Memorandum by the Centre for Global Development
COLLABORATION OF
IGOS/GOVERNANCE
1. Earlier this year, UK Government Officials
told us, "If we look at a typical, highly donor dependent
country, we might see 20 UN agencies, 35 bilateral agencies, 20
global, regional banks or financial institutions and 90 global
health initiatives".[16]
To what extent do IGOs collaborate within countries, in implementing
HIV/AIDS, TB and malaria programmes? If improvements could be
made, what are they, and how can they be achieved?
The Center for Global Development's HIV/AIDS
Monitor is examining HIV/AIDS donors such as PEPFAR, The Global
Fund and The World Bank MAP in three countries Mozambique, Uganda
and Zambia. A comparative analysis of financial flows[17]
for HIV/AIDS in these three countries shows that each of these
three major donors supports the national response using its unique
financing approach, but could improve their coordination and sharing
of information with each other to enhance efficiency of the response
and increase the effectiveness of aid. The study recommended that
the three donors jointly coordinate and plan activities to support
the National AIDS Plan. All three donors should coordinate to
avoid duplication, and ensure that resources are distributed across
the range of programming needs. Coordination should be based on
supporting the strategies articulated in each country's National
AIDS Plan. All three donors should work—either directly
or through their Recipient Organizations—with other country-level
stakeholders to finance activities that are consistent with the
national plan. Where a host country's plan is weak or has gaps,
donors should coordinate efforts to assist the government and
other country-level stakeholders to strengthen it.
More broadly, other work at CGD suggests that
multilateral agencies serve two broad functions in the delivery
of aid:
(i) Achieving collective action in the presence
of heterogeneous preferences among donors or between donors and
recipients.
(ii) Economies of scale and scope, especially
in information gathering and analysis.
One benefit for recipient countries of the multilateral
agency system is the partial restoring of the broken feedback
loop that is typical of bilateral aid where it is usually the
donors who can influence the political decision making process.
That is, it gives recipient countries a voice in decision making.
Of course, the voice of recipient countries in these agencies
is dependent on the voting systems in the multilateral agency.
One example is the need to address the governance of the World
Bank in order to better engage developing countries. In a 2005
working group report, one of the recommendations was "to
push the Bank's member governments to make the Bank's governance
more representative and thus more legitimate."[18]
In the specific example of the Global Fund to
Fight Aids, TB and Malaria (GFTAM), the 2006 CGD working group
report[19]
made a variety of recommendations that would allow for more effective
collaboration with other international agencies and recipient
countries. These include:
(i) The ED initiates a regular meeting, with
at a minimum, the Director General of the WHO, the ED of UNAIDS,
and the President of the World Bank to discuss complementary roles
and activities, including mutual support for operations on the
ground, technical assistance, procurements, monitoring and evaluation,
alignment and harmonization around country operations.
(ii) The GFATM move beyond a one-size-fits
all approach and design a range of operational models in different
countries. Differentiated models would help provide principal
recipients and country coordinating mechanisms with incentives
for strong performance and provide pooled financing where appropriate.
ADDITIONAL SOURCES
Birdsall, Nancy. 2007. "Do No Harm: Aid,
Weak Institutions, and the Missing Middle in Africa". CGD
Working Paper 113. http://www.cgdev.org/content/publications/detail/13115.
___. 2003. Why It Matters Who Runs the IMF and
the World Bank. CGD Working Paper 22. http://www.cgdev.org/content/publications/detail/2768
2. Many organizations told us that the only
effective way to coordinate external donors and multilateral partners
is to put the recipient country in charge of the coordination
and management of financial aid. How do you assess recipient countries'
capacity to negotiate with intergovernmental organizations such
as the GFATM, WB and other and to effectively coordinate various
programmes?
One means of assessing and improving recipient
countries' capacity to effectively coordinate programmes with
multilateral agencies like the World Bank is to enhance their
voice and representation in these agencies to signal more ownership
of programmes and projects, as described above.
