The Long Road to Adequate The Long Road to Adequate

and Sustained Donor Financing and Sustained Donor Financing

for Healthfor HealthProfessor Brook K. Baker

Northeastern U. School of Law, Program on Human Rights and the Global Economy

Health GAP (Global Access Project)

GHWA Health Workforce Advocacy Initiative

GHWA Forum

Kampala, Uganda ( March 2-8, 2008)

Outline of Presentation

• Current health spending; HRH/HSS resource needs and financing gaps.

• Critical assessment of HRH financing by:– World Bank

– PEPFAR

– Global Fund

– DfID, IHP+

• Campaigning for adequate and sustained donor financing for health.

Health Spending in Developing Countries

(90% of Global Disease Burden) is Anemic

• Total health spending in developing countries in

2003 was $410 billion, roughly 12% of global

total and 5.7% of developing country GDP. Most

is out of pocket (70% in low income countries 50% in African

countries) World Bank Strategy for HNP Results 2007.

Development Assistance for Health

is Even More Anemic

• Development assistance for health (DAH) rose from only $7 billion in 2000 to approximately $14 billion in 2005.

• DAH accounted for only 3% of developing country health spending in 2003.

• DAH as a percentage of all official development assistance grew from 4.6% in 1990 to nearly 13%in 2005.

• However, in Africa DAH accounts for 15% of health spending, and 30% or more in 12 countries.

AU, Health Financing in Africa 2006

AU, Health Financing in Africa 2006

Increased Donor Resources Are

Essential

• “Massive increases in external assistance

are needed” to finance MDG health goals. (WB, Health Financing Revisited 2006)

• World Bank estimates range between $25

billion and $70 billion in additional aid, per

year, to meet MDG health goals.

• These estimates may be far too low, even

for HRH alone.

Global Health Funding

Needs, Commitments, and Gaps

$109.52 billion$938.3 billionTotal

$35.5 billion$2.49 billion$38 billion

2006-15

Malaria

$32.87 billionNorway, Canada

Netherland, UK

$5.23 billion

$39 billion

2006-15

Maternal and

newborn

$22.5 billion$21.8 billion$44.3 billion

2006-15

TB

$189 billion$80 billion$269 billion

2008-15

HIV/AIDS

Phased scale-up

??$548 billion

2008-15

HRH Education

and 2x salary

Funding GapDomestic/donor

commitments

Resource NeedsProgram Area

Costs for Educating Health Workers and

Doubling Salaries (billions) WHO 2007

$86$14.62015

$80$12.72014

$74$10.92013

$69$9.22012

$66$8.02011

$64$7.52010

$58$6.72009

$51$5.82008

Dev. CountriesAfricaYear

Total $75.4 $548

Earlier HRH/HSS Funding Needs Estimates

(World Health Report 2006, p. 13-14)

???Additional, unestimated costs:

•Building health education facilities & health

infrastructure

•Hiring, training, and paying community health

workers

•Health system strengthening – procurement &

supply systems, health management

$53 billion/year Incremental costs for doubling salaries

$17.7 billion/year Incremental operating costs for hiring

new HCWs

$7.7 billion/year for 10 years Education & training costs (doctors,

nurses, & midwives)

Sources of Development Assistance

for Health

Promises, Promises

• July 2005 at Gleneagles, the G-8 promised that aid for all developing countries would increase by approximately $50 billion a year by 2010, $25 billion extra would go to Africa.

• First year, post Gleneagles, ODA actually decreased by 5.1% (OECD, 3 April 2007).

• Since DAH is only 13% of ODA, only an addition $3.25 billion per year will go to DAH and only a portion of that for HRH.

• Although donors make substantial aid commitments, disbursements are consistently less.

Recurrent Dilemmas in Health Aid

• Donor health aid is often earmarked for specific purposes and burdened by conditionalities.– Only 20% of all health aid goes to support the government’s

overall program.

– Over 50% is off budget and not available to support the health system or to pay recurrent public sector costs: staff, infrastructure, training, management, etc.

• Donor health aid is unpredictable, short-term and volatile, resulting in marginal improvements of existing services rather than significant scale-up and innovation.

• Aid flows and donor requirements are poorly harmonized.

• Donor aid is often fungible, meaning that countries can disinvest in health at the same time that donors are investing.

World Bank HSS/HRH financing

• 1997-2007, the Bank had cumulative HSS/HRH lending of $15 billion ($12 billion in disbursements).

• The importance of Bank HSS/HRH financing has been shrinking over time, though the Bank projected significant increases in health lending for FY07 to nearly $2.4 billion.

• The Bank does not specify how much of its DAH goes to HRH.

• Bank HSS financing has been quite volatile.

