Conclusions and recommendations
DFID's health systems work
1.
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. (Paragraph 12)
2. 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. (Paragraph
19)
3. 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. (Paragraph 26)
Information and accountability
4. 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.
(Paragraph 31)
5. 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. (Paragraph
35)
6. 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. (Paragraph
36)
7. 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. (Paragraph
39)
Foundations of strong health systems
8. The
lack of progress by many African governments on the health expenditure
commitment in the 2001 Abuja declaration is very worrying. It
suggests a culture of reliance on aid that is irreconcilable with
ultimate self-reliance. DFID aid should never be a blank cheque.
We recommend that, as well as making the positive case for
expenditure on health systems, DFID work with developing country
governments to agree medium-term aid plans based on concordance
with the Abuja target and fund accordingly, taking a tough line
with governments which are unwilling to take responsibility for
the long-term health of their own populations. We also recommend
that DFID make better use of local parliamentarians and medical
professionals as advocates for prioritising expenditure on health
systems over other demands. (Paragraph 54)
9. Health systems
governance and finance are complex political issues. The outcomes
of intervention in these areas tend to be uncertain and expenditure
on them can be harder to sell to electorates, donors and developing
country governments. DFID's international partners, given their
narrower objectives, are also less likely to be involved. However,
health systems governance and finance are vital to properly functioning
and ultimately self-sustaining health systems. DFID must lead
the way on strengthening them, including making the case for such
interventions to sceptics at home and abroad. (Paragraph 55)
10. The staffing of
the UK health sector should not be at the expense of health systems
in developing countries. We recommend DFID work with the Department
of Health to review its approach to the UK recruitment of health
workers from overseas. This review should consider options for
compensating source country systems, promoting training schemes
that involve a temporary stay in the UK, and strengthening local
programmes to enable more medical training to take place in-country.
(Paragraph 60)
11. Doctors, nurses
and other health professionals are at the centre of any wellfunctioning
health system. We are concerned that DFID does not know how much
it spends on human resources for health and or have means of monitoring
its performance. We recommend that DFID's review of its approach
to human resources for health extends to an ambitious strategy
which would set an example of best practice to international partners.
(Paragraph 62)
12. Community health
workers can be an important part of a developing health system.
They provide flexibility and enable programmes to be scaled-up
very quickly. However, they should not be seen as an easy remedy
for all health system problems, nor as a substitute for properly
trained and specialist health professionals. As in other areas,
DFID would benefit from sounder monitoring and a better evidence
base in assessing the role to be played by community health workers
in individual countries. (Paragraph 66)
13. Community services
and public health are important parts of an effective and efficient
health system. There can be a tendency, driven partly by standard
health system models, to focus on curative care in formal national
systems. We heard concerns that DFID sometimes falls into this
trap. It is too hard to assess whether this is the case. We
recommend that, in publishing the disaggregated data recommended
earlier in this Report, DFID prioritise community services and
public health. (Paragraph 74)
14. DFID rightly identifies
factors ranging from superstition and mistrust of formal health
systems to discrimination and violence against women and girls
as obstacles to improving healthcare. We recommend that DFID
press its international partners, including national governments,
to tackle unacceptable cultural barriers to access to health services.
(Paragraph 75)
Making better use of NHS expertise
15. Volunteering
overseas by UK medical staff can be highly advantageous for developing
health systems. Through the personal and professional development
of individuals, the sharing of best practice and the building
of global contacts, it can also be of great benefit to the NHS.
Existing volunteering schemes, though often successful, are small-scale
and fragmented. The Health Partnership Scheme is highly effective,
but its funding is a drop in the ocean. Volunteering schemes need
coordination, structure and scaling up. (Paragraph 82)
16. NHS staff should
be supported in seeking to apply their skills where need is greatest.
We recommend that the new NHS framework for volunteering establishes
a formal structure to facilitate the participation of many more
medical professionals, including through extended sabbaticals,
and makes clear that volunteering overseas is valued and consistent
with career progression. DFID should provide the necessary funds
to support these more ambitious schemes. We further recommend
that DFID investigates means of supporting those who volunteer,
including continuing NHS pension contributions and paying down
student loans. (Paragraph 83)
17. Demand for NHS
staff does not end with doctors and nurses. Though often criticised
at home, the NHS is held in high international regard and many
countries would greatly benefit from the assistance of those expert
in managing and financing such a successful health system. In
turn, NHS managers would benefit from tackling familiar problems
in unfamiliar settings. This is a challenge to traditional development
models and DFID must be sufficiently agile to adapt to changing
and increasingly complex needs. NICE International is a successful
example of how NHS expertise can benefit overseas systems, and
leverage funds from other donors in the process. We recommend
that DFID establish a clear strategy for how UK government should
work in partnership with the NHS to support overseas health systems.
(Paragraph 86)
DFID leadership
18. 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. (Paragraph 91)
19. 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. (Paragraph 95)
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