UN Special
 
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INTERNATIONAL HEALTH PARTNERSHIP:

OLD WINE IN NEW BOTTLES, OR DAWN OF A NEW ERA?

On 5 September 2007, at No. 10 Downing Street, London, the International Health Partnership (IHP) was launched. The signatories included Prime Ministers, senior figures and executive heads from the international health and development agencies, bilateral donors, funders, Ministers from a number of countries and other stakeholders committed to working in support of developing country health reforms.
This article clarifies what the IHP is aiming to do, who it will be taken forward,and some of the challenges it will have to tackle to be a success.

What is the International Health Partnership?
Put simply, it is a formal commitment to a new and better way of doing business in the sphere of strengthening health systems and international aid.

The launch documents describe it as a “new agreement between developing countries and international partners to accelerate action to scale up coverage and use of health services, and deliver improved outcomes against the health (Millennium Development Goals) MDGs... Global and country compacts will set out a process of mutual responsibility and accountability for the development and implementation of national health plans”. Responsibilities are then mapped out for development partners, partner countries and civil society. It also recognizes past agreements, in particular it will “put into practice the Paris Declaration on aid effectiveness in the health sector”.

The IHP emphasizes country-led ways of working, and strengthening of national health systems to deliver health outcomes. The “first wave” countries now numbering eight are Burundi, Cambodia, Ethiopia, Kenya, Mali, Mozambique, Nepal, and Zambia. All of these have well established coordination mechanisms in place that will form the basis for all the country work.

The IHP was not launched with any announcement of new money, and will not be a new global financing initiative. Instead, the need for extra resources, both domestic and international, will be assessed on a country-by-country basis with donors expected to make long-term commitments to projected shortfalls in financing of the health sector, aligned with national plans and strategies. It is also not an initiative limited to those that signed the global compact; those who work in the government-led implementation of national health plans and strategies, including civil society and private sector, will be the key stakeholders in taking work forward.

So what is new?
For ministers who supported the IHP at its launch, this heralds a new way of doing business, in line with commitments previously made with the signing of the Paris Declaration on aid effectiveness. The IHP promises higher levels of accountability from all international partners and national actors working to expand access to health services in individual countries. This will come from closer, more transparent, monitoring of agreements made in each country, greater focus on removing constraints both in-country and in the international agencies who provide support, and high-level political oversight both incountry and globally.

How will it be managed?
An implementation plan has been developed with eight of the international agencies working in health – WHO, UNAIDS, World Bank, UNICEF, United Nations Population Fund (UNFPA), the Global Fund to fight AIDS, Tuberculosis and Malaria, the Global Alliance on Vaccines Initiative (GAVI) and the Bill and Melinda Gates Foundation. This follows wide consultation with countries, and with development agencies, global health partnerships and international NGOs that focus on achieving the health MDGs. The work will mainly take place in countries, but also included in the work-plan are technical areas requiring innovation and new knowledge, coordination mechanisms and systems for accountability and performance management.

In each country there will be a system of mutual accountability defined in a country compact. There is not yet a consistent view on the content of these compacts, but they will likely focus on:

  • national strategic plans acting as a template around which to align national and external assistance;
  • identifying resources to act on health systems and agency constraints for the achievement of more ambitious health outcomes;
  • better use of existing aid resources through the application of the Paris Principles in the health sector; and
  • more effective accountability between government, civil society and development partners.

Currently the focus is on a country-by-country approach, using existing processes. It will be important that the IHP works through the existing coordination mechanisms in country, strengthening where necessary, and simplifying wherever possible.

At the international level the IHP will have a small inter-agency team based in Washington, Geneva and Brazzaville, the latter as part of an existing regional effort to harmonize support to national health sector plans. Oversight will be supplied by the eight international health agencies. Political momentum will come through structured engagements with the G8, concerned ministers and heads of agencies, and the UN Secretary General’s recently announced MDG initiative for Africa.

