House of Commons - Strengthening Health Systems in Developing Countries

Strengthening Health Systems in Developing Countries - International Development Committee Contents

6 DFID leadership

Leadership in systems strengthening

87. DFID reasserted its commitment to HSS in its July 2013 Health Position Paper.[224] The sentiments expressed in that document have been widely praised.[225] However, we also heard criticisms that it does not set out a clear strategy on HSS, indicate in detail how DFID intends to strengthen systems, or provide any clear targets or indicators.[226]

88. While DFID has retained an HSS focus in its bilateral programmes, it has done so quietly, preferring to publicise narrow outcome indicators,[227] and thus failing to capitalise on its international stature to promote HSS. NGOs have called on DFID to be a louder advocate of HSS, such as through promoting the International Health Partnership principles it was instrumental in establishing, and to invest more ministerial time in HSS promotion, whereas it declined to send a minister to the Third Global Forum on Human Resources for Health.[228] Dr Andrew Cassels told the Committee that DFID has "slightly lost […] thought leadership" on system strengthening, while STOPAIDS went as far as to say DFID have "ceded their role as leaders" in the field.[229]

89. As well as directly supporting HSS initiatives, we heard that DFID encourages other donors to do likewise.[230] The Gates Foundation, Global Fund and GAVI attribute an increased HSS focus in their work to the influence of DFID.[231] One of DFID's key opportunities to exert greater influence comes from its position on the boards of major multilaterals. We were told that DFID "has great know-how and also great funding power" to change the outlook of multilaterals.[232] For example, the UK played a significant role in establishing the UNITAID Medicine Patent Pool, a mechanism to promote access to generic HIV medicines which had resulted in sustained price decreases.[233] The Minister told us that DFID had ensured that GAVI had established more stable supply chains and vaccine markets in developing systems that would be sustainable after its support ended.[234]

90. DFID's influence is, however, limited: it is, for instance, just one of 20 members of the Global Fund's board.[235] Pressure from other donors with contrasting priorities could be a "pretty strong" influence on the approach of multilateral organisations.[236] For example, we were told that the WHO's attention had been diverted from its areas of HSS expertise towards programme delivery.[237] In the face of this, we heard calls for DFID to take a more assertive stance, particularly at strategic level. This was particularly important in middle-income countries where DFID does not have a bilateral programme,[238] or where a central, coordinating role was required.[239] We asked the Minister how DFID exercises its influence on its international partners to promote HSS. While we accept that such negotiations are inevitably a combination of "fight" and "constant dialogue", we were concerned by her inability to provide more convincing practical examples.[240]

91. DFID's own health systems strengthening work is world-leading. But that is not enough; DFID must be an active and vocal systems champion, driving the international agenda by experience and example, pressing other donors to prioritise systems strengthening and exercising its influence on the boards of multilaterals to ensure that they have genuine systems focus at strategic level. As it is, DFID, and its ministers in particular, are insufficiently vocal. This is a particular concern in the increasing number of countries where DFID does not have a bilateral programme. We recommend that DFID publish a clear health strategy, including measures of performance, setting out the rationale for system strengthening, how it intends to strengthen systems in its own work and what it expects from its international partners.

Post-2015 development goals and universal health coverage

92. The Millennium Development Goals shaped the global health agenda, provided a focus for increased aid funding and contributed to some major improvements in health outcomes.[241] Much of the debate about the post-2015 development goals that will replace them focuses on whether universal health coverage (UHC), that everyone who needs health services is able to get them without incurring financial hardship, should be a headline priority. We argued that it should be in our January 2013 Report on Post-2015 Development Goals.[242] In that Report, we also called for women's health to be explicitly set out in the post-2015 framework.[243]

93. Though it supports UHC, DFID has argued for an outcome-based health goal, which it suggests would have a greater galvanising effect.[244] The latest draft post-2015 development goals include an overarching objective to "attain healthy life for all at all ages", with nine accompanying targets. One of these targets is to "achieve UHC, including financial risk protection, with particular attention to the most marginalised and people in vulnerable situations".[245]

94. We heard concerns about targeting UHC, including that by encompassing entire populations it could lead to reduced focus on the poorest and most vulnerable, that it is a moving target as quality standards or population characteristics change, that it is too distant a prospect in some countries, and that it could lead to an over-emphasis on inefficient and ineffective insurance schemes.[246] However, we were also told that aiming for universal health coverage would necessitate HSS, as it was impossible to achieve without an effective health system and a long-term, cross-sector approach.[247] A UHC target could be a "critical mechanism for improving health system performance".[248] DFID concurred with this assessment, stating both that UHC would not be attained without strong health systems and that the NHS gave the UK a comparative advantage in working towards its achievement.[249]

95. We recommend DFID continue to press for universal health coverage as a prominent feature of a single post-2015 development goal for health. Universal health coverage cannot be attained without a properly functioning health system. Its incorporation in post-2015 goals would add considerable impetus to health system strengthening efforts. Given DFID's systems expertise and the unrivalled experience of the NHS, this would put the UK in a position of even greater influence and responsibility. Should universal health coverage be targeted, DFID must be willing to grasp the opportunity it provides and demonstrate genuine world leadership on health system strengthening.

224 DFID, Health position paper: delivering health results, July 2013, p2 Back

225 e.g. HSS29 [Save the Children] and HSS17 [VSO] Back

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

227 Q2 [Dr Andrew Cassels] Back

228 Q38 [Simon Wright], HSS22 [Action for Global Health] and HSS 29 [Save the Children] Back

229 Q7 [Dr Andrew Cassels] and HSS30 [STOPAIDS] Back

230 Q58 [Dr Kalipso Chalkidou] Back

231 HSS39 [Gates Foundation], HSS49 [Global Fund] and HSS31 [GAVI Alliance] Back

232 Q70 [Dr Kalipso Chalkidou] Back

233 HSS23 [Oxfam] Back

234 Q124 [Lynne Featherstone MP] Back

235 Q66 [Dr Michael Johnson] Back