Recent years have seen a major increase in aid for health programmes, matched by an almost bewildering proliferation in funding streams, partnerships and initiatives. According to a report from the OECD, there are now between 80 and 100 global health initiatives, and development assistance for health has more than doubled from just over $6 billion in 1999 to $13.4 billion in 2005. The bulk of this increase is credited to new global stakeholders including Global Health Partnerships (GHPs) such as the GAVI Alliance and the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), the President’s Emergency Plan for AIDS Relief (PEPFAR), and private foundations such as the Bill and Melinda Gates Foundation. These global and philanthropic programmes now account for around 20% to 25% of development assistance for health. This proliferation is ringing alarm bells in terms of the challenges for partner country leadership and transaction costs. It has, in turn, spawned new commitments and initiatives intended to rationalise and harmonise the aid landscape, with little apparent result to date.

So it was welcome news that the concept of "Health as a tracer sector" would be on the table at the Accra High Level Forum (HLF) in September 2008, as called for by participants at a meeting on Aid Effectiveness in Health at the OECD in December 2006. 

But when we look at the agenda for the Accra HLF, why has health been relegated to one of three topics to be addressed in one of the nine round tables?

The HLF no longer appears to have a "tracer sector" focus on health.  What is going on here? What was the process whereby health was effectively relegated to the margins? And why has this happened?

We are sure we can expect an update on the International Health Partnership (IHP) process, which will be one-year old by the time of the HLF, and possibly an update on the workings of the related ‘H8’.

But is that all we will see? Will we see the results of the UNAIDS Country Harmonisation and Alignment Tool (CHAT) – one of the first such tools to help gauge the degree of harmonisation and alignment of partners engaged in national AIDS responses?

More than five years have elapsed since the Rome Declaration, and much of what the IHP promises should have been delivered in the months thereafter. Since then we have seen energy invested in the Three Ones in AIDS in 2004, the Paris Declaration on Aid Effectiveness and the related Global Task Team (GTT) on AIDS in 2005. Still we are making new promises, without delivering on our old ones. A cynic might be tempted to comment that these new promises represent little more than an attempt to deflect attention from the poor progress that has been made.

The Accra forum should be the primary forum for accountability and reporting on progress – progress on the previous commitments to harmonise and align rather than a showcase for yet more promises.

Given the urgency of the task - delivering the MDGs by 2015 - and the overwhelmingly crowded and complex landscape we have created, should we not be hoping for some far more radical and profound action to bring order to the world of health aid? For example, this forum would provide the ideal platform for discussing how to maximise the opportunity for harmonisation, alignment and potential impact offered by the Global Fund.

So far the Fund has been hugely successful in bringing extra resources to bear, and ensuring the voice of civil society is being heard at country level in how these resources should be deployed. But, to make the most of the opportunity the Fund represents, shouldn’t it be replacing the other fragmented strands of financial support to partner countries’ health services, instead of creating yet more channels? Shouldn’t the Fund be aligning behind robust national strategies and systems for delivering health, and challenging these to be more robust and credible, rather than finding parallel work-arounds – such as Country Coordinating Mechanisms, Local Fund Agents or Fund-dedicated M&E indicators and reporting mechanisms?

Also, shouldn’t the Fund begin to cast its net wider than just the three diseases: AIDS, tuberculosis and malaria, and become a Global Fund for Health, so that it can more effectively deliver resources for the health system as a whole (including civil society)? It could maintain a disease focus, expanded to cover all the health MDGs and perhaps even other cost-effective interventions for other major burdens of ill health. The goals would be to raise money and monitor results, which is where the real added-value of a vertical focussed partnership can be seen, while reducing earmarking and external fund management.

If the HLF is not going to address these macro questions, or indeed delve into the reasons for limited delivery against past commitments, as outlined in the independent assessment of the GTT, the CHAT review, or the work of Wilkinson et al or Stillman & Bennett, and shed a critical light onto the messy world of aid for health, we will continue to tinker at the edges.

Not only does the present HLF Agenda present a real risk to the sustained interest and support that the public and G8 leaders have invested in global health and international cooperation, but also to the prospects of improving the performance of health systems that are required to deliver the MDGs.

What is needed in Accra is threefold. First, a binding commitment from partners to adhere to Paris Declaration and Three Ones principles; second, a transparent forum for accountability against the various related promises and commitments; and third, agreement on more radical approaches to get the best out of existing resources and institutions.

Should such an agreement include a radical new push for an expanded and reformed Global Health Fund? Would this not be a more effective way to channel resources to sustainable health services, responding to the health needs defined by the poorest countries? These are certainly the questions that should be high on the agenda at Accra.