Recent years have seen important shifts in global development assistance for health (DAH). Global health initiatives (GHIs) – consisting of bilateral donor and multilateral programs, and global public–private partnerships – have mobilized significant new financing for health programs, and equate to a considerable proportion of overall overseas development aid (ODA) for health in many low- and middle-income countries (LMICs). This has enabled a dramatic scaling up of health interventions, especially for HIV/AIDS. GHIs emerged from shifts in thinking about DAH in the 1990s/early 2000s, which was hitherto characterized by donor-prescribed projects and programs financed principally by bilateral donors and the World Bank. The shift in policy focus from international to global health, an increasing number of global financial actors, and the pressing need to meet persistent and newly emerging global health threats meant that a new response was required to coordinate global efforts to raise more money for health. Although GHIs share a common set of functions: to finance, resource, coordinate and/or implement disease control globally, the term global health initiative encompasses a range of financing and implementing entities (bilateral and multilateral actors, and global public–private partnerships) with diverse governance arrangements and programmatic foci.
In this article the focus is on four of the largest GHIs: the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the Global Alliance for Vaccines and Immunizations (GAVI Alliance), the President’s Emergency Plan for AIDS Relief (PEPFAR), and the World Bank’s Multi-country AIDS Program (MAP, which ceased financing in 2008). Table 1 summarizes the main features of these GHIs and other key initiatives and partnerships. The discussion is restricted to these four GHIs primarily because evidence is now beginning to emerge from empirical studies of their effects on country health systems – particularly the Global Fund; also because there is fairly limited data beyond these four large initiatives. GAVI, launched in 1999, was the first of the GHIs to disburse substantial funds at the global level, shortly followed by the MAP. High expectations surrounded the launch of the Global Fund in 2002: the initiative aimed to raise consciousness about important health issues, attract new partners, leverage substantial new funds, benefit from economies of scale in drug procurement, and promote coordination through pooling funds. There was, however, some reversal of the multilateral models of GAVI, MAP, and the Global Fund when PEPFAR was launched by the Bush Administration in 2003, a move criticized for operating in parallel to other actors and initiatives, and for adopting a prescriptive approach to determining the content of HIV/AIDS programs.
Reflecting the experimental nature of these new financing mechanisms and their sheer size, decision makers are inevitably curious about what impacts – both positive and negative – they have on recipient countries. There is an emerging literature on the effects of global initiatives and partnerships – most of which focuses on the largest HIV/AIDS initiatives – the Global Fund, PEPFAR and World Bank MAP, although there are also several studies on the GAVI Alliance. In this paper current knowledge on GHIs is reviewed, focusing on issues of healthcare financing. The achievements are reflected on, and also on the real and potential challenges that these initiatives create or reveal.
To What Extent Have Global Health Initiatives Increased Health Financing?
At the beginning of the 1990s, DAH was $5.7 billion. By the end of the decade, it had risen to just under $10 billion. A decade into the new century and DAH is pushing $25 billion annually, an increase of 124% in ten years. A 2010 report published by the Institute for Health Metrics and Evaluation discerns shifts in the balance of financial contributions to global health from traditional multilateral funders to GHIs. However, since 2007–08 when growth in DAH reached a peak of 17.5%, the rate of funding has been slowing down. In 2008–09 it dropped to just 6%. The proportion of bilateral funding has increased from 30% in 2001 to 45% in 2010, boosted by PEPFAR. So too has the proportion of funding from the Global Fund: from just 1% in its inaugural year to 11% by 2010. During the same period, UN agencies’ contributions have shrunk sharply from 24% in 2001 to 14% in 2010. The World Bank’s contribution has seen a dramatic reduction from 17% of total DAH in 2001 to just 5% in 2010.
For disease-specific health interventions, the Global Fund has punched well above its weight, and funding for HIV/AIDS, tuberculosis and malaria has increased dramatically. In 2009, this GHI disbursed just over $1.35 billion for these diseases. Financing HIV/AIDS, tuberculosis and malaria inevitably benefits maternal, neonatal, and child health (MNCH), and in this respect the Global Fund and GAVI have also contributed sizeable sums. In sub-Saharan Africa, for example, HIV/AIDS, tuberculosis and malaria are responsible for 52% of deaths among women of childbearing age and malaria alone accounts for 16–18% of child deaths. As funding for HIV/AIDS and other infectious diseases increased, funding for health systems and populations has experienced a corresponding decline. Between 1992 and 2003, funding for HIV/AIDS increased from 8% to a third of all commitments; during the same period, aid for population health experienced precisely opposite fortunes, decreasing from 32% to 8% of donor aid.