The management of all of these donors is extraordinarily
difficult for recipient countries. But sometimes the cure of "coordination"
is worse than the disease, especially from the recipient's point
of view. Suppose that all of the donors were truly coordinated
a donor agency set up for that purpose. That is likely to mean
that all the donors must meet and agree before the recipient country
can get anything. This would be an interminably unwieldy and inefficient
process. Furthermore, donors are unequal. Those with money and
prestige will wield more power and ultimately do an end run around
the donor coordinating agency in order to strike side-bargains
with the government. (There is anecdotal evidence that World Bank
task managers frequently felt forced to do such end runs around
UNAIDS.)
Alternatively, many recipient governments could
instead shop their ideas and proposals across a wide variety of
donors, until they find a donor with a desire and capability to
help with a particular project or program. Assessing a recipient
country's capacity to negotiate with an IGO like the GFATM or
the WB could begin with fixing a knowledge asymmetry (over and
above an inherent resource asymmetry) between the two. By providing
more complete and timely information about donors, recipients
can make decisions about requesting specific donors for support
for specific programs and minimize the coordination of multiple
donors.
BALANCE OF
INVESTMENT
3. UK Government Officials also suggested
that "within the AIDS opus there is an imbalance between
money going into prevention, treatment, care and palliative care".[20]
Have IGOs been placing too much emphasis on the treatment of HIV/AIDS,
and not enough on prevention? Should IGOs revise their priorities?
Different IGOs have revealed different preferences
with respect to the trade off between treatment and prevention.
The World Bank has been much slower to fund treatment, preferring
to fund prevention and health systems support mechanisms and community
based development styled support for patients and orphans. Figure
6 of the CGD working paper on PEPFAR (http://www.cgdev.org/content/publications/detail/15973/)
demonstrates that the US PEPFAR program shifted its funding somewhat
away from prevention and towards treatment between 2005 and 2006.
Research from the HIV/AIDS Monitor indicates
that:
Programmatic activities supported through
Global Fund grants varied significantly by country. Prevention,
for example, made up only a small share of total Global Fund monies
to Uganda but a substantial share of funding to Zambia. Even within
funding categories, resources often go to different types of interventions.
For instance, 41% of disbursements for prevention in 2004, and
88% in 2005, went toward condom distribution in Uganda, while
the available data for Zambia show an emphasis on outreach and
behavior change, and only small amounts for condom distribution.
The variation notwithstanding, a significant
and increasingly larger share of Global Fund money is being allocated
for treatment activities. The percentage of disbursements
going to ARV treatment and services in Uganda went from 21% in
2004 to 33% in 2005 and 72% in 2006.[21]
While no programmatic data are available for overall Global Fund
disbursements in Zambia, data from two ROs, ZNAN and CHAZ, reflect
the trend toward funding for ARV treatment—ZNAN disbursements
for treatment went from 0% of total disbursements in 2004 to 51%
in 2006, while CHAZ saw an increase from 0% to 15% of funding
in the same period. In addition, the Chief of Party for the MOH's
component of the grant has noted that most money going to his
ministry was programmed for ARV treatment.
Specific Recommendation provided to the Global
Fund based on the above evidence:
Keep the focus on funding gaps. The Global
Fund is right to focus on filling funding gaps. It should continue
to ask Country Coordinating Mechanisms (CCMs), as part of the
grant application process, to identify all major AIDS activities
ongoing in their country. This will help ensure that Global Fund
money is made available, where warranted, to support under-resourced
priorities such as prevention activities.
For further information please see: http://www.cgdev.org/content/publications/detail/14569
HORIZONTAL VERSUS
VERTICAL HEALTH
PROGRAMMES
4. In its 2007 report, Help Wanted,
MSF wrote, "efforts to further increase access to [antiretroviral
therapy (ART)] and maintain and improve quality of care are coming
up against a wall due to the severe shortage of health workers".[22]
What is the impact of the implementation of vertical programmes
on the wider health care systems? Should IGOs be doing more to
ensure that horizontal and vertical health programmes are successfully
integrated, and should they be placing more emphasis on horizontal
issues such as workforce shortages?
