and who are accountable? Seminar discussion with World Bank S. Møgedal Who sets priorities Health systems hit by AIDS:

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

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)

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 PUBLIC HEALTH DISASTER Escape

Civil Society Need to link frameworks and go beyond the public sector Public Sector Helsetjenester PRS (P) AIDS ACTION 3 ONES Health Services Delivery

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

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?

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”

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

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 PUBLIC SECTOR CIVIL SOCIETY ACTION REQUIRE LINKING IN PLANNING; DELIVERY PROBLEM SOLVING AND ACCOUNTABILITY: COUNTRY-UP