Does this shift mean that financing for specific diseases is displacing – or ‘crowding out’ – much-needed funding for other health priorities such as health system strengthening or non-communicable diseases; or conversely, has increased financing for specific diseases had a knock-on effect and increased funding for other health priorities? In terms of displacement of funds, there are multiple trends that indicate possible HIV/AIDS displacement effects, such as an increasing share of donor health and population funds. But there are also indications that HIV/AIDS funding is raising other health funding levels, particularly for control of other infectious diseases, though not for non-communicable diseases. At the same time that funding from global health financing partnerships is increasing, a widening mismatch between ODA and health need is becoming apparent, with high visibility global health problems and measurability of outputs being major drivers of funding.
Neither is it clear whether additional funding for health has been used in the manner intended by funders – namely on the health sector. The term used to describe the phenomenon of funding intended for a specific purpose but ultimately used for another is fungibility, and this is typically used when governments receiving donor funding reduce their own spending on the same health issue and therefore aid substitutes rather than increases local funding. Evidence whether financing from global initiatives and partnerships results in governments reallocating funds to other health areas, or indeed to non-health programs is inconclusive: in some cases domestic finances stay the same or decreases, in other domestic financing increases. For example, in Ghana there is no evidence that Global Fund support had led to deductions in government or other donor financing, whereas in Tanzania receipts of external financing for HIV/AIDS and tuberculosis had led the government to reallocate resources away from the health sector.
GHIs And Innovative Financing
To achieve the Millennium Development Goals, developing countries will have to spend approximately $60 per capita by 2015, or 100% more than they are currently spending. It is unrealistic for many countries to achieve this increase. In 2001 members of the Organization of African Unity (OAU) met at Abuja, Nigeria. The resulting ‘Abuja Declaration’ committed all members of the OAU to ensure that at least 15% of the domestically financed government expenditure went to health. Even if low-income countries were able to meet their Abuja commitments and divert 15% of government budget to health very few of them would generate enough funds to meet the $34 per capita threshold that the Commission on Macroeconomics and Health in 2001 deemed sufficient to meet basic health needs. Admittedly, this $34 has now appreciated to approximately $50, and some countries would not achieve that target even if 100% of the government budget was diverted to health. DAH from multiple donors, including GHIs, will go some way towards filling this gap, but in addition, GHIs – particularly GAVI and the Global Fund have championed innovative mechanisms for raising even more funds. Tasked with the challenge of identifying a range of innovative ways to raise money for health systems, a Taskforce for Innovative International Financing (TIIF) was established up in 2008 through the auspices of the International Health Partnership. It identified a tax on airline tickets, a currency transaction levy, and levies on other products and services such as mobile phone use, amongst other innovative ideas (Table 2). If brought to fruition, these mechanisms could increase ODA by $10 B. Through these innovations GHIs are proving to be essential vectors for new ways of raising muchneeded money.
These issues are discussed in the 2010 World Health Report which notes, if donors honored their international pledges, external funding would double and there would be no need for innovation (https://www.who.int/publications/i/item/9789241564021).
Is Financing From Global Health Initiatives Predictable?
In September 2008, development agencies met in Accra for the Third High Level Forum on Aid Effectiveness. Here, there were promises to increase the predictability of aid to enable developing countries to effectively plan and manage their short- and medium-term development programs. Unpredictable aid makes it difficult for countries receiving financial assistance to budget and implement their development agenda efficiently. Indeed, lack of predictability can shave off substantial value of aid and is believed to be one of the biggest constraints on its effectiveness. There is a fundamental missmatch between medium to long-term development strategies of recipient country governments (which would often include employing more doctors and nurses), and many donors, including GHIs, relatively short-term funding commitments. Typically, donors only commit aid 12 months in advance, and levels of aid can vary greatly from year to year. This weak alignment runs counter to funders’ stated commitment to country ownership, undermining governments’ authority to manage their health development programs.
