Transcript Leveraging donor financing to strengthen country

Global Health Aid:
What’s Ahead?
David de Ferranti
1
Outline
Health aid and its architecture: where
are we headed?
Will health aid do a better job of
strengthening country institutional
settings?
2
Why East Asia countries might care about
what is happening in global health aid
Aid and “the aid dialogue” are a source of:
•
Financial support
•
Ideas
•
Experience from other parts of the world
•
Initiatives and advocacy – on new priorities
And these can have implications for countries
•
Help or hinder local efforts
•
Absorptive capacity concerns
•
Fragmentation, efficiency, other
3
Health aid has increased
Billions of USD
10
Bilateral
Commitments
8
6
GF/GAVI
Commitments
4
World Bank
Commitments
2
Bilateral
Disbursements
0
GF/GAVI
Disbursements
2001 2002 2003 2004 2005 2006
… and shifting to recurrent cost financing for communicable disease control
Source: Lane and Glassman 2007
… and has gotten more complicated!
International
Philanthropy
Official Development Assistance
Product (RED)
Debt Buy-back
Multilateral
Banks
Bilateral
Agencies
UN Agencies (
WHO & others)
Global Health Partnerships
Airline Tax
Global Fund
AMC
UNITAID
Buy-downs, co-financing
GAVI
IFFIm
Private Capital
Health Service Delivery
Public Health & Community Health
Health Financing
Individual Preventive Public
Health Interventions
Other Gov.
Data, Health Education,
Environmental Health
Health Strategy
Finance
Ministry of
Health
Social Security
Private Payments
Out-of-Pocket Payments
Insurance
Public Providers
Individual Health Interventions,
Acute & Chronic Care
Public Providers
Private Providers
POPULATION
Ministry
Volatilty  unpredictable funding levels
20,000
16,000
12,000
Government
Development Aid
8,000
4,000
0
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Millions of Rwandan francs, 2000
prices
Rw anda: Governm ent and Aid Health Financing, 1997-2006
Source: Rw anda, Ministere de la Sante Rapport Annuel
2006
Changes are afoot
The new players are still expanding. And changing.
Gates and other new philanthropies
Global Fund, GAVI, and other disease-focused
initiatives
Others (Media stars, wealthy individuals, the BRICs, …)
The traditional players are trying new ideas
European bilaterals (DfID, France, Nordics, …)
US assistance (USAID, MCC, State, PEPFAR, etc.)
World Bank and regional multilaterals
BINGOs, LNGOs, FBOs, private health providers
Other (IMF, overall aid strategies, recipient governments)
The global environment is worsening
US economy and “the crisis from the north”
7
X years from now …
How will today’s tensions have evolved?
Vertical programs vs. health systems
Country-driven vs. donor-driven
Performance-based vs. input-focused
General support vs. project-oriented
Public vs. private roles in health
The trans-Atlantic divide
How will tomorrow’s trends have unfolded?
Epidemics and pandemics – old and new
New products, technology, and financial tools
8
X years from now … (continued)
Will the global health architecture have changed radically?
By default rather than by design?
Will support (public, political) for aid have weakened?
Impact of new generations of voters? Is a funding “cliff” coming?
Will the new players have achieved results?
Or changed the debate?
Or foundered on unrealistic expectations?
Or changed their own views of what is needed and what works?
Will the traditional players have changed?
Will aid be just IDA-type funding plus IFC-type support?
Will there be enough money to meet the priority needs?
9
The Great “Money Gap” Debate
UNAIDS says $55.1 bn is needed for 2006 - 2008 for HIV/AIDS
Funding gap: $6 bn in 2006 and $8.1 bn in 2007 1
GAVI: $35 bn to immunize 27 mn children by 2015
Funding gap: $11-15 bn 2
StopTB: $56.1 bn over 10 years
Funding gap: $30.8 bn 3
Maternal and Neonatal Health and Child Survival: $9 - 16 bn/yr
Funding gap: $5 bn/yr
Roll Back Malaria: $3.4 bn/yr
Funding gap: $2.7 bn/yr 4
1
Report on the Global Aids Epidemic. Geneva: Joint United Nations Programme on HIV/AIDS, 2006.
Albright, Alice. "Innovative Financing for Global Health." The Brookings Institution, Washington. 26 July 2006.
Lob-Levyt, Julian. "Progress & Phase 2." 3rd GAVI Partners' Meeting, New Delhi. 8 December 2006.
3 Stop TB Partnership. Actions for Life: The Global Plan to Stop TB 2006-2015. Geneva: World Health Organization, 2006.
4 WHO. "Who | Malaria". Geneva, 2006. World Health Organization.
<http://www.who.int/mediacentre/events/2006/g8summit/malaria/en/index.html>.
2
10
The Great “Money Gap” Debate (continued)
Adding it all up:
From World Bank for health-related MDG gap
$25 - 70 bn/yr (0.08 – 0.21% of global GDP)
From Commission on Macroeconomics and Health, WHO:
$40 - 52 bn/yr (0.08 – 0.12% of GDP)
From summing selected disease/intervention-specific estimates:
$30 - 50 bn/yr (0.10 – 0.15% of GDP)
From Copenhagen consensus estimate of WDR 1993 package
$337 bn/yr (1% of GDP)
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The Great “Money Gap” Debate (concluded)
$25 to $50 bn/yr is small compared to:
Total health spending worldwide: $3,198 bn/yr1
Global military spending: $1,118 bn in 20052
Global corporate net profits: Exxon/Mobile alone earned $36 bn in 2005
Total capital in global financial markets: $118,000 bn (a stock, not a flow)3
But large compared to:
Total current development aid for health: over $11.4 bn/yr (IMF/WB, 2004)
Total current ODA for all purposes: $80 bn/yr (OECD, 2004)
Total current health spending in recipient countries: $350 bn/yr1
And would be needed for a very long time
So …this is too big to solve by aid and philanthropy alone
Gottret, P. and George Schieber. 2006. Health Financing Revisited: A Practitioner’s Guide.
