The High Level Taskforce on Innovative International Financing for Health Systems

Abstract

‘Up to ten billion dollars a year’. That was the headline figure produced by the High Level Taskforce on Innovative International Financing for Health Systems, indicating the additional funding required to strengthen health systems and scale-up essential health care in 49 low-income countries (LICs) (Taskforce on Innovative International Financing for Health Systems 2009). Not a lot of money, especially in the context of the bail-out of US and UK banks, or the assets of the richest 0.1% of the world's population. Launched in September 2008, the Taskforce was established to come up with practical proposals for new and innovative sources of finance for health systems, and for improving the efficiency and effectiveness of aid to health. Two expert Working Groups were set up to produce detailed reports—one on the constraints to health systems strengthening and the costs of scaling-up essential health care, and the other on the sources of finance and the options for channelling such funding (Working Group 1, 2009; Working Group 2, 2009). Both reports cover a lot of ground and are worth reading in full before examining the report and 10 recommendations of the Taskforce itself. An important contribution of Working Group 1 has been the production of new cost estimates. Not an easy task. Calculating the cost of health systems strengthening and expansion is complex and riddled with uncertainties. The cost of improving health systems governance and management, for example, is simply not known in many countries; neither is it clear to what extent health worker remuneration needs to be improved to ensure adequate retention and levels of motivation. Added to this are data limitations on, for example, the disease burden within countries, or on the state of infrastructure of existing health facilities. There is also no consensus about the strategy and approach for strengthening health systems and expanding health care coverage. In fact the Taskforce drew on two separate and different costing models—one led by the World Health Organization (WHO), which was higher cost and placed more equal emphasis on the scaling-up of facility and community-based services; and the other by the World Bank and UNICEF, which was cheaper and advocated scaling-up low-cost, community-based services before undertaking any strengthening or expansion of facility-based services. As a result, behind the headline figure of US$10 billion is a wide range of estimates involving two costing models, as well as various assumptions and estimates about future economic growth and health spending patterns of governments, donors and private individuals. For example, using one set of costings, the difference between an optimistic and pessimistic scenario of future government and donor spending was US$138 billion. Under this pessimistic scenario, the additional funding required could amount to US$30 billion per year, not 10 billion. The key recommendations for new and innovative international sources of finance were to extend the mandatory solidarity levy on airline tickets to more countries (currently this is a source of finance mainly used to support paediatric AIDS treatment through UNITAID); explore the viability of levies connected to tobacco and currency transactions; encourage more voluntary private giving through a number of suggested mechanisms, including voluntary levies on the purchase of airline tickets and mobile phone minutes, and a scheme to earmark a share of VAT receipts when participating businesses agree to add a share of their profits (called a ‘De-Tax’); and to secure more private investment in health systems through establishing capital/risk mitigation fund(s). Out-sourcing to non-state providers and encouraging greater use of advanced market commitments were also mentioned as ways of securing better performance and investment from private sector actors. Four recommendations stand-out for making the money for health work better. First, more frontloading and predictability of aid, possibly by expanding the mandate of the International Financing Facility for Immunization. Second, expand the use of results-based ‘buy-down’ funding, which essentially means greater performance-based donor funding for the health sector. Third, establish a common health systems funding platform for the Global Fund, GAVI Alliance and the World Bank. And fourth, undertake a review of technical assistance in view of evidence that it currently consumes a large proportion of funding and appears to be poor value for money. Having reported to the G8 meeting in July 2009, a forum will be facilitated by WHO and the World Bank just prior to the UN General Assembly in September 2009, to allow countries and partners, including civil society, to monitor progress. What should be said at that forum? As far as the cost of scaling up essential health care is concerned, one issue that needs attention concerns the different approaches to health systems development of the two costing models. In addition to producing different price tags, they reflect different technocratic, strategic and ideological approaches, as well as different levels of ambition. The merits and demerits of both approaches therefore need more detailed examination and wider debate. But because approaches to health systems strengthening cannot be discussed independently of country-specific social, economic, political and topographical factors, the global price tag needs to be disaggregated. Presently