IHP+ a bold attempt to improve aid effectiveness for health

Dr Margaret Chan
Director-General of the World Health Organization

Opening remarks at the International Health Partnership and Related Initiatives (IHP+) Ministerial Review

Honourable ministers, colleagues in public health, ladies and gentlemen,

First and foremost, let me express my pleasure in welcoming you to this first ministerial review of the International Health Partnership and related initiatives, or IHP+.

You will be providing the first critical review, at the ministerial level, of progress on the partnership.

In my remarks, I will touch on three main areas. First, I will explain why I believe an initiative such as this one is so greatly needed. Second, I will offer just three small pieces of advice. Finally, I will make some comments about IHP+ in the context of two events: the financial crisis and renewed commitment to primary health care.

Ladies and gentlemen,

IHP+ aims for health development that is country-led, country-owned, and fully aligned with national priorities and capacities. For this reason, the views of health ministers in partner countries deserve our closest attention. Again, I warmly welcome this ministerial review.

IHP+ is a bold attempt to improve the alignment and coherence of aid for health development. At the centre of this effort is a costed and validated national health plan. This plan guides the commitment of donors, through either budgetary support or support to technical programmes.

In so doing, it provides the framework for holding all partners accountable for producing tangible and measurable results.

IHP+ also tackles one of the most challenging problems in public health today: the sorry state of health systems, especially in countries that rely on aid for health development.

Experience tells us this: simply channelling more money into existing systems will not bring us the results we all so desperately want and need. IHP+ calls for fundamental changes in behaviour, changes in the way all partners do business, at all levels. This is a noble aim.

The IHP and related initiatives are not operating in uncharted territory. We have known for decades, and certainly since the Declaration of Alma-Ata, that weak health systems are the bottleneck that slows progress and blocks the delivery of effective interventions.

Nor is IHP+ operating in virgin territory. On the contrary. Developing countries are littered with the debris of poorly coordinated aid, with dilapidated clinics at one extreme, and unused hospital beds at the other.

But the strengthening of health systems is definitely a territory that we have failed to conquer.

Health systems are weak because of decades of poor planning, poorly thought-out investments, and poorly coordinated aid.

During the 1990s, many within the donor community voiced scepticism about the effectiveness of aid. Blame was firmly placed on partner countries: lack of commitment, weak capacity to absorb aid, and widespread corruption that siphoned off the benefits.

More recently, hard questions are being asked about whether donor policies and practices may also be at fault. The partnership aims to put into practice many of the good intentions set out in the Paris Declaration on Aid Effectiveness and the related Accra Agenda for Action. Again, this is a noble aim.

The shift in thinking about aid effectiveness coincides with another recent trend: the crowding of the health sector with an unprecedented number of implementing agencies, partnerships, and donor-sponsored projects.

IHP+ aims to address the resulting problems. These are deeply familiar problems. Donors often opt for projects that bring short-term measurable results, and these projects are subject to rapid shifts, especially when political leadership changes. The health sector, with its predominance of long-term recurrent costs, cannot build capacity in the absence of predictable and sustained financial flows.

Viewed from a country perspective, we see a list of problems: duplication, fragmentation, high transaction costs, heavy reporting requirements, fierce competition for scarce health workers, and multiple separate channels for funding and financial management, drug procurement, laboratory support, monitoring, and evaluation.

I have heard exactly these complaints from ministers of health in developing countries. These ministers have suggested that, in some cases, too much of the wrong kind of development aid can do more harm than good. They can say this to me, of course, because I do not control the strings of a big purse of disbursements.

But multilateral organizations also contribute to the problem. We compete for attention and influence, and this is another source of duplication and fragmentation.

As I have said, all these problems require changes in behaviours at all levels, including some entrenched institutional behaviours. This is not an easy task. I know that behaviour change and accountability are on the agenda, and I look forward to hearing your views.

Ladies and gentlemen,

For me, one of the central message of IHP+ is this: the buck stops here. Aid will not be fully effective until we find ways for better coordination, better alignment, and more accountability.

Let me make some suggestions in the form of broad advice.

My first word of advice is directed to donors. Please make a special effort to keep your promises, and please ensure that national health plans are indeed country-owned and country-led.

Partner countries have long been at the mercy of the goals of funding agencies. The discretion to make spending decisions at country level has long been limited. This thinking needs to change.