A further problem is that unpredictable aid can increase fiscal and monetary instability, which in turn can lead to inflation and macroeconomic disruption. Ensuring macroeconomic stability is the raison d’eˆtre of the International Monetary Fund (IMF), an international financial institution that lends money to ailing economies. IMF loans typically come with a set of economic conditions – such as raising interest rates – derived from a set of economic principles sometimes referred to as the ‘Washington consensus.’ One controversial principle is the insistence on low – single-digit – inflation. The twin goals of raising interest rates and disinflation come with a high ‘sacrifice ratio’ (the amount of GDP growth a government ‘sacrifices’ to achieve the prescribed low level of inflation). As a country’s economy cools, negative consequences for health become apparent from resulting cuts in health spending and wage ceilings for health workers. Early experiences from countries in sub-Saharan Africa revealed tensions between IMF loan conditions and GHI funding for health. In Uganda, disbursement of a large tranche of Global Fund money ($201 M) was delayed in 2002 because of concerns by the Ugandan finance Minister – on the advice of the IMF – that receiving such large amounts of ‘additional’ funds would increase the value of the Ugandan currency and render its economy less competitive. In Kenya, the heath workforce was reduced by over 30% during the 1990s in response to IMF loan conditions, and was only able to use Global Fund and other global health initiative financing to hire new nurses after intense pressure from international nongovernmental organizations and strong leadership from the Kenyan Ministry of Health.
Do GHIs Commit Aid More Predictably Than Bilateral Donors?
It is suggested that GHI funding commitments are generally more predictable than bilateral commitments. Indeed, GAVI’s third strategic commitment was to improve the predictability and sustainability of financing for national immunization programs. According to the OECD, the Global Fund had a predictability ratio of 82% (where 100% meant that a donor disbursed the same amount as it initially planned). However, disbursement is tied to a country’s performance, and so this can have a negative effect on predictability of financing. In an effort to address problems associated with short-term funding cycles, the International Finance Facility for Immunization (IFFIm) was launched by the GAVI Alliance in 2006. The IFFIm is an innovative mechanism through which national donors raise money up-front by issuing bonds which are paid back over 23 years. So far IFFIm has raised more than US$3 billion for the GAVI Alliance’s immunization programs. A total anticipated IFFIm disbursement of US$4 billion is expected to protect more than 500 million children through immunization (Table 2).
Table 2 Innovative financing mechanisms championed through GHIs
Some aid modalities are more suited to predictable funding than others. General budget support – aid channeled directly into the budget of a recipient country – is arguably more effective than other modalities as it avoids project-based inefficiencies and is easier to align with country priorities. It does, of course, run the risk of mismanagement of funds in countries with weak economic governance. Budget support is not without its own problems – some of which go against other measures of aid effectiveness such as country ownership including, it can be argued, that budget support allows donors direct access to country decision making. Although there are positive examples of PEPFAR disbursements in sub-Saharan Africa, including Mozambique, Uganda, and Zambia, others argue that PEPFAR has been less predictable than other donors. Although GAVI, the Global Fund and the World Bank have been able to secure multi-year replenishments, long-term pledges, and innovative financing arrangements to accumulate funds, other GHIs, such as PEPFAR, are constrained by legal restraints on their primary funders. Although the Global Fund has contributed to more predictable financing through its shift to general budget rather than program support, the premium the partnership places on performance has had an adverse effect on predictability. Indeed the Global Fund’s requirements for frequent reporting were a major burden on recipients that caused delays in disbursement and resulted in the perception that its money is unpredictable. Indeed the Fund’s temporary suspension of grants in Uganda had a negative effect on perceptions of predictability by recipients which led sub-recipients to favor PEPFAR funding that was seen as more quickly disbursed and predictable.
Do GHIs Disburse Aid On Time Or Are Delays Or Interruptions Commonly Experienced?