Verification of national plans, strategies and results in country has been given a particular emphasis in the IHP. Work is under-way in two areas:

  • Looking at how national plans and strategies can best be used by donors and global health partnerships to provide financial and technical assistance to the health sector. This is particularly important to the Global Fund and GAVI, which both aim to align their support with national strategies and programs, moving away from stand-alone proposals and projects.
  • Joint agency work on a common country monitoring and evaluation framework for results, as a start to the dialogue on how to take forward some form of “independent” verification of country results.


What are the initial challenges?
Lack of coherence of international initiatives: The renewed interest in using a health systems approach as a way of complementing efforts on specific diseases or services, has led to multiple, sometimes overlapping initiatives. Some of these focus on specific aspects of health systems such as the Global Health Workforce Alliance and the Health Metrics Network. Others focus on specific public health issues, but also aim to address broader health system constraints – GAVI, PEPFAR, and to an increasing extent, the Global Fund. In addition, other new initiatives are coming with a focus on strengthening domestic policies on financing and social protection and expanding access to essential services. These include the “Providing for Health” initiative, Results Based Financing by the World Bank, the UNICEF expansion of community based maternal and child health services, and Norway’s support to expanding services to achieve MDGs 4 and 5, as described at the recent launch of the Global Campaign for Health MDGs.

To add to the picture, bilateral and multilateral donors such as the World Bank and European Commission design country-specific support to strengthen health systems through a mixture of budgetary and sector support and through customized projects. Keeping track of all these initiative is difficult, and only really possible on a country-by- country basis. If the International Health Partnership is to add value to this melee, it must bring simplicity and efficiency, and not more plans and proposal writing. It must also streamline communications across these initiatives so that country stakeholders have a better idea of what is on offer, and how they can access support if they require it.

Having the capacity to coordinate: Agencies and governments often lack the systems and staff incentives required for more collaborative ways of working, given that many staff are currently in place to take forward specific technical agendas. Efforts are being made to rectify this in many countries, but new skills and simpler ways of doing business are also needed to reduce the administrative burden on health ministries and those providing health services.

Civil society engagement: An early concern is how to protect the role that civil society plays in some mechanisms (e.g. the coordinating mechanisms used by the Global Fund) if these are simplified or merged with other mechanisms. An early agreement on “good practice” for civil society engagement in national planning and review may provide a solution.

Keeping to existing commitments for HIV/AIDS: Another concern is that the IHP may let governments and international donors move away from hard-earned agreements on universal access targets for HIV/AIDS. International donors, together with national financiers of health services, will need to convince these groups that more finances will be made available to address all health sector priorities, without backing away from existing commitments, and that compacts will cover national agreements on HIV/AIDS, as well as other national priorities.

So what happens next?
Many of the first wave countries have already started to map out what they want to be included in a compact, and how they will get there. However, in these early days, the mechanisms for bringing better performance and greater accountability are still being put in place. The year 2008 will be critically important, with a major meeting on aid effectiveness, organized by the Organisation for Economic Co-operation and Development/Development Assistance Committee (OECD/DAC), taking place in Accra in September 2008, by which time the potential benefits to the health sector should be a lot clearer.

Meanwhile, the number of actors involved makes this a major management challenge for the international community; tough decisions by donors may be required to reduce the number of initiatives and partnerships working with ministries of health in developing countries. Having said this, there seems to be sufficient consensus and goodwill to make the IHP and related work a success. However, only time will tell whether this commitment can lead to new way of doing business that allows national actors to do their work more efficiently. And only after that will we see if better health outcomes are being achieved in those groups that currently have insufficient access to effective health services.

Robert Fryatt, World Health Organization,
Via Appia 20, Geneva, 1211, Switzerland.
Tel: +41 22 7768554
e-mail: fryattr@who.int

Nicole Klingen, The World Bank, 1818 H Street,
NW, Washington, DC 20433 USA
Tel: +12024587413
e-mail: Nklingen@worldbank.org

Robert Fryatt and Nicole Klingen are members of the inter-agency core team set up to facilitate the implementation of the International Health Partnership and related initiatives.

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