My second word of advice, which is related, is directed to partner countries. Be frank. This is probably your best chance ever to be up-front about what you need, what you can reasonably manage, and what technical support you need in order to manage more, better.

At the same time, be realistic. Funding always comes with an expectation of results. A good national health plan does not translate into a blank cheque. Continued investment of domestic resources is part of a mutually accountable partnership.

For example, the heads of state and government in all African Union countries pledged 15% of their budgets to health. This is another promise that must be kept.

As you know, a high level taskforce on innovative international financing for health systems has been established. This is an item on your agenda. The taskforce has an urgent mission to recommend options for innovative financing, and to suggest ways to channel these funds to low-income countries.

My third piece of advice relates to results. The IHP+ was launched, in part, because of concern about stalled progress towards the health-related Millennium Development Goals.

With the exception of maternal mortality, the health-related MDGs are largely an infectious disease agenda. In most cases, deaths from these diseases can be averted through a limited set of interventions: DOTS for TB, bednets, indoor residual spraying and ACTs for malaria, antiretroviral therapy for HIV/AIDS, and vaccines for young children.

Reductions in maternal and neonatal mortality depend absolutely on a well-functioning health system that approaches universal coverage, with access to emergency obstetric care, adequate numbers of appropriately trained staff, sufficient financing, and good health information systems.

In fact, reducing maternal mortality depends on meeting the MDGs in their entirety. This means meeting the targets set for nutrition, gender equity, education, and water supply and sanitation.

When progress is evaluated by countries and their development partners, I suggest that you give particular attention to maternal mortality as an indicator of improved access to basic services.

A robust and equitable health system that can reduce maternal mortality will also prepare countries to withstand future shocks, such as those coming from the rise of chronic diseases, climate change, and the current financial crisis.

Ladies and gentlemen,

On several occasions, I have expressed my conviction that we will not be able to reach the health-related Millennium Development Goals unless we return to the values, principles, and approaches of primary health care.

The calls for a renewal of primary health care keep getting stronger, with support from health ministers, numerous conferences, and the literature, including a special series in The Lancet and last year’s World Health Report.

The calls come as we move into what the experts say is the most severe financial crisis and economic downturn seen since the Great Depression began in 1929.

Money is tight. It is set to get tighter. A single-minded pursuit of greed has left all of us out on a limb. And when the bough breaks, it is usually the social sectors, including health, that come tumbling down.

This puts the health sector under great pressure to demonstrate cost-effectiveness and efficiency gains, in addition to results. We cannot afford to waste money, which brings us back to that long list of familiar problems that the IHP+ aims to address.

In times of economic crisis, traditional economic theory points to the need for trade-offs between the goals of equity and efficiency. Let me argue: we don’t need a trade-off. Primary health care does both. It increases fairness, and it increases efficiency.

The World Health Report on primary health care sets out four broad policy directions for the renewal of primary health care.

The first, inclusive leadership, is at the very heart of the IHP+ initiative. Leadership needs to include the voices and experience of civil society, as they provide another important mechanism for accountability.

The second, on tackling health inequities through universal coverage, is a prime justification for the launch of this initiative Reducing health inequities and gaps in health outcomes depends on stronger systems for service delivery. Governments need to demonstrate not only results on the ground, but also fair distribution of resources.

The third, on positioning health more centrally in the policies of other sectors, takes us back to the Declaration of Alma-Ata, and forward to the recommendations of the Commission on Social Determinants of Health. It opens the door for discussions about how ministers of health, with limited resources, can maximize health gains by shaping policies in other sectors

Finally, efforts to strengthen health systems must put people at the centre of care, which is the fourth policy direction. Expectations for health care are rising in every country. More and more, people want care that is fair, as well as efficient and affordable for all.

Ladies and gentlemen,

My last comment is this: the financial crisis should spur us to redouble our efforts to reach the health-related Millennium Development Goals. This is also a call for exponentially accelerating efforts to strengthen health systems.

This, I believe, is the most farsighted and prudent approach, as robust health systems are the best safety net for the current crisis and our best insurance policy for the other global crises, like climate change, like pandemic disease, that our imperfect world is certain to deliver.

Health is not an expendable luxury item that can be dispensed with during a crisis. It is the very foundation for responding to the crisis.

Health is the human capital for moving towards recovery. And health systems are the social institutions, the social capital, that make response and recovery possible.

For all of these reasons, I welcome the International Health Partnership and related initiatives, and wish you a most productive meeting.

Thank you.