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
236
Q4 [Dr David Evans] Back
237
Q10 [Dr Andrew Cassels] Back
238
HSS23 [Oxfam] and HSS34 [International HIV/AIDS Alliance] Back
239
HSS51 [ICAI] Back
240
Q114 and Q119 [Lynne Featherstone MP] Back
241
Q8 [Dr Andrew Cassels] and Q55 [Dr Julian Lob-Levyt] Back
242
International Development Committee, Eighth Report of Session
2012-13, Post-2015 Development Goals, HC 657 para 47 Back
243
Ibid, para 61 Back
244
Q145 [Lynne Featherstone MP] Back
245
UN Sustainable Development Knowledge Platform, Introduction to the Proposal of the Open Working Group for Sustainable Development Goals,
July 2015, target 3.7 Back
246
HSS15 [Malaria Consortium], HSS1 [GSK], HSS41 [Michael King and Elspeth King]
and HSS23 [Oxfam] Back
247
For example, HSS15 [Malaria Consortium], HSS22 [Action for Global Health],
HSS28 [Royal College of General Practitioners, HSS29 [Save the Children]
and HSS27 [GRM Futures Group International] Back
248
HSS37 [Sightsavers] Back
249
HSS19 [DFID] Back
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