not fund the government because of corruption risks, ICAI found system strengthening efforts to be incoherent and unsustainable.[64] ICAI called on DFID, which unlike the Global Fund and GAVI has a permanent presence in the country, to take a more central coordinating role to establish a clear division of labour between development partners.[65]

24. DFID was instrumental in 2007 in the creation of the International Health Partnership (IHP+).[66] IHP+ does not disburse funds but is a framework for coordination, intended to put international principles for effective aid and development cooperation into practice in the health sector. The partners include developing countries, all of the major bilateral and multilateral donors in the health sector and civil society organisations. IHP+ aims to support single, country-led national health strategies, and we were told that it is "central to enhancing harmonisation and coordination of global health multilaterals".[67]

25. In December 2012, IHP+ identified seven systems-focused behaviours that international partners needed to adopt in order to be more effective, partly because donors were making less progress than developing country governments in putting IHP+ principles into practice.[68] We were told that DFID has made no clear response to these recommendations.[69]We also heard that, though the UK continues to fund IHP+ and serve on its steering committee, it is "no longer a prominent champion" of the IHP+ or the principles on which it was founded.[70]

26. DFID expresses continued support for the International Health Partnership (IHP+), but it is not providing the impetus for increased coordination it did in the past. We recommend DFID reaffirm its commitment to IHP+ by publishing on an annual basis the steps it is taking to implement, and encourage its international partners to adopt, IHP+ principles and recommended behaviours.

16 http://devtracker.dfid.gov.uk/ Back

17 HSS22 [Action for Global Health] Back

18 OECD statistics, http://stats.oecd.org/, Official Bilateral Commitments (or Gross Disbursements) by Sector. Back

19 DFID Annual Report and Accounts 2013-14, table B.3 and pp100-114

GAVI was previously the Global Alliance for Vaccines and Immunisation

UNITAID was established in 2006 by the governments of Brazil, Chile, France, Norway and the UK as the "International Drug Purchasing Facility". It aims to use "innovative financing to increase funding for greater access to treatments and diagnostics for HIV/AIDS, malaria and tuberculosis in low-income countries". See http://www.unitaid.eu/. Back

20 HSS29 [Save the Children] Back

21 HSS19B [DFID]. We were disappointed that DFID was unable to provide the same detail in health expenditure for 201314 as it provided for earlier years in that submission, despite publishing its Annual Report and Accounts for 2013-14 on 15 July 2014. Back

22 HSS19 [DFID] Back

23 HSS22 [Action for Global Health] and HSS29 [Save the Children] Back

24 World Health Organization, World Health Report 2006, p xxiv Back

25 HSS19 [DFID] Back