I largely concur with Garrett, but like Paul Farmer do not think that these perverse effects are inevitable, and like Jeffrey Sachs do not think that the windfall exceeds the sums which his Commission estimated are required for the poor to have a minimum of care. Clearly what is needed are major changes to the way aid is delivered so that funds continue to flow and are put to improved use.
Garrett’s bleak assessment stems largely, although not exclusively, from the fact that much of the recent increase in finance has been channelled through a plethora of poorly coordinated and integrated new global health initiatives. These initiatives typically target specific diseases with product-driven interventions rather than building the public health infrastructure – including workforce – required to improve population health. Thereby they often reinforce a tendency of some bilateral and multilateral funding agencies to support vertical disease-specific programmes or projects as opposed to taking a more holistic approach to health systems strengthening and to investing in ‘broad measures that affect populations’ well-being’.
The financing trends to which Garrett alludes are confirmed by a recent analysis by George Schieber and colleagues at the World Bank, published in the IMF’s Finance and Development which finds that development assistance for health has climbed from about $2 billion in 1990 to almost $12 billion in 2004). The reasons why the lion’s share of these new funds, for example those from the Global Fund to Fight AIDS, TB and Malaria are earmarked for specific expenditures or categories of expenditures within a project-based approach are numerous. Three central reasons include: first, it is easier politically to raise funds for specific problems or concerns – indeed the purpose of most global initiatives is to raise the profile of a specific problem or solution – as opposed to dealing with the wider dysfunctions in the public health and public expenditure systems. Second, such dysfunctions make project- and programme-specific funding attractive because such approaches lend themselves to easier risk management. Third, poor accountability in the expenditure of domestic and external resources has understandably provoked interest in performance- or results-oriented disbursements which tend to favour shorter-term, narrower and lower-order targets than those corresponding to less tractable and measurable systemic concerns.
Garrett makes a number of sensible recommendations, among them that programmes should only be funded if they can demonstrate that they do more good than harm, that support should be provided to integrate disease-specific programmes into general public health systems, and that programmes should build rather than deplete national capacity.
ODI research, however, suggests that there is much that can and is being done to ensure that the billions raised for global health will be spent to better effect. Lessons can be learned from global health initiatives in relation to delivering on the ground – in terms of the use of performance-based metrics as well as using vertical initiatives to strengthen health systems through ‘diagonalisation.’ Moreover a recent article published in the journal Social Science and Medicine and a related ODI Briefing Paper set an ambitious but achievable agenda for global public-private health partnerships. Based on external evaluations and interviews with partnership staff, the articles identify common problems among partnerships but also feasible solutions which some forward-looking partnerships have adopted and which should now be mainstreamed. We recommend 7 actions to partnerships which can be read via the 2 links above.
While the recommendations we make will do much to improve the effectiveness of the partnership movement, they are patently only part of the solution to the global health challenges identified by Garrett. Much remains to be done to more explicitly build national systems (be they the foundations of public health or fiduciary management). Similarly, the global response needs to be strengthened; we have elaborated agendas for some of the key global players, such as the WHO, World Bank, the Global Fund for Fight AIDS, TB and Malaria, the UK’s Department for International Health, and USAID in the Journal of the Royal Society for Medicine. Yet while each of the individual players could undoubtedly do a better job, more fundamental challenges relate to the lack of coherence in the overall global aid architecture – the subject of a future blog.