and who are accountable?

1
and who are accountable?
Health systems hit by AIDS
Who sets priorities

• Seminar discussion with World Bank 26.05.05
• S. Møgedal

2
Health Systems under pressure

• Technology and opportunity pressure
• beyond the scope of public budgets in all
  countries.
• HIV/AIDS pressure
• on top of long term under investment (..the
  unfinished agenda of 20/20)
• Reform pressure
• right sizing of public service provision,
  financing, decentralization
• Performance pressure
• targeted, performance based initiatives ,
  governance etc
• Health work force leakage pressure
• Global market

3
Health Systems under pressure

• Technology and opportunity pressure
• beyond the scope of public budgets in all
  countries.
• HIV/AIDS pressure
• on top of long term under investment (..the
  unfinished agenda of 20/20)
• Reform pressure
• right sizing of public service provision,
  financing, decentralization
• Performance pressure
• targeted, performance based initiatives ,
  governance etc
• Health work force leakage pressure
• Global market

Aggravated by multiple players and supply drives

• Aggravated by double messages from the
• international community
• MDG and macroeconomic governance
• AIDS scale up and a health system that delivers
  care for
• broader basic needs
• Unclear roles in the donor architecture (who
  funds
• infrastructure and human resources)
• Competing coordination mechanisms (AIDS)

4
Health Systems under pressure

• Technology and opportunity pressure
• beyond the scope of public budgets in all
  countries.
• HIV/AIDS pressure
• on top of long term under investment (..the
  unfinished agenda of 20/20)
• Reform pressure
• right sizing of public service provision,
  financing, decentralization
• Performance pressure
• targeted, performance based initiatives ,
  governance etc
• Health work force leakage pressure
• Global market

Escape
PUBLIC HEALTH DISASTER
5
Need to link frameworks and go beyond the public
sector
AIDS ACTION 3 ONES
Civil Society
Public Sector
PRS (P)
Health Services Delivery
Helsetjenester
6
Need for a new COUNTRY-UP paradigm

• National ownership (inclusive of NGOs, with
  respect for state) is the basis for The Three
  Ones and for Rome/ Paris OECD-DAC
• In spite of agreement, national ownership still
  undermined, with major consequences for sustained
  action
• Many of the most critical challenges require
  country specific solutions (both defining the
  bottlenecks and tailoring action)
• In-country partners have a problem solving
  potential that is not fully used (academic, civil
  society, private sector, external partners with a
  country presence)
• Global action must respond to and enable country
  level problem solving partnerships and country-up
  processes

7
The basic challenges

• Action priorities that drive alignment among all
  partners
• Means the need to make choices and negotiate
  competing interests (- what about countries that
  for different reasons do not deliver on this?)
• Accountability
• for priorities and results to people and clients
  (WDR 2004)
• for alignment among partners must be mutual
  what mechanism?
• Accountability for effective use of resources
• Empowering national capacity/systems
• Defining and managing effective technical support
  and dealing with underinvestment and competing
  forces in the health work force market represent
  agendas undermined
• Harmonization
• a tool for reducing the transaction costs and
  distortions of aid, but not a purpose in itself
• has possibly been too focused on donor procedures
  and thereby overshadowed the critical need for
  priorities that an drive alignment?

8
Why must countries be in front?Illustration
Health work force

• A globalized world (globalized market, globalized
  health problems) require empowered and inclusive
  national governance as well as international
  mechanisms for dealing with common/competing
  interests
• Work force issues are
• Multi-sectoral in nature, and therefore often
  fall between many chairs
• invariably political because require policy
  choice, negotiation and alliance building
• not resolved with blue print solutions
• not resolved by money alone (training, retention,
  distribution, drivers and competing forces of the
  internal market, regional and global market)
• Calling for a problem-solving mode country-up

9
Challenges to partners

• What is required for countries to make the
  exceptionality argument?
• HIV/AIDS
• health work force
• How can partners enable national processes for
  setting priorities
• based on inclusive processes (civil society and
  academics )
• clear enough to drive alignment
• serve as a basis for vertical and horisontal
  accountability
• What are mechanisms for in-country problem
  solving, peer review and mutual accountability?
• medium term health workforce framework, work
  force impact assessments?
• AIDS impact assessment and health systems
  readiness ?
• Country Action Alliances/Partnership Forums

10
Challenges to partners

• What is required for countries to make the
  exceptionality argument?
• HIV/AIDS
• clear enough to drive alignment
• health work force
• How can partners enable national processes for
  setting priorities
• based on inclusive processes (civil society and
  academics )
• serve as a basis for vertical and horisontal
  accountability
• What are mechanisms for in-country problem
  solving, peer review and mutual accountability?
• medium term health workforce framework, work
  force impact assessments?
• AIDS impact assessment and health systems
  readiness ?
• Country Action Alliances/Partnership Forums

HEALTH SERVICES
AIDS ACTION
REQUIRE LINKING IN PLANNING DELIVERYPROBLEM
SOLVING AND ACCOUNTABILITY COUNTRY-UP
CIVIL SOCIETY ACTION
PUBLIC SECTOR