Current research (paper is expected to be released
in August 2008) suggests that the Global Funds health system strengthening
inputs vary by country and depend on the country's identified
needs for this type of support. While results from this analysis
are still preliminary, a key recommendation to the Global Fund
for its role in health systems strengthening (HSS) is that it
strongly communicates its ability to support HSS activities to
recipients so that proposals submitted to the Global Fund can
indicate this as a priority if other donors are not adequately
supporting weak components of the health system such as supply
chains, health information systems and mitigating the severe shortage
of health workers. In addition assessments of the health system
should be improved to enable more focused Global Fund inputs for
health system strengthening.
Additional input from Mead Over suggests:
On the first question, the reader can consult
Section D on page 21 of the working paper cited above, which is
titled: D. Expanding AIDS treatment may crowd out other health
care. However, the bottom line is "We don't know yet."
The answers to the questions about whether donors should do more
to strengthen health systems is unequivocally "yes".
This would include improving health worker educational systems.
However the attempt to prevent health worker migration from AIDS
affected countries (or their immigration into donor countries)
is misguided and likely to have the unintended consequence of
reducing both the quantity and quality of local health care workers.
See Michael Clemens' Working Paper on migration of health workers
from African countries to donor countries.
PERFORMANCE OF
GLOBAL FUNDS
AND PARTNERSHIPS
5. In a 2007 report, the UK Department for
International Development (DFID) concluded that "the [Global]
Fund is playing a valuable role within the international architecture
mainly due to its ability to rapidly raise significant additional
resources for the three diseases and produce impressive concrete
results... However, individual country performance is varied,
as proposals are dependent on the capacity within country to prepare
them. There is also a concern about the Global Fund's impact on
health systems (which are generally under-resourced) and the sustainability
of its operations, more generally".[23]
What is your view on the performance of major donors like the
Global Fund in providing treatment/prevention to patients in developing
countries? Have these Funds and Partnerships produced positive
results? Are the results and operations of these organisations
sustainable? What is your assessment of their value for money?
Formal assessments of the impact of the Global
Fund have not been conducted until recently (see below). However,
comparative research and analysis from the HIV/AIDS Monitor suggest
that the Global Fund is an important and much needed funding mechanism
for AIDS given its ability to provide flexible funding for country
identified priorities. Through ongoing research the HIV/AIDS Monitor
has found that the Global Fund can strengthen its financing model,
by (in addition to ensuring that its funding supports those areas
of the response that other donors cannot fund-see above recommendation):
— Re-examining strategies to
build local capacity. Global Fund ROs continue to face capacity
constraints, suggesting that the Global Fund should re-examine
how it identifies and/or addresses capacity constraints.
— Simplifying procedures for
good performers. The Global Fund should streamline reporting
requirements for ROs that have demonstrated an ability to effectively
use earlier Global Fund grants. For example, these ROs could receive
larger individual disbursements to cover at least twelve months
of subsequent program activities. The Global Fund will soon adopt
a streamlined procedure for good performers to access new funding
(for up to six years) at the end of a current grant.
— Publicly disclosing additional
data. The Global Fund should publicly disclose additional
financial data that it already collects from ROs. In particular,
the Global Fund should consider posting to its website the following
information: first-year budgets and second-year budget estimates
which are prepared at the outset of each grant; grant-specific
documents known as "Sources and Uses of Funds"; and
the Fiscal Year Progress reports submitted by each RO. By disclosing
these data, the Global Fund will enhance its demonstrated ability
to share information with multiple stakeholders and increase the
effective use of its resources.
Additionally, the strength of the GFATM is its
unique inclusion of civil society in the proposal development,
program management and program evaluation for grant resources.
This structure arguably gives the GFATM more legitimacy and makes
its activities more transparent than is the case for the other
donors. This is true regardless of the "effectiveness"
of the GFATM vis-a"-vis the other IGOs on more output
oriented measures.
Furthermore, the GFATM and other multilaterals
have a special advantage as channels for AIDS treatment funding.
Donor countries which directly finance AIDS treatment for individual
patients in poor countries are creating a dependency relationship
between those patients and the donor. Since over the span of several
years the patients who remain alive only because of this donor
will find it increasingly difficult to oppose that donor in other
areas (such as on UN votes), this engendered dependency relationship
can be viewed as a kind of "post-modern colonialism".