World Bank, Approach Paper: Evaluation of the World Bank’s Assistance for

Health, Nutrition, and Population (Independent Evaluation Group, 2007)

Bank MAP (AIDS) Financing for

System Strengthening 2001-06

• Ministries of Health $22 million/$805 million (13,181 staff trained) = 2.6%

• Civil Society Organizations $55 million/$805 million (47,439 staff trained)

• Other ministries $55 million/$805 million (74,793 staff trained)

• Other organizations, e.g., consultants, $244 million/ $805 million

World Bank has Troubling Assumptions

about DAH

• “Large increases in donor funding for

health, much of it for recurrent spending,

raise important questions about the ability

of countries to absorb these funds, the

predictability and maturity of these funds,

and the ability of countries to sustain

services once donor funding stops.”

Lack of “Absorptive Capacity”

• “Lack of absorptive capacity” has been raised

every step of the way.

• But, developing countries’ inability to plan and

implement health reforms can be ameliorated by

donors paying for capacity development and

supporting recurrent health managements costs.

• Harmonization and alignment of aid, reduction in

conditionalities, and coordination in M&E can

help eliminate absorptive capacity bottlenecks.

“Fiscal Sustainability”

• “A country’s capacity to accommodate expenditures financed with aid within the domestic budget constraint in a reasonable period of time, while maintaining sustainable levels of debt to GDP and debt service to exports.” (WB, Health Financing Revisited, p. 139).

• According to the World Bank, donor aid is fickle and therefore countries need to rely on their own meager resources.

• If this understanding of sustainability persists, expanding and improving human resources for health and reaching MDG health goals will remain not only elusive, but illusionary.

• The solution to sustainability is adequate, long-term, and predictable DAH from bilateral and multilateral donors.

Macroeconomic Stability

• Bank focuses on maintaining “sound

macroeconomic and fiscal policy and

country competitiveness.”

• This translates into public sector fiscal

restraint, low inflation targets, and investor-

friendly economic environment. In case of

conflict, macroeconomic stability trumps

HSS/HRH.

Loans not Grants

• Virtually all Bank HSS funding will be via

IDA concessionary loans.

• Loans today create the debt crisis of

tomorrow.

• Loans for infrastructure development may

make some sense, but loans for recurrent

costs make almost no sense.

PEPFAR Report on Workforce

Capacity and HIV/AIDS (2006):

PEPFAR’s Stated Focus:• Support for policy reform to promote task-shifting from

physicians and nurses to community health workers;

• Development of information systems and Human resources assessments;

• Training support for health workers, including community health workers;

• Retention strategies; and

• Twinning partnerships.

– Note: No real focus on expanding HRH.

PEPFAR HRH/HSS Spending2008 Annual Report to Congress: The Power of Partnerships: PEPFAR

• FY ’07, $638 million was spent on capacity building in the public and private health sectors; in FY ’06 $350 million was spent. – Networks $133,758,635

– Human resources $195,186,583

– Local organization capacity development $128,129,771

– Training $181,387,958

• It has provided an unspecified amount of salary support for 110,000 health care workers through FY 2008.

• Some support for hiring community health workers.

U.S. Restrictions on Payment of

Recurrent Costs

• However, the USG has policy restraints on

payment of recurrent costs, e.g., salaries in the

public sector.

• Occasionally it works around these restrictions via

public sector salary support or more commonly by

creating non-governmental outsourcing

mechanisms to hire, train, and deploy health

providers on a contract basis to public-sector

health centers (Kenya).

PEPFAR Retention strategies

• Incentives such as housing allowances,

hardship allowance, transportation

allowances, and educational stipends for

their children, medical insurance or refunds

for medical expenses,

• Salary increments for good performance,

scholarship opportunities, and a supportive

work environment.

PEPFAR is heavily focused on

in-service training

• From FY’s 04-07, PEPFAR spent $281 million

supporting training and retraining for nearly 2.6

million health workers.

• There are plans for training/retraining 2.8 million

health workers in FY 08, especially on task-

shifting.

• PEPFAR has provided limited support for pre-

service training ($1 million per focus country FY

07, $3 million per focus country FY 08).

In PEPFAR Evaluation, Institute of Medicines’

HRH/HSS-related Recommendations

• Must transition “to an emphasis on long-term

strategic planning and capacity building for a

sustainable response.

• Must address “Building workforce capacity by

increasing its support and including the education

of new health care workers in addition to AIDS-

related training for existing health care workers.”

Global Fund’s Conflicted HSS Mandate(Sources: Global Fund Progress Report 2007, Drager et al 2006)

• Mandated to support priority disease programming so as to strengthen health systems and human resource capacity.

• Has walked a tightrope between supporting immediate measures addressing priority diseases and supporting long-term measures for increasing in-country capacity for scale-up.

• “The systematic, long-term development of fundamental health infrastructure is beyond the mandate and resources of the Global Fund.”

Strategic Guidance

• Global Fund has adopted five strategic

guidance points for HRH:

– Scale-up of workforce planning

– Synergize across priority programs

– Simplify services and task shift

– Secure health and safety of health workers

– Foster collaboration.

