Astana Global PHC Conference: Official side event on "International cooperation and strengthening or weakening national health policies and systems"

Since then, according to many analysts, and despite some achievements, the “aid paradigm” has failed to drive sustainable progress for people who most in need of better lives. Globally and in many countries, inequality has grown, and in absolute numbers, there are currently more people living in absolute poverty than 40 years ago, not to mention the urgent demographic (population growth and aging), epidemiologic (rise of non-communicable diseases) and ecological (climate change, biodiversity loss) challenges ahead of us. Any progress is arguably mainly the result of overall economic development and policy reforms led by countries. It remains difficult to clearly establish what progress can be attributed to aid.

During the MDGs era, vertical health interventions, often externally financed, helped to reduce the burden of a number of infectious diseases. There are concerns, however, that such vertical investments have not been accompanied by sufficient attention to the development of system-wide capacities and to addressing the social determinants of health. In addition, externally financed health systems support, which amounts to only 11% of total aid for the health sector (estimates, 2015), has been poorly coordinated, leading to duplication of effort, and in some cases, competing visions of health systems priorities.

There are contextual issues that need to be taken into account when discussing effective development cooperation agenda for the future:

• A growing number of countries have moved to middle income status, with development assistance for health (DAH) representing less than 3% of total health expenditure.
• An increasing number of countries are in one way or another transiting towards greater self-reliance for programs historically dependent on external financing, in particular immunization, tuberculosis, malaria and HIV/AIDS.
• Aid continues to play an important role in low-income countries, and in particular in fragile or conflict affected countries.
• Since the Alma-Ata Conference 40 years ago, burden of disease and demographic situation in countries have changed or are rapidly changing.
• The legacy of a decade on dialogue on aid effectiveness shows that principles have proven relevant for strengthening systems, from planning to management and accountability for results.

While the predecessor of  UHC2030, the “International Health Partnership” IHP+ wanted to be a platform for a conversation between developing countries, bi-lateral donor countries and international development agencies on what it needs to support strong and comprehensive country and government-led national health plans in a well-coordinated way, and while the IHP+ “Global Compact” focused on the commitment to principles of effective development cooperation, the topic has disappeared from the top-level of attention.

According to their website, “UHC2030 draws on lessons from the IHP+ experience, about what has worked well and what has not, including how to better promote the principles of effective development cooperation, like the Seven Behaviours. These principles are anchored in country ownership and guide the actions of all partners towards more effective and aligned efforts towards HSS and thereby UHC.”

But in times when the mainstream discourse on Universal Health Coverage health systems is about national leadership and the mobilization of national resources, it is not easy to call for a continued, honest debate about the role of development cooperation in strengthening (or weakening) health systems, as the Medicus Mundi International Network has done it over the last few years and continues to do so.

On this background, we were happy – and grateful to UHC2030 – that the side event at the Astana PHC Conference provided some important perspectives to reinvigorate the essence of the effective development cooperation agenda in terms of alignment with PHC based national policies, strategies and plans.

A particular challenge of the Astana session was to apply a “Primary Health Care lens” on development cooperation and health systems. The organizers framed it as follows:

• Empower people and communities as owners of their health, as advocates for the policies that promote and protect it, and as architects of the health and social services that contribute to it;
• Address the social, economic, environmental and commercial determinants of health through evidence-based policies and actions across all sectors; and

• Ensure strong public health and primary care throughout people’s lives, as the core of integrated service delivery.

The panel discussion moderated by Githinji Gitahi, Global CEO of AMREF Health Africa, and UHC2030 co-chair, included two rounds. The conversation was opened to the audience in the room and, via online survey, to those who could not make it to Astana, along the following lead questions:

1. What are the most critical challenges we need to address to ensure development cooperation strengthens health systems for PHC?

• Lack of transparency and predictability of aid flows?
• Uncoordinated technical assistance?
• Crowding out of  domestic funding and distortions of national allocations?
• Tension between earmarked donor support/quick wins and longer term investment in institutions and capacity development?
• Difficulty to engage communities and people?
• Other?

2. Where do you see most critical need to continue this conversation?

• Providing space and structures for mutual learning, widening the evidence base and sharing best practices across countries/partners?
• Reframing normative guidance/principles (e.g. IHP+ 7 behaviours, codes of conduct)?
• Promoting instruments for country level coordination and mutual accountability,  embedded in country processes?
• Facilitating  discussion on the role of aid in supporting health systems strengthening and domestic resources mobilisation? 
• Supporting advocacy efforts to promote PHC as the foundation of UHC?
• Other?

The following selection of inputs by the panellists is not expected to be comprehensive, but based on personal notes by the author:

Emmanuel Odame, Director Policy planning, monitoring and evaluation at the Ministry of Health of Ghana was quite clear that, after the times of the MDGs and their focus on vertical, disease-specific programmes, the time is now to see “how to use aid to move beyond aid”. International cooperation should focus on strengthening the systems in place, and its focus should be on health, not on diseases, addressing all sectors that affect health, health policies and health systems including energy or transport.

Rachel Arrundale, Head of the Health Services Team at DFID (UK) called for overcoming any quick-fix approaches and expectations. For this, and to attract global attention and cooperation to more sustainable investments in national policies and systems, the health systems story needs to be told better, and underlined with data. International cooperation should focus on the gains the countries want to achieve, based on the needs expressed by the people. This can also be explained to the tax payers in the UK, as it refers to their own realities.

Tran Thi Mai Oanh, Director Health Strategy and Policy Institute, Vietnam, agreed that financial and technical support should directly refer to a country’s needs. Strengthening national capacities and governance is core. Instead of vertical programs, multisectoral action is needed.

Itai Rusike, Community Working Group on Health, Zimbabwe and also representing the MMI Network on the panel, highlighted the role of communities and their structures and organizations, to be strengthened to actively participate in public health policy making and in the provision of the health services the communities want. The support of people, communities and, overall, the strengthening of responsive and democratic national structures, should be at the core of international cooperation.

Agnès Soucat, Director Health Systems Governance and Financing at WHO, agreed that the issue of development cooperation in the context of the SDG is not yet fully explored. She recalled the overall framework of the World Health Organization’s 13^th General Programme of Work for driving public health impact, with a differentiated approach based on each country’s capacity, ranging from fragile to mature health systems:

• fill critical gaps in emergencies – through service delivery
• build national institutions – through technical assistance
• build high performing systems – through strategic support
• develop systems of the future – through policy dialogue

In this sense, development cooperation must be “fit for purpose” and refer to the context. If countries still need external support, it should contribute to building the foundations of a health system, though investments in national institutions and policies. On the other hand, dealing with countries in transition towards a more mature health system, it is important to “de-learn”, to shift the way of working and not get stuck in the old patterns and routine. If this shift does not happen, aid has the potential to crowd out domestic funding and to distort national policies, strategies and allocations of funds.

Panellists also agreed that global solidarity and cooperation might shift towards producing and financing global public goods such as research and regulation that will support countries in their health policies. However, it is not obvious how to shift both attention and money to these more complex fields.

The session concluded with a broad agreement that the conversation needs to be continued – and with the related expectation and mandate to the organizers to provide modalities and platforms for this.

Thomas Schwarz
1 November 2018

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This report is work in progress. Panelists, co-organizers and other participants are invited to provide feedback and further input.

Session programme, with list of speakers: here
Moderation slides with list of key topics: here