This response to Kirigia and Diarra-Nama’s paper points out that they do not propose alternative strategies to enable African countries to mobilise the funds without depending solely on donor funding. Kirigia and Diarra-Nama argue that eight countries whose current military spending is above the regional average of US$ 16 per person may have scope for savings. Thirteen countries whose tax share of GDP is less than 15% have scope for raising additional revenue by improving efficiency of their tax administration systems. The amounts, however small, are not insignificant in these countries where more than 60% of the population live below the international poverty line of US$1 per person per day. The effectiveness of international aid should also be judged on the extent to which it helps recipient countries to ‘wean themselves off’ external donor funding.
Resource allocation and health financing
There is no good reason why a country with an income of US$366 per capita cannot afford to increase its domestic health spending from US$20 to US$34. It is the value of forgone alternative benefits (as perceived through either collective decision making or unilateral decisions of political authority) that puts a limit on how much a society can spend on health, not some health expenditure-GDP ratio technical limit. Further, general lessons of experience from parts of east and south-east Asia and Latin America show that, as countries experience substantial broad-based economic and social progress, greater health funding becomes feasible. Such a situation requires time, but has been realised in these countries within about 20 to 40 years. The author believes it will take a long time to reduce the high dependency on donor aid, but Africa should aim to increase domestic resource mobilisation.
In 2005, the member states of WHO adopted a resolution to develop health financing systems to deliver universal coverage of health services by moving away from out-of-pocket payments and developing prepayment methods instead. This paper proposes a comprehensive framework, focusing on health financing rules and organisations, that countries can use to achieve universal coverage. For many countries, it will obviously take some years to achieve the goal and their responses will be determined partly by their own histories and the way their health financing systems have developed to date, as well as by social preferences relating to concepts of solidarity. The proposed framework considers fund collection, pooling and purchasing/provision separately, as well as the links between the three functions to indicate what rules need to be modified or developed and where organisational capacity should be strengthened.
About 11 million of 33 million HIV-positive people have tuberculosis (TB) and, if financially troubled nations renege on aid pledges, it would deprive the poor of life-saving treatment. New Nobel laureate and HIV co-discoverer, Francoise Barre-Sinoussi, fears that the global economic crisis could cause nations to renege on commitments to fight tuberculosis and wipe out gains made against AIDS because so many people suffer from both diseases. The world is achieving success with antiretroviral treatment for HIV, but we have an epidemic of multi-resistance to tuberculosis treatment, which is really alarming. An estimated 33 million people worldwide are infected with HIV. About 11 million of them also have tuberculosis. By suppressing the immune system, HIV leaves people susceptible to other infections, especially TB.
The provision of universal access to healthcare, a right enshrined in the South African Constitution, is the responsibility of government. Although much progress has been made towards the creation of a national health system which makes ‘access to health for all’ a reality, much remains to be done. As a means to facilitate debate on the subject, the Policy Analysis Unit of the HSRC hosted a colloquium on ‘Health within a comprehensive system of social security’. The main purpose of the colloquium was to initiate policy dialogue and critical discussion on how health services are accessed, provided and funded – and to formulate ideas, views and recommendations that could be presented to those involved in health policy development. This publication contains the keynote addresses and a summary of deliberations that emerged from the colloquium.
The United Nations has teamed up with world leaders to launch a new initiative to strengthen health systems in an effort to reduce the number of women who die in pregnancy and childbirth, one of the eight Millennium Development Goals (MDGs), with a 2015 deadline. The task force on maternal mortality, which will be co-chaired by British Prime Minister Gordon Brown and World Bank President Robert Zoellick, will focus on innovative financing to strengthen health care systems and pay for health care workers. The recommendations that will flow from the group, which will include UN World Health Organization (WHO) Director-General Margaret Chan and several global leaders, will potentially save the lives of 10 million women and children by 2015. They will be presented to next year's meeting of the leaders of the Group of Eight (G-8) industrialised nations, to be held in Italy.
African church leaders have expressed fear that the interests of the poor are not reflected in draft documents produced for Accra High-Level Forum on Aid Effectiveness. Half of all aid comes in the form of expensive consultants responding to directives from donors. Local communities must have a greater role in making decisions that ultimately affect their lives the most. Imposed conditions of international donors continue to undermine democratic ownership of aid. Rich country governments are behaving shamefully in tying aid to promoting their own economic interests. Requiring food aid be supplied by Northern producers in the current food crisis is immoral. Aid should not benefit the rich while the poor go hungry. Churches and faith-based organisations are major providers of health, education and other social services in developing countries; as such they must be recognised as partners in delivering development aid.
Developing countries reliant on aid want to escape from this dependence, and yet they appear unable to do so. This book shows how developing countries can liberate themselves from aid that pretends to be developmental but is not. Exiting aid dependence should be at the top of the political agenda of all countries. The Third High-Level Forum on Aid Effectiveness was promoted as helping ‘developing countries and marginalised people in their fight against poverty by making aid more transparent, accountable and results-oriented'. This book cautions developing countries against endorsing the agenda proposed at this meeting. If adopted, it would subject recipients to a discipline of collective control by the donors right up to the village level. This will especially affect present donor-dependent countries - particularly poorer countries in Africa, Asia and the Caribbean.
The performance of donors and recipient countries for delivery and use of aid undermine its potential to do good. Some conditionalities imposed to aid recipient countries, like Mozambique, reduce the extent to which it can contribute to poverty reduction and achieve the MDGs - by forcing governments to implement policies that lead to unemployment, declining public services and reduced capacity by citizens to access basic services. On the other hand, Mozambique still faces challenges in ensuring good governance, adequate institutional capacity and coordination of activities at different levels. Corruption practices without an appropriate mechanism for imputing responsibilities, lack of coordination across sectors and weak institutions and systems combined with the absence or weak donors’ coordination and harmonisation practices undermine the full potential of aid.
The Accra high-level meeting on aid effectiveness comes at a critical juncture for the international community, with the global economy beset by the food and energy crises, and the financial market slowdown that threaten to set back hard-won gains in poverty alleviation. The 2005 Paris Declaration on Aid Effectiveness is a first step in establishing a framework for development cooperation, but its implementation is far behind expectations. Only a few genuine partnerships between donor and recipient countries have been created. With attention paid to national ownership and preservation of national policy space, multi- and bilateral donors should prioritise implementing national International Labour Organisation-supported decent-work strategies as part of development cooperation, and should maintain adequate and predictable budget levels for this purpose. Consulting trade unions and other actors in donor and recipient countries is also important in governing aid effectiveness.