Difficulties have been reported drawing down Global Fund and MAP finances because of problems created by certain countries’ low absorptive capacity, and also because of performance-based funding conditions. In contrast, PEPFAR has disbursed finances more quickly since these finances are not routed through government implementers and do not rely on government systems. There are mixed experiences from different countries on timeliness of GHI funding. In Kenya, PEPFAR disbursements were reported as timely, whereas the Global Fund grant application process was lengthy and complex. In Haiti and the Central African Republic delays between Global Fund grant approval and disbursement were experienced. In the Central African Republic this stemmed from human resource constraints delaying the reporting required to trigger disbursements. The Global Fund delayed disbursements in Laos because of the country’s weak financial monitoring and evaluation systems, and interruptions in Global Fund disbursements to nongovernmental sub-recipients in Kyrgyzstan were reported as a key reason for intermittent HIV/ AIDS service delivery.
Are Global Health Initiatives Financing Sustainable Health Programs?
GHIs have aimed to provide short to medium-term finances with the intention of stimulating increases in longer term financing for health programs from country governments or other domestic sources. However, in countries with high levels of external financing from GHI vertical programs serious concerns have been raised about increasing aid dependency, while few or no strategies are in place for longer term financing.
Country evidence is thin on whether they are stepping up domestic financing in parallel with GHI financing leading to sustainable programs. In some countries such as Ethiopia, Mozambique, Uganda and Zambia GHI financing is linked to reductions in domestic financing for focal diseases programs, and in Haiti – which received substantial PEPFAR and Global Fund financing – it is expected that when these grants finish focal health programs will need to end. The problem is not confined to low-income countries. A study in the middle-income country of Georgia showed that scale-up of HIV/AIDS, tuberculosis and malaria programs financed by relatively modest Global Fund grants led to government diverting financial resources to non-focal disease healthcare priorities. At the same time rising recurrent cost requirements in focal service areas aggravated the potential for longer term funding shortages with the government unlikely to be in a position to replace GHI financing.
GHIs are increasingly seeking to make investments in longer term health systems strengthening (HSS) interventions, thereby creating a more tangible legacy of their programs. For example, PEPFAR invested US$ 640 million to systems strengthening work including health worker training in 2007. Global Fund financing has supported a range of HSS strategies including those relating to strengthening human resources for health and has expanded support of HSS in Global Fund applications. However, the imperative of the initiative to rapidly disburse finances and demonstrate their impacts is reflected in the tendency for programs to place most attention on in-service training, task shifting and expanding the numbers of lower cadre workers, and in some countries on the recruitment of nongovernmental workers on short-term contracts, rather than training and recruiting new highly skilled health workers. In those countries nongovernmental organizations acting as implementers of HIV/AIDS Global Fund financed HIV/AIDS programs were reported as heavily dependent on Global Fund financial support, which jeopardized their long-term existence.
Before 2010, it seemed as though the Global Fund was in a strong position to continue to fund countries’ health needs. However, in 2010 cracks began to appear in the strength of donor support for the Fund. Donors committed far less to the Fund for the period 2011–13 than was expected or hoped for. However, towards the end of 2011 in the following year, the Global Fund announced that it had insufficient funds to finance any new projects until 2014. This was a catastrophe for the Fund. In mid-May 2012 the Global Fund was able to release $1.6 billion to spend on new projects – still far less than was anticipated. The future of the Fund is now uncertain, although under the new leadership of Mark Dybul confidence may be returning. Despite its dramatic reversal of fortune, it is nevertheless true that before 2010, the Fund had generated massive scale-up of new funds. These have had undeniably positive effects on health.
Is Financing From Global Health Initiatives Harmonized And Aligned?
The proliferation of global health actors, including new GHIs, has heightened concerns about the lack of harmonization of health programs, and poor alignment between GHI programs and country priorities, systems and procedures. This concern is central to the aid effectiveness agenda that recognizes that while substantial new resources are being mobilized for focal health issues and disease areas, this aid may not be used as effectively as it might. Indeed, GHI funding may have some damaging effects on recipient countries with fragile health systems. The principles articulated in the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action have sought to galvanize global commitments to improve the ways aid was disbursed by ensuring that aid is better harmonized and aligned, more predictable, based on country ownership and demonstrate greater mutual accountability; an agenda embodied in the health sector with the launch of the International Health Partnership in 2007. This raises the question – have GHIs stepped up to the expectations of Paris and Accra?
