Aid Accountability

1
Aid Accountability and Effectiveness An NGO
code of conduct Wendy Johnson, MD, MPH Health
Alliance International University of Washington
2
From the WHO Report of the Commission on the
Social Determinants of Health
3
Comparative average US monthly spending for
military operations and ODA for social services
(As of 2003)

• Sources of basic data US Congressional Research
  Services OECD-DAC
• www.realityofaid.org

4
Where is the money not going?
Public Investment in Developing Countries,
1970-2000
1. Public Investment in Developing Countries,
1970-2000
as a of GDP
Source Everhart and Sumlinski
5
Why has public investment spending declined ?

• Structural Adjustment programs and IMF imposed
  fiscal and monetary policies.
• Controversies about aid to public sector
• Theories about the Predatory State
• Private sector would compensate for drop in
  public investment
• Crowding-out (fear that public system would
  crowd-out private enterpriseSCHIP, health
  reform-no public option)

6
(No Transcript)
7
What Really Happened?
Private sector did not compensate for the drop in
public investment

• Recent research IMF research (2005) shows that
  the private sector did not compensate for the
  drop in public investment as it was hoped
• The Report of the Commission for Africa (2005)
  concluded that the sharp reduction in
  infrastructure investment was a policy mistake
  founded in a new dogma of the 1980s and 1990s
  asserting that infrastructure would now be
  financed by the private sector

8
From the WHO Report on the Commission on the
Social Determinants of Health
9
Effect of Privatization

• Upwards of 100 million people are pushed into
  poverty yearly through the catastrophic household
  health costs that result from payments for access
  to services.
• --WHO Report from the Commission on Social
  Determinants of Health

10
Effects on Public Health Care Systems

• Health services
• Decreased quality of services
• Less money for drugs, fuel, supervision
• Service fees/ User fees
• Decreased utilization
• Inadequate workforceeroding salaries, low morale
  and exodus
• Health Impact difficult to measure, but
  leveling off of mortality rates

11
Distribution of health workers by level of health
expenditure and burden of disease
Source Mullen F
12
GLOBAL INEQUITY

• Estimated shortage of almost 4.3 million doctors,
  midwives, nurses and support workers worldwide.
• 57 countries, mostly in sub-Saharan Africa have
  critical shortages.
• Sub-Saharan Africa has only 4 of health workers
  but 25 of the global burden of disease (GBD).
• The Americas have 37 of health workers but only
  10 of GBD.

13
Donors turn to NGOs

• When the state is weak or not interested, civil
  society and the social capital it engenders can
  be a crucial provider of informal social
  insurance and can facilitate economic
  development
• World Bank, 2002

14
NGOs Seize Opportunity to Expand

• T he number of international NGOs was reported
  to have increased from 6,000 in 1990 to 26,000 in
  1999
• The number of international NGOs supported by
  USAID increased from 18 in 1970 to 195 in 2000
  (USAID 2002).
• Civil society involvement in World Bank
  operations has risen steadily over the past
  decade, from 21.5 percent of the total number of
  projects in fiscal 1990 to nearly 72 percent in
  fiscal 2003.

15
USAID Policies PEPFAR

• Dependence on NGOs for delivery
• 16 to governments, 84 to NGOs and other private
  institutions (US universities)
• Tied aid and Buy US policies
• Require purchase of FDA approved (branded) drugs.
• Difficult to fund salaries, recurrent costs,
  other needs within the public system.

16

• Gado, Tanzania

17
Real Aid Action Aid Report
18
(No Transcript)
19
Bilateral Donor Support to Tanzania, 2000-2002

Source Foreign Policy, Ranking the Rich 2004
20
Source Center for Global Development
21
Vertical Programs vs. Primary Care

• Diverted Resources away from Primary Care
• Fashionable diseases have priority
• Workers pulled away to work in other vertically
  funded programs (HIV)
• Internal Brain Drain to NGOs

22
(No Transcript)
23
(No Transcript)
24
Weakening the Public Health System

• Channeling resources and staff towards NGOs and
  away from public sector
• Creation of parallel systems
• Inequity in service delivery
• Increased management burden to MOH
• Accountability?
• Sustainability?
• Reliance on unpaid volunteers (CHW)

25
(No Transcript)
26
NGO code of conduct

• Code of Conduct Development Group
• Health Alliance International
• Partners in Health
• ActionAid International (USA)
• Physicians for Human Rights
• Health GAP
• Equinet
• Oxfam UK
• Over 35 signatories currently

27
NGO code of conduct (1)

• NGOs pledge to engage in hiring practices that
  ensure long-term health system sustainability.
• Limit hiring from local systems to mitigate brain
  drain, support improved public sector conditions
  to encourage workers to stay.
• NGOs pledge to enact employee compensation
  practices that strengthen the public sector.
  Support Primary Health Care.
• Limit pay inequity, support better pay for public
  employees, provide compensation for CHW.

28
NGO code of conduct (2)

• NGOs pledge to create and maintain human
  resources training and support systems that are
  good for the countries where they work.
• Support government in expanding training,
  including pre-service training, support for
  instructors, and management as well as clinical
  training.
• NGOs pledge to minimize the NGO management burden
  for ministries.
• Commit to joint planning, limit parallel
  structures, respect for MOH priorities.

29
NGO code of conduct (3)

• NGOs pledge to support ministries of health as
  they engage with communities to integrate them
  into the formal health systems
• NGOs embrace their role in supporting the public
  sector through advocacy and promotion.

30
Removing Impediments to Health Systems
Strengthening

• Foreign AID/Phantom AID
• Vertical Funding
• NGOs vs. National Health Systems
• NGO practices and Internal Brain Drain
• Preventing/Eliminating External Brain Drain

31
Reconceptualize Aid (1)

• Support nations to develop plans for
  comprehensive primary health care
• Advocate with donors to provide resources to PHC
  and HSS instead of exclusively vertical programs
• Advocate for Ministries of Finance/Planning to
  expand health sector budgets and workforce
• Remove IMF and World Bank constraints and reduce
  dependence on IFIs.

32
Reconceptualize Aid (2)

• Advocate for debt cancellation
• Alternative models of aid
• Untied
• Basket-funding
• Support Nationally-defined rather than externally
  defined needs
• Increase direct support for governments

33
(No Transcript)