1. Billy Stewart Health Adviser, Global Health Partnerships Team December 2005 Health system development for equity – a bilateral’s perspective 1 Palace Street, London SW1E 5HE Abercrombie House, Eaglesham Road, East Kilbride, Glasgow G75 8EA

2. Page 1 About this presentation Objective: to move closer to a coherent view which: better links the scaling up of TB services with the broader scaling up agenda for health, and questions how we can apply an equity lens at all levels Outline Discourse on equity Scaling up in health – DFID analysis Challenges to scaling up for health User fees Social transfers Global initiatives Role of donors – better aid Conclusions

3. Page 2 Why the concern with health equity? (1) A matter of: Economic growth - equity in human capacities through health (& education and social protection) is key strategy to level the playing field for people to lead productive, fulfilling lives [WDR 2006; CfA 2005] Development and poverty reduction - equity at core of health systems is prerequisite to achieving MDGs [WB 2004, WHO 2005] Social justice and human rights - risk of scaling up not delivering benefits to the poor/poorest and socially excluded [WB 2004]

4. Page 3 Why the concern with health equity? (2) Health system as ‘core social institution’ – can increase inequity and social exclusion, or protect citizens from poverty and discrimination [UNMP 2005] Recognise need to make health systems more inclusive and equitable AND to address underlying causes of health inequalities (eg. Income, nutrition, education) [WHO CoSDH]  Increasing international commitment to tackling inequities  Scaling up resources reduces trade-offs between equity and efficiency – new choices

5. Page 4 Scaling up in Health 1: G8 commitments at Gleneagles G8 responded to Commission for Africa recommendations by agreeing: Comprehensive package of support – the “big push” on peace and security, governance, health, education. Additional $50bn globally and $25bn for Africa by 2010; Debt relief worth up to $55bn for up to 38 of the poorest countries, as well as $17bn for Nigeria, Developing countries have the right to plan, sequence and implement their own economic reforms. Africa Partnership Forum should monitor implementation 1 Palace Street, London SW1E 5HE Abercrombie House, Eaglesham Road, East Kilbride, Glasgow G75 8EA

6. Page 5 Scaling up in health 2: DFID Paper – Plan of Action To turn commitment to action will require: Increase in overall aid for health in low income countries of $20 billion by 2010 Support to governments to develop ambitious plans once financing commitments are clear Donors to make progress in implementing the Paris commitments on aid effectiveness and recommendations of the GTT on AIDS Donors to commit to developing and piloting mechanisms to increase the predictability of development assistance for health Partner countries to meet their commitments to increase funding to the social sectors

7. Page 6 Challenges…all have an equity dimension Balancing targeted approaches and health system strengthening Increases in resources that are spent more effectively and equitably Responding to the health staffing crisis Harnessing the contribution of non-state service providers Increasing demand and accountability Strengthening governance Investing in better health in fragile states Building effective health information systems Research into the health problems of low income countries

8. Page 7 Challenges: User fees - 1 Charging poor people fees for service can be a significant barrier to access basic health care Removal of user fees does not equate to universal free services for all (G8 and HMT commitment) Removal of official user fees has less impact where:  Many other cost barriers faced by poor people  Many other social-cultural, geographical barriers  Dominant private sector service provision  Symptom of under-investment in primary healthcare Also need investment in service expansion and quality

9. Page 8 Challenges: User fees – 2 DFID policy line (2005) Yes, remove user fees…but it’s not a magic bullet: Support removal of official user fees for basic health care Help identify alternative sources of finance Encourage removal of other fees and charges Part of broad-based efforts to fund and deliver quality, equitable healthcare for all (eg. Uganda)

10. Page 9 Challenges: Cash transfers - 1 Non-contributory, regular and predictable cash grants delivered direct to households or individuals Demand-side financing and social protection Multiple objectives – reduce income poverty, hunger & food security, child labour; improve human development; can also stimulate local markets and growth; OVC care package Can also provide sense of entitlement to claim citizen’s rights to access services

11. Page 10 Challenges: Cash transfers - 2 Cash transfers can improve human development (CfA,WB):  Equitable access to services: tackle demand side barriers beyond user fees - indirect and opportunity costs, gender discrimination  Tackle factors underlying health inequalities: malnutrition, income poverty  Target resources to poorest and socially excluded  Prevent inter-generational transmission of poverty Also need investment in health and education sectors to respond to scaled up demand and to improve quality

