Title: Europe, Health and development : Europe as a donor Action for Global Health Conference Madrid 2627 M
1Europe, Health and development Europe as a
donorAction for Global Health
ConferenceMadrid 26-27 May 2008
- Juan Garay
- Health team coordinator and
- DG Development, European Commission
2The facts MDG progress
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4Nutrition and risk of ill health
- Main risk factors
- Nutrition 25 AR
- Sexual behaviour 10
- Water and sanitation 6
- in-door air-pollution 4
- lifestyle factors 8
- New evidence
- Social inquities (CSDH)
- Environmental and climate change threats (IPCC)
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6The wide health response
- Prevention multisectrorial
7Public financing of the health sector The need
minimum thresholds for public financing
- Public financing for basic health services is
essential to aim at universal and equitable
coverage and especially pro-poor fair financing. - Large of people in poverty Regulate
guarantee often provide - Lesses of people in poverty regulate gt
guarantee gt provide - There are specific preventive and treatment
interventions which can reduce the burden of
disease and prevent premature deaths (while
socio-economic conditions take their time to
reduce risks) - CMH comprehensive package of essential services
(including HIV/AIDS) costs 24-32 pc and year in
low-income countries - (similar BHCP costing analysis in several ACP
countries)
8FIRST ACTION PLAN (2008-2010)FOR THE
IMPLEMENTATION OF THE AFRICA-EU STRATEGIC
PARTNERSHIP
- identify joint actions to strengthen district
and national health systems, including
participatory and action-led health management
information systems, the elimination of fees for
basic health care, strengthening preventive
health care systems and health education, and
stronger involvement of civil society partners
9Gap and potential gap
- Global Public financing gap under CMH threshold
- 70 countries, with a total gap 42,2 b
- If countries were to allocate 15 of their
government's budgets to health (Abuja target) - additional public funding form domestic sources
would be 25,6 b - only 50 countries -35 ACP (34 in Africa)-, would
still face a gap of 13,4 b (10 b for ACP)
10Abuja space, but qualified?
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13Public financing capacities
- Potential (15) public financing gt 20/pc
- eg. Angola Aid vs. TA/political dialogue?
- Potential (15) public financing lt 20/pc
- predictable GBS/SBS at a minimum level of
- (minimum threshold-potential public
finanacing)/potential public inancing ) x
National Budget - vs.
- exceptional case/fiscal speace for health (eg
medicines in kind)
14The response of health systems in ACP countries
financing capacities
15The response
- Sufficient?
- Fragmented?
- Equitable?
- Alligned?
- Predictable?
16DAC data on healtjh ODA vs. potential
financing gap
3.5 b for Heath general / basic (2.8) vs gt 8
b for HIV/AIDS?
17Health needs/ODA/gap vs AIDS needs/ODA/gap
54 b by 2010
18Health system fragmented
- gt 100 global initiatives
- Advocacies by problems, isolated funding gap
analysis (consolidated gt 30 b!), vertical
approaches, duplication and opportunity cost - The case of a safe delivery basic service
- Vs. divided into?
- MDG 1 reducing low birth weight and
malnutrition - MDG 4 reducing neonatal death
- MDG 5 SRHRs reducing maternal deaths
- MDG 6
- AIDS PMTCT
- Malaria AN PrTx
- Tb BCG
19MozambiqueTotal budget for the health sector
2008
- The health sector funding is heavily dependant
on external funding. - The state budget is estimated at 27 and
external funds accounts for 73 of the health
sector funds (2008). The total amount of funds
for the health sector is estimated to be 512.1
millions US ( 2008).
20Funding Modalities
21Mozambique
Paris? Which Paris?
22Levels of health ODA
23EC health support
24Countries where health is a focal sector
- 31 countries
- ACP (4/ GBS) Liberia, Ivory Coast, DRC, Angola,
Zimbabwe, Burundi, Chad, East Timor, Haiti,
Lesotho, Swaziland, South Africa, Zambia,
Mozambique, - Asia (17) Afghanistan, Burma, India,
Philippines, Vietnam, Regional - Latin America (Soc cohesion)Honduras and Ecuador
- North Africa /Middle East and Eastern Europe
(8,8) Algeria, Morocco, Egypt, Syria, Libya,
Yemen, Ukraine, Moldova, Georgia.
25Thematic EC health supportChapter under
investing in people Good health for all
- Four key health issues
- crisis in human resources in health care (21m,
07-10) - strengthen Europe's role in addressing the main
poverty-related diseases such as HIV/AIDS,
malaria and tuberculosis and neglected diseases
and emerging health threats (235 m 07-10) - sexual and reproductive health and rights (SRHR)
(41 m 07-10) - balanced approach between prevention, treatment
and care, including attention to the burden of
non-communicable diseases and tobacco control.
26Reduce fragmentation, increase ownership
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28Reduce fragmentation
- Initiatives for SWAP revival ?