Global Fund has a modest impact on

HRH

• Approximately 22% of the Global Fund’s portfolio is

devoted to human resources and training.

Global Fund Spending Now at

$1 billion/year (est. $220 million on HRH)

Global Fund HRH/HSS

Conditionalities

• The Global Fund has used evolving guidelines re HRH/HSS and has only permitted separate HSS proposals in Round 5.

• Global Fund has historically required evidence of sustainability – e.g., “the ability to service recurrent expenditures” – in HRH/HSS proposals, a requirement it had not imposed in other areas.

• Global Fund also requires recipients to demonstrate a direct link between HRH/HSS spending and effect on the target population.

Round 7 – TRP HSS Critique

• Out of $2.8 billion approved in Round 7, $363

million is targeted toward HSS.

• Proposed HSS actions focus too much on

addressing obstacles to delivery of health services,

and not enough on planning, financing and

building health systems in the first place.

• HSS technical assistance has been problematic

Findings from Other Studies

Global Fund HSS/HRH:

• Weaknesses in HSS application guidance; applicants are unsure abut the precise scope of permitted HSS proposals.

• Focus is on in-service training– By the end of 2006, the GF supported training and retraining of 3.6

million HCWs.

• Limited recruitment of new HRH– The bulk of professional staff recruitment proposals are at the

program management level.

– Staff are often hired only for project duration.

• Some proposals provide for salary support, but the bulk of proposals provide other incentives, especially for assignments in rural settings.

Examples of Global Fund HRH

Activities

• Global Fund has helped support innovative

Emergency Human Resource Strategy in Malawi

adding $40 million to the $100 million provided

by DfID.

• Global Fund is supporting the training and

appointment of 30,000 community health workers

in Ethiopia.

• Global Fund is supporting salary support for

essential health service workers in Cambodia.

GAVI

• Countries identify and address health

system bottlenecks to increase and sustain

high immunization coverage

• GAVI’s HSS funding ($500 million over

five years) focuses on health workforce,

supply/distribution/maintenance,

organization and management.

UK DfID’s Global Health StrategyCrisp, Global Health Partnerships: The UK contribution to health in developing

countries 2007; DfID, Working together for better health 2007

• 2005-06, DfID spent £481.4 million bilaterally and £173.6 million multilaterally on global health aid. It has committed to doubling its aid budget between 2008-13; in 2007 it spent close to £800 million on global health.

• DfID has committed £55 million over six years to support recruitment, training and retention of health workers in Malawi.

• DfID is focused on sexual and reproductive health; it donated £100 million to UNFPA in Oct.

• 50% of its aid is for basic health services.

DfID’s Global Health Strategy

• DfID is focusing on country-ownership, longer-

term aid, direct budget support, and health system

planning and strengthening, including educating

and training an expanded health workforce and

mitigating the brain drain.

• DfID is also focused on improving the

effectiveness and coherence of international

funding for health.

“International Health Partnership”

A New Focus on Coordination

• UNAIDS, UNFPA, UNICEF, WHO, World Bank; UK, Norway, France, Germany, Italy, Netherlands; European Commission, GAVI, GFATM; Gates Foundation

• Focused on providing better coordination among donors; improving health systems, supporting the development and implementation of health plans.

• First-wave, focus countries: Benin, Burkina Faso, Burundi, Ethiopia, Ghana, Kenya, Madagascar, Mali, Mozambique, Niger, Zambia, Cambodia, Nepal.

• Projected new commitment $50 million per country for three years ($50 million x 13 = $650 million/year)

Global Campaign for the Health

MDGs and other Initiatives• The Partnership for Maternal, Newborn & Child Health

– “more resources will be raised”

– World Bank will coordinate through IDA

• Norway-Led Initiative – Deliver Now for Women & Children (formerly Global Business Plan)– Focus countries: India, Pakistan, Ethiopia (Nigeria?)

• UNICEF/Canada and others “Catalytic Initiative to Save a Million Lives”– Focus countries: Benin, Ethiopia, Ghana, Liberia, Mali,

Mozambique, Tanzania, Afghanistan, Cambodia, Pakistan

• Germany/France, Providing for Health Initiative– Supports social health-protection systems

New Commitments for HSS and support of

primary and child and maternal health

• Norway has pledged $1 billion to childhood

immunization through 2015

• The Netherlands has pledged $125 euros

over three years

• Canada $105 million over 5 years, matched

by UNICEF

Needed $70 billion/year for HRH

$1.77 b/year, $650

m. HSS, HRH?

HSS, primary,

maternal child

UK and IHP+

$1 b/year, $220 m

HSS, HRH?

HSS, training,

some HRH

GLOBAL FUND

$6 b/year AIDS,

$638 m HSS, HRH?

HRH, Training,

Networks, CSS

PEPFAR

$2.4 b/year health,

HRH ?

Training, CSSWORLD BANK

EST. ANNUAL

FUNDING

FOCUS

AREAS

PROGRAM