Lenias Hwenda, Ph.D., Contributing Blogger
Access to Medicine Foundation Independent Expert Advisor on Global Health and Access to Medicine

Harald Siem, M.D., Contributing Blogger
Senior Adviser, Norwegian Directorate of Health

According to a study reported in The Lancet, Niger has managed to decrease child mortality at a pace that exceeds that outlined in Millenium Development Goal 4.[1] Key features of Malawi’s approach include universal access to free health care for pregnant women and children, and decentralized nutrition programs. These encouraging results inspire new ideas about health systems and global health.

Global health governance discourse is grappling to articulate optimal approaches to improve health for the poorest populations. Strategies being tested include universal health coverage, a single global health fund, increased focus on human rights protections equity and sustainability, and others outlined in agendas set by Rio +20 and post-2015 discussions. One of the biggest challenges facing the global health community is how to achieve a comprehensive systems approach to improving population health within countries.

Strong health systems as service providers and as advocates for health in all policies are fundamental for improving health outcomes. This requires an understanding of the multiple relationships and interactions between the different components of a health system. Country case studies such as that from Niger demonstrate that the solutions required to improve population health need not necessarily be complex. Simple, bottom-up interventions can achieve great improvements in population health. National leadership, careful national long- term planning for health, implementation of solutions based on country-specific needs assessments, good governance and predictable funding are necessary attributes to achieving this.

Whilst appreciation of the importance of health systems is growing, the political prioritization of systems strengthening remains inadequate. The allocation of government resources towards health systems remains woefully limited and global policy continues to be primarily based on a demand for greater predictable donor commitments. Donor funds, however, remain an unreliable financing mechanism and aid is on the decline. Aid is also increasingly under attack as its effectiveness continues to be undermined by poor country ownership, donor fragmentation, misalignment with recipients’ national health developmental strategies and lack of mutual accountability.

Health development aid has been, and is important. It also creates a perpetual cycle of demanding donor support, which allows recipient governments to remain unaccountable to their taxpayers. Lack of accountability gives national health authorities little incentive to improve their performance or achieve greater efficiencies in strengthening health systems and delivering quality care to citizens. Accountability has been perceived as responsibility to the board of directors of a benevolent donor. Prime accountability, however, must be to the beneficiary population in question. Mutual accountability of donors is equally important. Whilst donors may demand accountability from recipient governments, they also sometimes ignore failures and misuse of funds for political and economic expediency.

Transparent practice needs to form the basis of enhanced mutual accountability.[2] Achieving transparency and increasing accountability requires a global policy narrative that does not neglect government obligations towards national health systems. The end result of global health policy action should be sustainable health development. This should be based on the understanding that reinforcing the results of sustainable development requires leveraging and strengthening diverse sources of finance to support more inclusive health development. Cooperation is part of the solution for supporting sustainable development. Nevertheless, stable and predictable funding requires other models for health financing than health development aid. These should include effective strategies for domestic resource mobilization alongside development policies that enable countries to benefit from opportunities presented by global trade and investment.[3]

Global efforts to strengthen health systems would therefore benefit from a shift in policy from donor domination to country-led efforts based on clear national development goals in which donors eventually play a supporting role. Health as a strategic priority of national development agendas provides governments with a better rationale for increasing allocation of national budgetary resources towards it.

Government commitments to increase predictability and sustainability of health financing such as the Abuja Declaration, through which governments committed to direct 15% of government expenditure to health, and the Busan partnership for effective development cooperation are critical to the objective of gradually increasing countries’ independence from aid. With due consideration for the poorest populations and countries, they galvanize efforts towards greater political commitment to improve population health.

For example, subsequent to the Abuja declaration, half of African countries increased national health budgetary allocation between 2001 and 2007.[4] Though insufficient, this indicates growing political momentum towards improving population health. Commitments of this nature when adequate, can set countries on a path of progress towards sustainable health development that is embedded in locally relevant solutions. Alongside continued donor support at an eventually declining scale, this could create the policy space that allows donors to cede control of health agenda- and priority-setting to national authorities. Global policy actors may not be ready for a discussion on reducing health development aid. Nevertheless, agreements such as the Busan partnership suggest a shift in policy attitudes from donor focus to national leadership.

It is possible for countries to reduce aid dependency. Ghana is estimated to be a decade away from ending aid-dependency and Rwanda is working towards this goal. Global policy has made tremendous achievements with HIV/AIDS treatment, now accessible to 7 million people. Similarly, through the implementation of programs to achieve universal access to antiretroviral therapy (ART) that were once widely dismissed as overambitious and impossible, the Botswanan government has achieved universal access to ART whilst paying the greatest portion of the cost.[5]

A greater capacity to manage national resources and to consolidate national development   agendas with health at their core will be part of the solution,  allowing countries to free more resources for health systems strengthening. Global aid should continue, but it should not relieve governments of their responsibility and accountability to their populations. Future policy developments like “universal coverage” should therefore stress the importance of population health for economic development and advocate for greater capacity for countries to better manage national resources and free more funding for health.

Countries experiencing consistent economic growth are in a good position to commit to increased health expenditure. National leadership is an essential component in efforts to achieve adequate, significant, secure and sustained long term financing required for achieving widespread improvements in health outcomes of the poorest. Financial austerity and dwindling health development aid make rational and effective health systems more important than ever.



[1] Amouzou A, Habi O, Bensaid K, Reduction in Child Mortality on Niger: A countdown to 2015 Country Case Study, The Lancet 29 Sept 2012; 380: 1169-78.  doi:10.1016/S0140-6736(12)61376-2

[2] Busan Partnership for Effective Development , Fourth High Level Forum on Aid Effeciveness, Busan, Republic of Korea. 29 Nov-1 Dec 2011. Available from : http://www.aideffectiveness.org/busanhlf4/en/component/content/article/698.html.  Accessed 20 Nov 2012.

[3] Busan Partnership for Effective Development , Fourth High Level Forum on Aid Effeciveness, Busan, Republic of Korea. 29 Nov-1 Dec 2011. Available from : http://www.aideffectiveness.org/busanhlf4/en/component/content/article/698.html.  Accessed 20 Nov 2012.

[4] Trends in development assistance and domestic financing for health in implementing countries. The Global Fund to fight AIDS, tuberculosis and malaria. Third Replenishment. 2011-2013.

[5] De Korte D, Mazonde P, Darkoh E. Introducing ARV therapy in the public sector in Botswana: case study perspectives and practice in antiretroviral therapy. WHO. 2004.