In his paper, Mead Over argues argues that this new kind of colonialism,
stemming from generous impulses, can nevertheless produce resentment
among recipient countries just as traditional colonialism did.
To counteract this trend, he suggests that the US should commit
its AIDS treatment financing increasingly through the intermediary
of the GFATM or other multilateral organizations.
6. How effective are these programmes in evaluating
their results and their impact on health outcomes in beneficiary
countries?
Donor-funded health programs have a mixed record
of assessing their impacts on health and other dimensions of human
welfare. In general, donor-funded programs—including many
in the health sector—have been characterized by weak evaluation,
often focusing on inputs (amount of money spent) and failing to
measure results. This is the case for many reasons, including:
(a) the knowledge generated through evaluation
is a public good, and so no single agency or program has sufficient
incentive to invest adequately;
(b) agencies that fund or implement programs
generally place priority on "doing" rather than "learning,"
and may see in-depth evaluation as unnecessary research; and
(c) there are bureaucratic disincentives
to transparent evaluation if funding or prestige are placed at
risk by revealing failures.
Health programs have generally undertaken better-than-average
evaluation, however, because of the scientific tradition in the
health sector, and the relative ease of measuring key outcome
variables, such as child mortality (relative, for example, to
development outcomes such as improved gender equality or stronger
democracies).
Unfortunately, among global health efforts,
HIV/AIDS programs have been among the least rigorously evaluated.
The "emergency" and politically visible nature of the
programs to scale-up anti-retroviral treatment has compromised
opportunities for rigorous evaluation. For example, in the US
PEPFAR program, decisions were made early on not to embed rigorous
impact evaluation in the program design. Moreover, the relative
scarcity of resources for prevention activities, as well as some
significant methodological challenges (estimating "infections
averted" in the absence of a context-specific model of HIV
transmission) have resulted in relatively little evaluation of
prevention efforts.
The GFATM is currently doing an "impact
evaluation" which fails to articulate a coherent strategy
for establishing a counterfactual and thus cannot actually aspire
to "evaluate" any "impacts" at all. The World
Bank funded a program called the Treatment Acceleration Project
which was to have a "Learning Agenda". However, they
failed to fully fund the Learning Agenda and are now pulling out
of the Treatment Acceleration Project and its associated learning
after only four years. One promising action is that some IGOs
are supporting the new institution called the International Initiative
for Impact Evaluation (3IE). See the following link for more information
http://www.cgdev.org/section/initiatives/_active/evalgap
27 May 2008
16 Dr Stewart Tyson (DFID), Oral Evidence, Q 1. Back
17
See Oomman, N, M Bernstein and S Rosenzweig, "Following the
Funding: A Comparative Analysis of the Funding Practices of PEPFAR,
the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia.
Center for Global Development. 2007 available at http://www.cgdev.org/content/publications/detail/14569/ Back
18
Center for Global Development. 2005. "The Hardest Job in
the World: Five Crucial Tasks for the Next President of the World
Bank". CGD Working Group Report. http://www.cgdev.org/content/publications/detail/2868 Back
19
___. 2006 "Challenges and Opportunities for the New Executive
Director of the Global Fund". CGD Working Group Report. http://www.cgdev.org/content/publications/detail/10948 Back
20
Dr Stewart Tyson (DFID), Oral Evidence, Q 6. Back
21
Some of this large increase in ARV treatment and services as
a percentage of total disbursements in 2006 in Uganda can be attributed
to the suspension of Uganda's grants in 2005, and the Global Fund's
decision to continue funding most facilities that were providing
life-saving ARV drugs. Back
22
Médecins Sans Frontie"res, Help Wanted: Confronting
the health care worker crisis to expand access to HIV/AIDS treatment:
MSF experience in southern Africa (Johannesburg, MSF: 2007), p
2. Available online at http://www.doctorswithoutborders.org/publications/reports/2007/healthcare_worker_report_05-2007.pdf Back
23
DFID, GFATM Development Effectiveness Summary (London:
DFID, 2007), p 5. Available at http://www.dfid.gov.uk/pubs/files/mdes/GFATM.pdf
(accessed 30 March 2008). Back
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