Improving the long-term sustainability of health aid: are Global Health Partnerships leading the way?

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine ß The Author 2010; all rights reserved. Advance Access publication 14 May 2010 Health Policy and Planning 2010;25:363–371 doi:10.1093/heapol/czq014 Improving the long-term sustainability of health aid: are Global Health Partnerships leading the way? Rebecca Dodd1* and Christopher Lane2 1 *Corresponding author. World Health Organization, 22 Avenue Appia, Geneva 1211, Switzerland. E-mail: Accepted 27 November 2009 Over the last decade development assistance for health has more than doubled. This increase provides an unprecedented opportunity to scale up health services, and in doing so, achieve the health Millennium Development Goals. However, sustaining scaling up will in turn require sustainable donor support until domestic health financing can substitute for it. The provision of long-term predictable finance is of particular concern in health because the bulk of costs are recurrent and many interventions require sustained, multi-year support to be successful. This is also true for health systems strengthening efforts. As the bulk of new aid resources flow through Global Health Partnerships (GHPs), their ability to make long-term commitments is critical to health systems development. In order to better understand the constraints that prevent development partners from making long-term commitments of health aid, the World Health Organization reviewed the practices of seven major health partners in committing development assistance funds over the long term. The review found increasing evidence of long-term commitments of aid for health in each of the seven agencies. The GHPs and their funders have been at the forefront of this trend, pioneering many of the new approaches. The study concludes that all partners have scope to improve the duration of aid within existing rules and regulations, and that the main constraints to doing so are political. Predictability is even more of a concern in current global economic circumstances, as access to resources begins to be squeezed. In this context it is important that we learn from GHPs, which have successfully tested innovative approaches to both raising and disbursing health funds. The prospects for change associated with the new administration in the United States—the largest health donor and the most unpredictable, but also a major supporter of GHPs— make this task even more urgent. Keywords Health systems, health policy, aid 363 World Health Organization, Geneva, Switzerland and 2International Monetary Fund, Washington, DC, USA. E-mail: 364 HEALTH POLICY AND PLANNING KEY MESSAGES The provision of long-term predictable finance is a key aspect of scaling up health services to reach the Millennium Development Goals, because the bulk of health costs are recurrent and many interventions require sustained, multi-year support if they are to be successful.  Health donors are increasingly providing aid over the long term. The global health partnerships are at the forefront of this trend, pioneering many of the new approaches.  However, all partners have scope to improve the duration of aid within their existing rules and regulations: the main constraints to doing so are political.  Increased monitoring of aid duration and better incentives for donor agency staff to take on the risks and difficulties associated with making longer term commitments are needed. Introduction Between 2002 and 2006, Official Development Assistance (ODA) for health increased at an annual rate of 25% (Figure 1), reaching US$16.7 billion in 2006 (OECD 2008). As the level of health aid (and overall aid) has risen, so has interest in the way in which money is provided: if aid resources are to be used effectively, it is argued, they must be provided predictably, and sustained over the long term (Clemens 2004; Heller 2005; Williams 2005; Lane and Glassman 2007). The development community’s concern with long-term predictable funding (Council on Foreign Relations 2004) is reflected in commitments of the Paris Declaration on Aid Effectiveness (OECD 2005), and the subsequent Accra Agenda for Action (Third High Level Forum on Aid Effectiveness 2008). Research into the volatility of aid flows (Hamann and Bulir 2001) suggests that aid is more volatile than fiscal revenues, particularly in highly aid-dependent countries. There is surprisingly little research into a closely related issue, the duration of aid commitments; neither on current practice, nor on the barriers to increasing the length of commitments, nor on the desirability of doing so. 16 14 Disbursements 1/ US$ billions 12 10 8 Commitments 2/ 25%+ annual growth Arguments for and against long-term funding in health 6 4 2 0 2002 This study seeks to fill that gap. It systematically reviews current donor practice in the provision of long-term aid for health, identifies the practical constraints that agencies face in making long-term commitments, and provides 10 examples of existing good practice that could be more widely adopted. It also provides a brief overview of the arguments for and against provision of long-term aid as they are understood by the agencies that participated in this study. The purpose is not to make a judgement on the veracity of the arguments, but rather to understand the political context in which calls for long-term funding are taking place. Since the research for this review was undertaken there has been a dramatic shift in the global economic outlook. With many developed economies now officially in recession, there is mounting uncertainty about whether the scaling up of aid flows for health can be extended or even maintained (Anonymous 2008; Holmqvist 2008; IRIN 2008). At the same time, local funding for health services may also face adverse pressures as developing economies adjust to slower domestic and global growth (Parry and Humphreys 2009). Those agencies that have secured long-term predictable funding with multi-year financing arrangements are arguably better placed to weather the financial crisis than those relying on annual funding rounds. It is therefore a particularly opportune time to consider how provision of predictable long-term funding can be extended and expanded. 2003 2004 2005 2006 Note: 1/ Excludes IDA and GAVI. 2/ Excludes GAVI Source: OECD Credit Reporting System. Figure 1 OECD Official Development Assistance for health and population aid activities, 2002–06 The provision of long-term predictable finance is of particular interest in health because the bulk of costs are recurrent and many interventions require sustained, multi-year support if they are to be successful (DFID 2004; Foster 2006). For example, expanding training programmes for skilled health personnel typically takes 8–10 years (WHO 2006). The average length of antiretroviral treatment for HIV is between 5 and 15 years for first-line drugs and 10–15 years for secon (...truncated)