Just Another Initiative?
By Sue Perez
Despite the constant uphill battle in getting its issues on the table and our concerns heard, civil society recognizes that the International Health Partnership presents opportunities.
Launched in September 2007 by UK Prime Minister Gordon Brown, the International Health Partnership and related initiatives (IHP+) is the newest invention by a collective of major international donors including several high-income country governments, the World Bank and UN agencies aimed at helping developing countries achieve the health-related Millennium Development Goals (MDGs), which include eradicating hunger; reducing child mortality; improving maternal health; and combating AIDS, tuberculosis, and malaria.
The IHP+ was not designed to create anything new but to make aid more effective and efficient. Improved donor coordination or “harmonization and alignment” is touted as a means to make lives easier for ministries of finance and ministries of health in developing countries, which are encouraged to set terms on how they want donors to behave—that is, to provide aid based on countries’ individual budget cycles and priorities, to allow countries to report on expenditures in one format acceptable to all donors, host fewer donor missions, and develop one comprehensive national health plan.
AIDS activists working on global health, along with their allies in other advocacy fields, have emphasized that better donor coordination alone will not be enough to achieve the health MDGs. Greatly increased donor funding for health in developing countries will be crucial. Ethiopia, the first IHP+ partner country to develop budget estimates for its comprehensive health plan, identified a significant funding gap of up to $2.8 billion between 2008 and 2010. However, Ethiopia has yet to see any major new money to fill this gap.
What worries AIDS and TB activists the most is that the IHP+ is driven by donors who have directed their attention increasingly to the sector wide health systems corner. AIDS and TB activists readily admit there is a need to increase investment in health systems because any health interventions, including those for HIV/ AIDS and TB, cannot be sustained without functioning health systems. However, with limited resources, donors will have to make choices about where to put their money, and this could result in the cutting of existing funding for AIDS, TB, and malaria, and moving money to general “[health] sector wide approaches” (or SWAps) that, as a result of its record, have gained a poor reputation for preserving high-quality priority-disease programs. For example, in the 1980s and ’90s, several African countries dismantled their TB programs as a result of donorsupported SWAps and macroeconomic policies advised by the International Monetary Fund (IMF), contributing to the disastrous upsurge in TB cases that accompanied the explosive emergence of the HIV pandemic. AIDS and TB activists have strongly warned the IHP+ partners about the potential for collateral damage to diseasespecific programs as a result of shifting money to health systems strengthening. The UK government’s announcement in June 2008 of its new HIV/AIDS strategy, which committed £6 billion for “health systems and services” between 2008 and 2015 yet did not commit any specified funding amount for HIV/AIDS-specific interventions, is a prime example of the threat this shift poses to achieving universal access to treatment, prevention, care, and support for those infected with HIV and TB.
Activists have also targeted the lack of meaningful involvement of civil society in the IHP+, especially at the national level. Despite lip service, activists and civil society were not offered seats at the table of the IHP+ oversight group. The voices of TAG and other strong activists had to advocate loudly to gain meaningful participation. This was a bit of a feat considering that the table hosts the World Bank; WHO; UNFPA; UNAIDS; UNICEF; the Global Alliance for Vaccines and Immunizations; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the Bill and Melinda Gates Foundation. Not all IHP+ partners have historically welcomed civil society participation. TAG has been serving as one of two civil society representatives to the IHP+ oversight group, and has played a central role in voicing against what civil society views as a “robbing Peter to pay Paul” situation in terms of shifting resources to health systems strengthening. TAG and others have also loudly spoken out against tokenistic civil society involvement in IHP+ processes at all levels and against the resistance by IHP+ partners to address harmful policies by the IMF.
The IHP+ heard our message about civil society engagement loud and clear. In May 2008, the World Bank and WHO organized an IHP+ civil society forum that brought together members of civil society groups from nearly all 14 IHP+ developing country partners and donor and UN agency representatives. Activists and civil society used the opportunity to air all their questions, concerns, and warnings to staff from donors and UN agencies present. Several of TAG’s African and Asian partners participated. At the meeting, civil society presented its three key principles of the IHP+ as follows: (1) comprehensive primary health care for all; (2) governments must pay their fair share; (3) people’s voices must be heard. These principles inspired a show of unity among global health advocates. A declaration outlining these principles was signed by over 100 health systems, child and maternal health, and AIDS and TB advocates.
Despite the constant uphill battle in getting its issues on the table and our concerns heard, civil society recognizes that the IHP+ presents opportunities. Activists see the potential of the IHP+ to build a global health movement that unites rather than divides civil society in the either/or categories of health systems or priority disease programs for AIDS, TB, and malaria.
The IHP+ is an opportunity to change the donordeveloping country government dynamic where assessment, development, planning, and budgeting for the health sector typically exclude civil society input. These plans then end up as government plans and not “country plans” and thus often leave out specific strategies for reaching poor, vulnerable, and marginalized communities. The IHP+ also presents an opportunity to push forward efforts to reform the role of the IMF in health and development. Numerous studies have shown that IMF policies create caps on developing country public sector budgets—including health budgets. The impact of IMF policies is a key factor that has severely hindered African countries from reaching the Abuja Declaration target of allocating 15% of total budget to health. With all of the challenges and opportunities, activists have a lot of work to do.
As we head into year two of the IHP+, the jury is out as to whether the IHP+ is just another donor-motivated initiative or one that truly changes things for the better. AIDS and TB activists will continue to keep a watchful eye on the IHP+ and lead the way in making sure that other voices are heard.