Healthier and wealthier countries receive more aid than those at the bottom of health league tables
BANGKOK (AlertNet) – Doctors and aid agencies have appealed to donors to focus health funding on countries that need it the most, saying wealthier countries with better health systems can receive more aid per capita than those struggling at the bottom of the health league tables.
"Why should Sierra Leone, with a (child death rate) six times worse than Botswana, only get a tenth as much (aid) per head?" Ben Phillips, Save the Children's director of strategy for Asia told AlertNet on the sidelines of the Second Global Forum on Human Resources for Health which ended on Jan. 29 in Bangkok.
Namibia, with three doctors and 31 nurses per 10,000 people receives $34 per person in aid, while Guinea, with one doctor and half a nurse for the same population only receives $2.80 per person, according to the Global Health Worker Alliance (GHWA) one of the organisers of the Forum.
In addition, there are anomalies over how aid is prioritised within developing countries.
In Ethiopia, the U.S. agency for development USAID's health aid spent over $424 million on health in 2010, GHWA said. Three-quarters of it targeted HIV/AIDS and $17 million was spent on maternal and child health.
HIV/AIDs prevalence in Ethiopia is a relatively low 2.1 percent according to the U.N. children's agency UNICEF, whereas the country has one of the highest infant mortality rates in the world according to GHWA.
JUMP IN FINANCING BUT NOT EFFECTIVE SPENDING
Studies and aid workers say political, historic and economic ties – rather than needs - dictate donors' generosity.
Although this is not a new phenomenon, it is a concern for many who advocate on behalf of the poorest. Millions of people still die because of poor health care even though global health funding has soared in recent years.
According to the first comprehensive study of funding on health projects by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington published in June 2009, financing quadrupled from $5.6 billion in 1990 to $21.8 billion in 2007 mainly as a result of private donors.
And, despite the global economic crisis, the figure increased, albeit at a lower rate, to $26.87 billion in 2010. The United States is the largest donor, followed by continental Europe, then the UK.
Yet both studies found aid is not provided based on needs.
The latest IHME study, published in November 2010, says that "11 of the 30 countries with the highest number of people suffering from disease and high mortality receive less health funding than countries with stronger economies and lower disease burdens".
MAKING AID SUSTAINABLE
Fiona Campbell, head of policy at medical aid agency Merlin, said funding for the organisation's work in a particular zone in Democratic Republic of Congo ranges from about a dollar per head to $4.
However, there's no consistency across the different donors and their health financing policies are different across the different parts of the zone, she told AlertNet.
"In order to provide comprehensive health services in a zone, you need at least some sort of coordination by different donors and some sort of idea of what is a reasonable amount required to provide basic health services," she said.
In addition, the bulk of Merlin's work in fragile states is supported by short-term humanitarian funding, rather than long-term development aid.
"If you're going to support an effective health system, you need to be able to plan several years – you're talking 5 to 10 years," Campbell said. "That needs commitment and predictability of funding."
Save the Children's Phillips said it is also important for donors to help strengthen government health systems instead of only funding their own programmes.
"Where the country is in live conflict (like Somalia) then often NGOs and others do need to oversee programmes at scale but the ultimate, most successful, sustainable solution is to eventually mainstream them into government systems," Phillips said.
According to a 2009 study by IHME, only "about a nickel out of every dollar channelled to health assistance goes to system-wide health support – like funding for new clinics, doctor training and prevention programs".
PROACTIVE COUNTRIES BENEFIT
A country that has bucked the trend is Rwanda, a poor, crowded country struggling to recover from the 1994 genocide which almost halved the size of the economy.
Angelique Rwiyereka, director of clinical services at Rwanda's Ministry of Health, said the country took full advantage of increased funding for HIV/AIDS which rose from $5.7 million in 2000 to over $100 million in 2008.
Some experts have criticised the focus on HIV/AIDS in a country where 3 percent of the country's adult population is living with HIV, a small prevalence rate compared to its neighbours.
Rwiyereka, however, said the money has worked for the health system as a whole. Instead of having a few doctors specialising in HIV/AIDS, all healthcare workers - including traditional birth attendants in rural areas - were trained in caring for pregnant women. Programmes preventing HIV transmission from mother to child covered both HIV screening and testing for opportunistic diseases and benefitted every mother, Rwiyereka said.
The government put funding from both the Global Fund to Fight AIDS, Tuberculosis and Malaria and PEPFAR (the U.S. President's Emergency Plan for AIDS Relief) in one basket, so that "it's no longer PEPFAR patients or Global Fund patients. We have Rwandan patients," Rwiyereka said.
As a result of the government's use of the funds, the number of women dying as a result of pregnancy and childbirth has fallen from a high of 1,071 out of 100,000 women in 2000, to 383 in 2009, Rwiyereka said.
"So at the end of the day, can I say HIV money is strengthening Rwanda's healthcare system? Yes," she said.
"But in countries where they are not thinking how to make the best of every single dollar that is coming into their country, the donors will not do it for them. We are not expecting solutions from donors," she said.
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