Washington, DC: IBRD/World Bank.
2 Stockholm International Peace Research Institute, 2006
3 McKinsey Global Institute, 2005
1
12
Strengthening Country Institutional Settings
What is it?
•
Strengthening institutions such as
•
•
•
•
•
Laws and regulatory regime
Health workforce talent pool and incentives
Management systems
Transparency, governance
Similar to “enabling environment” and “investment
climate” concepts in macro policy?
Not the same as:
•
Capacity building
•
Traditional technical assistance
13
Prospects for Improving Aid Effectiveness
And Its Impact on Country Institutional Settings
What to expect from the new initiatives that promote:
•
Greater strategic coherence (IHP++, etc.)
•
Harmonization and alignment (Paris, Rome, etc.)
•
Results-based aid (Norway, etc.)
•
Pooling of aid (budget support, SWAps, etc.)
•
Better use of traditional tools (e.g., technical assistance)
•
Strengthening health systems
And from new efforts to:
•
Strengthen incentives and institutions
•
Attack demand and supply side constraints simultaneously
14
Why East Asia countries might care about
what is happening in global health aid:
REVISITED
Aid and “the aid dialogue” are a source of:
•
Financial support: RECENT INCREASES COULD
BE IMPORTANT FOR A FEW COUNTRIES BUT
NOT FOR MANY. RISKS OF FUTURE DECLINES?
•
Ideas: MUCH FERMENT. HOW USEFUL???
•
Experience from other parts of the world: A LOT TO
LEARN FROM NOW. MORE COMING.
•
Initiatives and advocacy – on new priorities: MANY
NEW EFFORTS. THEIR VALUE STILL UNCLEAR
15
Why East Asia countries might care about
what is happening in global health aid:
REVISITED (continued)
And these can have implications for countries
•
Help or hinder local efforts:
•
•
CHOOSE CAREFULLY – WHICH GLOBAL
INITIATIVESTO PARTICIPATE IN AND WHICH NOT.
Absorptive capacity, fragmentation, efficiency, other:
• PUSH BACK – TAKE CHARGE – WHEN
DEALING WITH DONORS. MAKE “COUNTRYDRIVEN” A REALITY.
• EVEN WITH THE WORLD BANK!
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End
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Other Money Problems Within Countries
Low Income
Lower Middle
Income
Upper Middle
Income
High Income
0%
20%
40%
Private: out of pocket
60%
Private: pooled
80%
100%
Public
Source: WHO National Health Accounts, updated 2002.
18
Global Health Spending
Global Disease Burden
Low- and Middle-Income
Countries
Low- and Middle-Income
Countries
High-Income Countries
High-Income Countries
Source: Gottret, P. and G. Schieber. 2006. “Health Financing Revisited.” World Bank.
19
Volatile revenue flows
Average absolute percentage deviation from trend 1996-2005
25
Percent
20
15
10
5
0
Government Spending on Health
Health Aid
US$ per capita data for 59 countries. Excludes micro states, countries where
health aid < 10 percent of govt. spending. Source WHO.
Trend: Hodrick-Prescott filter; Source: Lane and Glassman 2007
Options for Change
Accelerate efforts to …
Help countries move toward stronger health systems
Based on more effective built-in incentives for better performance
Develop powerful new interventions
Cost-effective vaccines, programs, financing strategies, etc.
Improve uptake of existing interventions (new or neglected)
Requires focus on country health systems
Get more impact from
Success stories – from innovative country programs
Bridging divides between leaders and ideas
Evaluation of experience
Press key players (WB, WHO) to do better
New initiatives should add value
New initiatives should be active constituents holding main players accountable,
not competitors
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Four inter-linked initiatives
Project on Innovative Financing
IFFIm, airline tax, advance market commitment
Private sector: their role and investment
Task Force on Health Financing
Mary Robinson, Julio Frenk, Ngozi Okonjo, etc.
Within-country and aid-flow issues
Programs on Improving Implementation
Focus on governance, corruption, transparency, accountability
Private sector risk-pooling in Africa
Dutch government support
22
Developing countries that experience high aid volatility tend to be
those that are most dependent on aid and aid dependency is growing
Country Health Aid and Spending Volatility 96-05
Health aid volatility
Government health spending
volatility
LOW
Niger, Mozambique,
Central African Republic,
Bolivia, Jordan,
Bangladesh, Mauritania,
Eritrea, Djibouti
LOW
HIGH
Nigeria, Chad, Trinidad & Tobago,
Benin, Swaziland, Lao, Mongolia,
Comoros, Tajikistan, Kyrgyzstan,
Ethiopia, Bhutan, Cameroon, Papua
New Guinea, Buruundi, Timor Leste,
Tanzania, Romania, Zambia, Senegal,
Gambia, Yemen, Cape Verde, Cote
d'Ivoire, Sudan, Ghana, Namibia,
Cambodia, Sierra Leone, Uganda, Haiti,
Malawi, Honduras, Burkina Faso,
Typical health aid
Nicaragua, Togo, Mali
dependent country
Guinea, Guinea Bissau,
Madagascar
Somalia, Iraq, Afghanistan, Angola, Eq.
Guinea, Liberia, Myanmar, Georgia,
Zimbabwe, Armenia, Rwanda, Nepal,
Dem. Rep. Congo
Post conflict &
HIGH
other fragile states
High/Low Threshold: 12 percent avg. deviation from trend.