Strengthening Health Systems in Developing Countries - International Development Committee Contents

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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Prepared 12 September 2014