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Can the International Health Partnership deliver a new way of funding health spending?

Written by Simon Maxwell

The International Health Partnership was launched in London on 6 September, signed by 8 bilateral donors, 7 developing countries, 9 international organisations, and 2 other donors.  Importantly, the ‘signature party’ was led by two Prime Ministers, Gordon Brown from the UK and Jens Stoltenberg from Norway.  A high profile initiative, but here’s the interesting thing – no new money was involved.  The key focus of the initiative is ‘coordination’.  Two Prime Ministers and all those others, spending time and political capital on a dry subject like coordination.  What’s that about?

The answer is that the initiative has been conceived to raise the profile of health spending, but also to help solve the problems caused by the proliferation of national donors, international agencies, special purpose vehicles like the Global Fund, and private foundations, like Gates: the problems caused, in fact, by the very existence of all those who signed up to the Partnership.  As the DFID website announcing the launch observes, there are more than 40 bilateral donors working in this field, 26 UN agencies, 20 global and regional funds, and 90 global health initiatives.  Developing country ministers at the launch events spoke eloquently about the burden of donor overload, but also about the highly selective focus of donor health spending: AIDS and malaria are high profile and reasonably well-funded, but there are many forgotten diseases and problems. Under-nutrition, for example, is a neglected topic.

Thus, the International Health Partnership is firmly focused on the health problems facing the developing world, and on the need for more effort if the health MDGs are to be met.  It is framed in the context of a ‘Global Campaign for the Health MDGs’. The relevant statistics are there: 28,000 children die every day, every minute another mother dies in childbirth.  The real meat, however, lies in what the document has to say about working together to deliver better health.

The key objective is to ensure that collective efforts back ‘comprehensive, country-owned and developed health plans which produce tangible and measurable results’.  There need to be ‘sustainable health systems’  and ‘sustainable and fair structures for health systems financing’.  This means ‘strengthening and using existing systems of coordination, coordinating support to implementation of sector plans and shared accountability for achieving results.’

In this context, developing countries commit themselves to produce comprehensive health plans, in a participatory way and with accountability to their citizens for delivery; and donors commit themselves to working together to support these plans.  In an important phrase, donors commit themselves to ‘work to ensure that disease and population specific approaches and those to achieve broad health system strengthening are mutually reinforcing’.

Of course, the principles at play in the initiative are familiar from the discourse on ownership, alignment and harmonisation that characterise the Paris Declaration on Aid Effectiveness.  Explicit mention is made of the Paris Declaration, though a separate monitoring and evaluation mechanism is proposed for the initiative.

Finally, other partners are invited to join.  The initial list is: on the recipient side, Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal and Zambia; on the donor side, UK, Norway, Germany, France, Italy, Portugal, Netherlands and Canada; among the international organisations, WHO, the World Bank, the Global Fund, GAVI, UNFPA, UNAIDS, UNCEF, UNDG and the EC; listed as others, the Gates Foundation and the African Development Bank.

So much for the facts.  What thoughts are triggered by all of this?

First, it is surely an initiative that must be welcomed.  The problems being tackled are real, as we have consistently argued at ODI, for example in our work on aid architecture, but also in our sector-specific work on health policy, for example by Kent Buse.  There are three potential ‘big wins: (a) refocusing health aid from treatment of specific disease to the development of health systems as a whole, including infrastructure, training and so on; (b) reversing the tendency to fund certain diseases and ignore others, so-called forgotten or orphan illnesses; and (c) providing a framework for harmonisation and alignment which will greatly reduce the transaction costs and distortions facing recipient countries.

Second, and obviously, the value of the initiative will grow to the extent that others join – big donors like the US and Japan, other special programmes like PEPFAR or the various malaria programmes, and of course the many developing countries not yet listed.

Third, and again, obviously, the proof of the pudding is in the eating.  Paris has not proved an easy agenda to implement, as various evaluations have shown.  In particular, donors are often reluctant to give up their special enthusiasms and to sacrifice their trusted procedures.  There are also real problems in implementing the alignment agenda in fragile states where coherent and democratically accountable planning is still no more than an aspiraton.

Fourth, and following on from this, a big question will be whether the new partnership will be able to leverage the large reallocations in health that are likely to be needed if the principles are to be followed.  In particular, the untied budgets, those not pre-allocated to special purpose vehicles like the Global Fund, may find themselves cast in the role of funders of last resort, left to pick up the residual budget lines in national plans, or plans as a whole in unglamorous countries.  How will that go down?

Fifth, even if these problems can be solved, there remains the question about the size of health budgets relative to other sectors.  Is full funding of health budgets the right thing to do if other sectors are under-funded?  Who is making resource allocations at the margin?  How does the Ministry of Finance manage the macro-economy, including the size and distribution of public expenditure, in the face of global campaigns like this one for the health MDGs, or Education For All?

This is not to be churlish, however.  There has been much criticism of the proliferation of vertical funds, and the new International Health Partnership may provide the opportunity to implement a strategy that has been described as ‘campaign vertically but spend horizontally’ – in other words, campaign ‘vertically’ around key MDG targets, but embed spending ‘horizontally’ in government budgets.  There is lots to commend, therefore, and the challenge will be to see the partnership succeed.