however, there is no plan to place the country-specific costings in the public domain. This is a great pity. WHO, the World Bank and respective governments should be pressed to make country-specific data available to enable country-specific discussions on health systems strengthening. Because the costing models are complex and open to challenge, placing the detailed analyses of each country in the public domain would need to be accompanied by explanations and other efforts to make them locally understandable. This would be a worthwhile activity for strengthening country-level capacity and country-based approaches towards health sector policy-making and planning. The need for country-specific discussion is accentuated by other unresolved policy debates on health systems development, such as on the desirable mix of public and private financing; the appropriateness of expanding the role of for-profit actors within the health system; the feasibility of scaling-up community-based health insurance; and the desirable relationship between vertical, disease-based programmes and comprehensive health systems development. These debates need to move beyond generalizations to more specific and detailed country-by-country analysis and discussion. Given the current fragmentation and disorganization of development assistance for health, having a common health systems funding platform for GAVI, the Global Fund and the World Bank should be welcome. However, all three agencies have, at best, a mixed track record on health systems strengthening, and there are also many unanswered questions about how this common funding platform would work in practice. For example, will it have a policy-setting agenda, and to what extent will funding be performance-based? It is also unclear as to how bilateral donor agencies, the WHO and other agencies such as the World Trade Organization, the International Monetary Fund (IMF) and private foundations will be harnessed to support a coordinated, appropriate and equitable health systems strengthening agenda. So these are issues that need attention. As far as new sources of finance for health are concerned, the Taskforce has been mostly disappointing. Although the endorsement of taxation as a legitimate source of global public finance for health and development is welcome, given the integrated and globalized nature of all economies, the actual recommendations put forward lack ambition and conviction. As the world enters a global economic recession on the back of unprecedented levels of inequality, and as climate change threatens to eclipse the health gains of the past 20 years, the opportunity to link taxes and revenue generation to a redistributive and environmental agenda has been ignored. No mention was made about the ‘innovative finance’ used to bail out discredited banks and shore up the high-consumption economies of rich countries being extended to supporting the basic health systems of low-income countries. Neither did the Taskforce recommend carbon or luxury taxes, nor interventions to reduce illicit capital outflows from low-income countries, nor interventions to leverage a higher return on the natural resources and primary commodities of poor countries. Instead, the focus was on the relatively low value commercial transactions of ordinary consumers. More alarming was the emphasis placed on expanding private (profit-seeking) investment through the use of public funds to mitigate risk. The Taskforce report must also be read and understood within the broader context of traditional and ‘un-innovative’ funding for health systems. Most rich countries continue to fall short of their obligation to allocate 0.7% of their gross national income (GNI) to development assistance. If they met this, the requirement for new sources of innovative funding would be less important. The strong promotion of the ‘De-Tax’ by the Italian government while it was slashing its aid budget by half warns of the potential for ‘innovative finance’ to be a distraction if not a smokescreen for backsliding on commitments by donor countries. Perhaps more importantly, the expansion of domestic public funding for health needs attention. Although the Taskforce highlights the importance of governments allocating 12–15% of their public budgets to health, it did not discuss the problem of fiscal and macroeconomic policies capping public expenditure and wage bills, nor the potential to increase the overall size of the public budget in terms of GDP. Expanding the domestic resource base of low-income countries, an agenda that would simultaneously tackle the triple challenges of resource mobilization, good governance and self-determination, has been neglected in recent decades and deserves greater attention from the international health community (United Nations Conference on Trade and Development 2009). The Taskforce has provided much useful new analysis. But it has also revealed a number of deficiencies. We now need to move beyond the calculation of a global price tag and support further country-specific discussion and debate about the best way to finance and strengthen health systems. The pro-private recommendations of the Taskforce which appear to contradict the analysis of Working Group 1 need to be interrogated and debated, as does the lack of political ambition and imagination to use ‘innovative financing’ as a lever to address some of the underlying structural and economic causes of inequality, poverty and ecological collapse.

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