12. Page 11 Conditional vs. no strings attached Evidence of Latin American conditional cash transfers – marked increases in utilisation of primary health care and school attendance and performance; also in nutrition and health outcomes Well-targeted to the poorest Unconditional cash transfers – more flexible, spent on household priorities: Namibia and South African pensions Less evidence in low income countries – pilots in Kenya (OVC); Kalomo district, Zambia Need to monitor and evaluate pilots as they move into national safety nets; compare conditional vs. unconditional Politics

13. Page 12 Challenges: Global Health partnerships - 1 Opportunities Increasing within context of growing assistance in health Targeted at the poorest countries Support cost-effective interventions Technical/advocacy partnerships – promote equitable approaches Risks Transaction costs - multiple coordination structures Impact on domestic resource allocation Introduction of high value commodities – countries running to keep up, or Entrenching lower levels of spending Impact on health systems – role of community health workers

14. Page 13 Challenges: Global health partnerships - 2 National Health Strategy (Plan) (often limited to public sector) Non-public provision and care capacity AIDS National Action Frame work Multi Year Imm uni sation Plan Health Work Force Policy Framework National TB Strategy After: Sigrun Mogedal Alignment Simplification of coordinating mechanisms Coordinated health workforce policy framework

15. Page 14 Donor financing 1 – DFID paper: making aid more effective Channel scaled up aid through range of instruments – where possible use flexible programmatic instruments (PRBS, sector budget support) Better ownership and alignment to national priorities, improved efficiency in public expenditure management, reduced transaction costs – all should impact on equity Marginal costs of expanding are lower than for project finance Broad based approach to tackling MDGs (e.g. capacity in education to train more health workers) Additional public spending needed will be largely recurrent costs – needs longer term predictable finance

16. Page 15 Donor financing 2 SWAps and PRBS: Opportunities for equity (the theory) SWAps based on open participatory planning allow for incorporation of health needs identified by NGOs and civil society SWAps: Resource allocation across sector according to national needs and priorities, not on a project basis Improved diagnosis of barriers to service utilisation PRBS: “the aid instrument most likely to support a relationship between donor and developing country partners which will help to build the accountability and capacity of the state” (DFID)

17. Page 16 Donor financing 3 – SWAps and PRBS: Risks Published evidence indicates limited participation of civil society (Foster, 2000) Little evidence that they help to resolve politically sensitive problems Risks of disrupted services during transition (Foster, 2000 – though rpeorted as largely anecdotal) Risks that health sector will not receive fair share of funds under PRBS - education received greater priority for funds under debt relief programmes (Gilson, 2005) PRBS – could it undermine the role of the Health Ministry by making Ministries of Finance more responsive to donors (Gilson, 2005) PRBS – is it actually more predictable? (DFID PRBS paper)

18. Page 17 Donor financing 3 – SWAps and PRBS: Way forward Health sector not marginalised where country aligned policies and plans for pro-poor service delivery in line with PRSp (Gilson, 2005) Also need specific targets for health care financing and delivery and monitoring of progress and outcome indicators. Role of qualitative data Malawi – new relationship between NTP staff and District Health Officers – to ensure quality TB services, increased case notification, and simplified diagnostic pathways Establishment of Equity and Access sub group in Malawi – opportunity for lesson learning Link to wider poverty monitoring initiatives Analysis of existing data Review district allocation formulae National health accounts Review of accountability framework

19. Page 18 Conclusion – Making the links On the TB programme side At country level: For some time experience of integration of TB programmes – but the challenges of new programmatic tools argue for attention to lesson learning both on service delivery and on equity Improve alignment and complementarity of global initiatives At global level: Continue to mainstream equity within new Stop TB strategy – TB and poverty network Provision of TA within overall human resource frameworks On the health and development side Poverty monitoring and analysis of barriers to access – Malawi experience Monitoring and evaluation of outcomes – inc TB Consideration of disease control services within sector reviews (include TB experts?) Broad based approaches to reaching MDG goals – e.g. social transfers Understanding of resource needs for TB, linkage to health systems, fed into planning 1 Palace Street, London SW1E 5HE Abercrombie House, Eaglesham Road, East Kilbride, Glasgow G75 8EA