House of Commons - Strengthening Health Systems in Developing Countries

Strengthening Health Systems in Developing Countries - International Development Committee Contents

3 Information and accountability

Expenditure and performance indicators

DFID

27. We heard conflicting evidence on whether DFID should dedicate a specific proportion of health expenditure to HSS. While this could provide clarity of focus, there was also a danger it could act to isolate HSS, whereas ideally it should be integrated with other programmes such as infectious disease control and reproductive health.[71]

28. DFID acknowledged that it can estimate only roughly how much it spends on HSS.[72] This means that HSS expenditure cannot be assessed for impact and value for money in the same way as that targeted on specific diseases.[73] Action for Global Health told us that DFID could be held more accountable for its health work if it published more detailed data on HSS expenditure, disaggregated by the area of the health system targeted.[74]

29. A lack of DFID performance indicators for HSS was also identified as a problem. Their absence is partly because system strengthening, particularly in areas such as corporate governance, is difficult to measure.[75] Yet, HSS indicators are potentially important as both a management tool, in helping to ensure that resources are allocated and used effectively, and a means of measurement, enabling DFID to be held accountable for its HSS work.[76] System measures could also be useful for assessing the efficacy of interventions in the short run as impacts on health outcomes may not register within the timeframe of projects.[77] For example, vaccination rates are more readily recorded than disease prevalence.

30. DFID uses system measures for monitoring some individual projects, but the Minister acknowledged that it was unsatisfactory that DFID does not have HSS indicators to assess its broader performance.[78] However, she expressed concern that targeting system measures could divert focus from health outcomes.[79] Professor Kara Hanson added that indicators can cease to be good measures once they become targets.[80] Results UK told us that DFID should publish proxies for system functionality, such as immunisation coverage and the proportion of children who are undernourished.[81] Others thought a narrowing of focus could be overcome by using broad indicators relating to universal health coverage,[82] stating that measures of service coverage were effective measures of system performance,[83] and that effective HSS indicators already exist.[84] Jane Edmondson, Head of Human Development, DFID, told us that the Department was working with the WHO and World Bank to develop internationally-recognised system measures that could be used to monitor performance against post-2015 development goals.[85]

31. It is impossible to know how well DFID is delivering its health systems strengthening strategy without knowing how much it spends or having indicators of its performance. Nor can DFID allocate its resources efficiently in the dark. These deficiencies are best addressed through the publication of data to internationally-agreed standards. This would ensure comparability and enable DFID to exert influence on its partners to improve their system strengthening work. We recommend that DFID prioritise international agreement on measures of system strengthening expenditure and efficacy as part of discussions about the post-2015 development goals. We further recommend that, once agreed, these measures form part of DFID's regular reporting.

INTERNATIONAL PARTNERS

32. The difficulties in assessing expenditure and performance in HSS are exacerbated by DFID channelling an increased proportion of its health expenditure through multilaterals.[86] Witnesses told us that these multilaterals are "less accountable for expenditure and results than providers of technical assistance contracted through a competitive process"[87] and that multilateralism takes DFID "one step away from accountability" for ensuring HSS is afforded appropriate attention.[88] DFID is unable to estimate what proportion of its core funding of multilaterals is spent on HSS.[89] This is a particular problem given our concerns, set out in the last chapter, that some major multilaterals do not share DFID's commitment to broad system strengthening.

33. The Minister told us that the Global Fund had been "a phenomenon" in driving down the price of important health commodities, such as antiretroviral drugs for HIV, and noted that the Multilateral Aid Review had found it and GAVI to be good value for money.[90] However, NICE International, though noting that a multilateral approach can bring economies of scale, said that there were "significant opportunities for efficiencies" in the expenditure of the Global Fund, which showed insufficient regard for the relative clinical effectiveness and value for money of different treatments.[91] The Malaria Consortium recommended that DFID conducts further analysis to understand how its money is being spent by the Global Fund.[92]