GHIs have embraced a disease-specific ‘vertical’ financing approach to target particular health issues, in part because this enables donors to demonstrate a link between their financial inputs and impacts. In this context many commentators agree that the expectation that GHIs would simplify aid architecture has not been achieved. Country experiences reveal misalignment between predominantly vertical GHI programs and country priorities and/or country disease burdens. Duplication and lack of coordination have inevitably stemmed from the introduction of parallel initiatives and donor programs, although experiences vary between initiative and recipient country and have improved over time. For example, Global Fund, PEPFAR and World Bank MAP programs each adopted different procedures for procurement and disbursement of drug supplies, and the Global Fund’s requirement for a country coordinating mechanism (CCM) differed from the requirement of the World Bank and was perceived as a Global Fund rather than country-owner structure.
It is widely accepted that high transaction costs of the Global Fund and PEPFAR, and indeed other donors, impose different reporting procedures that place substantial demands on fragile country health systems, including institutional capacities and staff. PEPFAR’s imposition of rigid budget allocations to prescribed interventions had undermined the initiative’s commitment to country ownership, lack of transparency and lack of willingness to coordinate with other donors. Global Fund programs were reported as not engaging with pre-existing country coordination structures such as SWAps, and this reinforced vertical tendencies against government priorities to integrate health interventions at the primary healthcare level, as experienced in Georgia. In other countries in Africa, Global Fund, GAVI and PEPFAR financing is believed to be driven by global agendas that gave recipients limited flexibility to allocate finances according to their own priorities.
To What Extent Is GHI Financing Transparent?
Although the Five-Year Evaluation of the Global Fund suggests that Performance-Based Funding (PBF) has contributed to a culture of accountability, it also accepts that the approach has ‘evolved into a complex and burdensome system,’ and there remain weak monitoring, evaluation and information systems limiting the PBF approach. Similarly in the Central African Republic and Rwanda the introduction of PBF by initiatives including the Global Fund and GAVI served to improve performance, transparency and management thereby fostering accountability and reducing waste. In Haiti, PEPFAR and Global Fund financing made grantees more efficient, accountable and strengthened administrative and managerial capacity, as had Global Fund financing in Ukraine and Kyrgyzstan, although in Kenya and Kyrgyzstan performance-based monitoring had delayed grant disbursement. PEPFAR funding practices were reported as lacking transparency in some countries such as Rwanda.
Global health initiatives have raised and disbursed substantial new financing for major diseases and health issues. Although there are clear benefits of this increased financing in terms of significant programmatic scale-up, GHIs have revealed and in some cases aggravated weaknesses within fragile health systems. Particular concerns remain about the longer term legacies of these initiatives on the countries they aim to benefit. There are multiple problems: first, the global financial crisis puts at risk donors’ commitments to make longer term financial pledges to GHI programs, threatening to undo the important gains so far; second, the ability of initiatives to strengthen country health systems in the longer term has been limited by their vertical, disease-specific nature; and third, recipient governments’ strategies to scale up domestic financing to supplement or replace external health support have been restricted by international loan conditions that indirectly restrict domestic spending on health, thereby jeopardizing the sustainability of focal disease programs beyond the life of current GHI financing.
Generating evidence on the effects of GHIs is not without methodological problems: GHIs and other donors have financed complex, multi-level country programs making it difficult to attribute the effects of a single initiative or program and findings are often context-specific and quickly out of date in the context of evolving, multiple financing streams. Considerable evidence is derived from mixed quantitative– qualitative studies and the synthesis of cross-country qualitative evidence, approaches that are not as universally accepted as traditional quantitative study designs. GHIs have introduced new models of financing major health programs, yet the contrast between different models – global public–private partnerships in the form of the Global Fund and GAVI Alliance, the multilateral World Bank MAP and the bilateral PEPFAR initiative – reflects what is very little global consensus about which financing models are best. Nevertheless all four initiatives have demonstrated their willingness to learn from and respond to emerging evidence, and a number of promising ‘course corrections’ over their relatively short lives have been apparent.
The global health arena is a dynamic one and GHIs have become pivotal actors. There are discussions on establishing a joint GAVI Alliance, World Bank and Global Fund Funding Platform for HSS, and there have been calls to amalgamate major GHIs programs to form a Global Health Fund to coordinate global funding for broader health programs. Evidence will be needed to capture and assess the impacts of these and other changes, as GHIs evolve and effects of the global financial crisis become fully apparent.
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