- High Level Forum on Health MDGs (HLF)
- G8 communiqué on scaling up for health in Africa,
- International Health Partnership (IHP)
- Global Campaign on Health MDGs
- Catalytic Initiative to Save a Million Lives,
- "scaling up for better health" (by the so-called
"H8" The Gates Foundation, GAVI Alliance,
Global Fund to Fight AIDS, Tuberculosis and
Malaria, UNAIDS, UN Population Fund, UNICEF,
World Health Organization and the World Bank). - Results Based Financing in the World Bank
- GAVI health systems window,
- GFATM modalities for health systems support
- Count down 2015
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30EC Budget support and health
- Advantages / Impact
- Reduces fragmentattion/fungibility and increases
ownership - Has induced (through incentive tranches)
increased national budget allocation to health - Disadvantages/failures
- In some cases
- Not increased allocations (esp. If high
inflation) - Not increased net allocations (low execution
rates) - Requires adequate level () and dialogue
- In 10 African countries, the level required of
GBS, at 15 health allocation, to meet CMH, would
be 4 times the national fiscal revenues
exceptional acse for health vs. Celings on
social/public spending?
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32Equitable ODA for health?
33Addressing aid orphans Division of labour
- May 2007 Code of Conduct on Division of Labour in
Development Policy , includes cross-sector
complementarity - It includes addressing the orphans gap
- EC vs MS added value in health?
34Progress on DoL
- In donor darling countries like Burkina Faso,
Ghana, Kenya, Mali, Mozambique, Senegal, Vietnam
- coordination is fairly good,
- but the principles of the Code are not yet being
applied. - too many donors by sector (In Mali, more than 26
donors are active in rural development), more
than three sectors of concentration per donor and
very limited use of implementation instruments
(e.g. delegated cooperation, co-financing, silent
partnerships). - In orphan countries such as
Congo-Brazzaville, Madagascar, RCA and Togo the
picture is more uneven. - Dialogue among donors is often less coordinated.
- Incentives for DoL are limited
- i.e. few donors, many needs, and the principles
are sometimes not applicable (e.g. no country
leadership). - good practices are observed in some countries
such as in Chad and Niger in particular in
post-conflict countries where coordination is
deemed necessary such as in Côte dIvoire, Togo,
and Lebanon. - In Vietnam, the EC will concentrate 80 of its
aid for 2007-2010 in two sectors of concentration
(general budget support and capacity building in
the health sector). The remaining 20 will be
dedicated to non-focal sectors (trade and
governance).
35Assessment of Community added value
- The European Consensus has refined the definition
of the Communitys comparative advantages in a
two-step approach. - at institutional level, the Commission will aim
to provide added value through the following
elements - its global presence (lead in many fragile
states?) - policy coherence promotion of development best
practices - facilitation of coordination and harmonisation
- delivery in areas where size and critical mass
- promotion of democracy, human rights, good
governance and respect for international law, - with special attention paid to transparency and
anti-corruption and the facilitation of dialogue
with local economic and social interest partners. - EDF support is usually concentrated in four
sectors, except in fragile, post-crisis
countries. The main ones are - general budget support (gt40 of countries, around
30 of volume), - infrastructure, including water/energy (gt60 of
countries, around 30 of volume), - governance, including peace/security (gt60 of
countries, around 15 of volume), - rural development and agriculture (gt30 of
countries, around 8 of volume). - Social sectors receive relatively modest direct
support (8 to specific health and education in
10 EDF) - Potential EC added value in health ? (ongoing
evaluations?) - On-budget support and links to health
dialogue/inputs/results? - Health in fragile states/LRRD?
- Links to health of infrastrcutures, social
governance, rural development?
36More predictable aid
- On average, aid flows are at least six times more
volatile than fiscal revenues. The relative
volatility of aid is highest for the most
aid-dependent countries. - The MDG Contract offers long-term predictability
in return for greater commitment to results by
partners.
37MDG-C Objectives
- Objective to improve the effectiveness of
budget support in accelerating progress towards
the MDGs by increasing its long term
predictability and focussing on results - it is a budget support instrument. Other
instruments will be needed where budget support
is not appropriate - Alsoto catalyse improvements in delivery of
budget support from other budget support
providers, while remaining within existing
harmonisation frameworks - MDG
- Strong focus on the MDGs, notably health and
education - Contract
- mutual responsibilities more predictability for
enhanced focus on (and financial commitment to)
MDGs - with hard financial engagements set out in signed
financial agreements
38Key features
- Overview core features, common to all
- Six year time frame (cf 3 yrs at present)
- At least 80 of total commitment to be
disbursed, subject to no breach in eligibility/
criteria or fundamental/essential elements (cf
average 65 fixed at present) - Fixed annual disbursements, subject to adjustment
at mid-contract review (cf. annual FT and VT) - Annual monitoring, and reinforced dialogue (cf
partial VT or delayed FT) - Safety valve (10) to respond to eligibility
concerns (as opposed to breaches) - Targeted at strong performers
-
- Main areas for country flexibility
- Phasing of the 80 fixed component
- Mechanism for translating assessments of
performance into financing decision for second
half - Choice of indicators (focus on outcomes and PFM)
39Eligibility
- Proposed criteria
- GBS already programmed in EDF10 CSP and compliant
with standard GBS eligibility criteria - Positive track record of GBS implementation
- Medium term framework for assessing performance
with active donor coordination mechanisms - Expected countries
- Benin, Burkina Faso, Ghana, Madagascar, Mali,
Mozambique, Rwanda, Tanzania, Uganda, and Zambia
(10) - 60 of all EDF 10 GBS, 16 of EDF 10
- Eligibility to be formally assessed and confirmed
during design
40EC opportunities in aid effectiveness in health
- Level EU conveeining gt EC as donor
- Fragmentation On-budget SWAP
- Equity Division of labour process
- Alignment PRBS dialogue
- Predictability MDGc