34. Dr Julian Lob-Levyt told us that DFID could do better in assessing the HSS work of multilaterals by using more sophisticated indicators of their performance.[93] The Minister expressed concern that detailed value for money assessment of the work of multilaterals could be very resource-intensive.[94] Dr Kalipso Chalkidou, Director of NICE International, suggested that DFID would not have to do all such analysis itself and that the most effective means of holding multilaterals such as the Global Fund accountable for their expenditure would be for much more information to be published freely online.[95] Dr Michael Johnson said that the Global Fund would be happy to publish more data when possible, and the Minister said that DFID would seek to use its influence on the Global Fund's board to encourage them to be more transparent.[96]

35. The Global Fund and GAVI have been highly successful in improving health outcomes in some of the poorest parts of the world. The multilateral model has advantages in economies of scale. However, it is unacceptably difficult to assess whether these organisations have genuinely and sufficiently switched focus to system strengthening. The multilaterals and their donors have a responsibility ensure that their assistance has the greatest possible impact. DFID has a responsibility to UK taxpayers to ensure that their money can be followed and is spent wisely. We recommend that DFID insist that the Global Fund and GAVI publish better measures of system strengthening expenditure and performance. If DFID is not satisfied that system strengthening is being given sufficient priority by an organisation, and that organisation does not change, DFID should be prepared to withhold funds. We further recommend that DFID press the Global Fund and GAVI for programme data to be published online. Freely accessible data will facilitate more accountability and scrutiny, and should also be of benefit to systems strengthening research.

36. Other donors do not share DFID's responsibilities to UK taxpayers. Private donors such as the Gates Foundation are rightly free to set their own priorities. However, health development is invariably a complex team effort. Transparency about expenditure and performance is imperative for these arrangements to work well. We recommend that DFID work harder to encourage its partners to make more data on their health systems strengthening work freely available. Accepting our recommendation that it publish more disaggregated statistics of the expenditure and performance of its own programmes would set a good example and make this task easier.

Research

37. DFID has long been a world leader in health systems research, and we heard praise for its evidence-based decision-making.[97] However, we were told that "knowledge on how best to strengthen health systems is limited" and that research in areas such as universal health coverage, system financing and non-communicable diseases was struggling to keep up with a growth in interest.[98] DFID aimed to "develop better ways of demonstrating the association between systems strengthening and health outcomes" as isolating such effects was more complex than for targeted interventions.[99] Nevertheless, health systems research accounts for less than one per cent of DFID expenditure on health, excluding core contributions to multilateral agencies, and is equivalent to only three per cent of the its total research and evidence division budget.[100] Over the five years to 2012-13, just 15 per cent of DFID's expenditure on health research was on systems.[101] Professor Kara Hanson told us that insufficient resources were being devoted to HSS research.[102]

38. The London School of Hygiene and Tropical Medicine described DFID's long-term approach to health systems research funding as a "key strength", though in oral evidence Professor Hanson, of the School, expressed concern that in recent years there has been "increased focus on quick results, and quickly getting research into policy and practice" which could limit the ambition of research.[103] Successful HSS research often took many years to come to fruition; for example, decades-old DFID-funded research on health contracting in South Africa had informed recent initiatives in post-conflict settings including Afghanistan.[104] We also heard concerns that the lessons of successful programmes in one country are not always spread effectively to others.[105]

39. Understanding what works is an important part of effective and efficient intervention in health systems. At the moment, too little is known. DFID has a large research budget and allocating more of it to health systems is likely to be good value for money. We recommend that DFID increase funding for health system strengthening research.

71 Q9 [Dr David Evans and Dr Andrew Cassels] Back

72 HSS19 [DFID] Back

73 HSS44 [Dr Julian Lob-Levyt] Back

74 HSS22 [Action for Global Health] Back

75 Q61 [Dr Kalipso Chalkidou] Back

76 HSS22 [Action for Global Health] Back

77 Q39 [Simon Wright] Back

78 Q118 [Jane Edmondson] Back

79 Q117 [Lynne Featherstone MP] Back

80 Q8 [Prof Kara Hanson] Back

81 HSS25 [Results UK] Back

82 Q8 [Prof Kara Hanson and Dr David Evans] Back