Country Ownership: New Rhetoric, Old Mechanisms

In the last decade, 'vertical' aid for health, specifically HIV/AIDS, has increased substantially, most noticeably through the United States government's external pagePEPFARcall_made initiative, which has channelled over $30 billion to HIV/AIDS programming around the world. This initiative, lauded as the largest health initiative in history for a single disease, has largely bypassed national health systems and financing, instead focusing on contracts for service provision with local and international organizations as the direct recipients of funding. This phenomenon has been coupled by a rapid rise in private funding for health, led by the Bill and Melinda Gates Foundation and multilateral funds such as the Global Fund, which have also increased funding for earmarked projects and specific diseases.

The international community has long advocated for greater integration and coordination of funding, led by host countries themselves. Recent statements by key development partners seem to point to a long overdue change in direction. US Secretary of State Hillary Clinton's external pagestatementcall_made in August seems to indicate a shift in this direction when she stated: "We need to lay the groundwork now for more progress down the road by tackling some of those systemic problems, and working with our partner countries to uproot the most deep-seated obstacles that impede their own people's health."

Similarly, the European Commission recently released a external pageworking documentcall_made in which it advocated for the European Union to undertake a more comprehensive approach to global aid for health and proposed to allocate, by 2015, at least 80 percent of its health aid using country systems.

These recent statements from Washington and the EU have been strong on rhetoric, advocating for strengthened efforts in integrated programming and country ownership. However, these statements merely reiterate long-held policy goals. Why, then, have funds increasingly been channelled into vertical, unilateral programs?

This last decade's exponential increase in health funding, as well as the more recent global economic crisis, have arguably created incentives to channel funding through increasingly vertical, bilateral channels. As aid budgets are flat-lined and new sources of funding become scarcer, funding for global health initiatives has greater strategic importance than ever. In the near term, it can be argued that traditional funding mechanisms and the strategic considerations of donors will lead to very little change in programming and financing, despite public statements to the contrary.

Rhetoric and old-fashioned mechanisms

The terms 'country ownership' and 'integration' are misleading. They obscure a set of very distinct development strategies, including the comprehensiveness of the aid (often referred to as 'vertical' versus 'horizontal' strategies) and the integration of financing (ranging from the direct funding of implementing partners to aid channelled through national budgets.)

Policymakers obscure the term further while referring to a wide spectrum of programs, including, at the strong end, funds provided directly to governments for budget support and multilateral funding mechanisms for sector-wide approaches, to, at the weak end, merely improved communication with host countries. At the same time, rhetoric is oftentimes coupled with very little in the way of financing. When terms are vague, they can encompass an enormous amount of disparity when it comes to implementation.

Despite its practicality and general desirability, policymakers and politicians are not incentivized to funnel aid into integrated, country-led programs. Surprisingly, the international architecture for aid has changed very little in the last half century. The current systems for global aid were built for bilateral funding: they provide levers to increase political capital, most often through short-term conduits that allow for increased influence during a time of crisis or political need. Despite a proliferation of global partnership mechanisms, aid commitments still rest largely on the shoulders of elected officials with relatively short terms of office. Politicians dependent on ingratiating electorates are incentivized to fund initiatives with short time horizons and easily-produced results. Outputs associated with aid that is integrated with other donors or host governments is difficult to attribute, and therefore difficult to sell to constituents.

A external pagerecent studycall_made identifying the constraints facing global health partnerships explains: "The main constraints are political: donors may not want to commit far beyond their electoral mandate, they may view making long-term commitments to countries with a poor governance or human rights record as high-risk; or they may see provision of long-term aid as counter-productive to the raising of domestic resources."

Multilaterals and hybrid approaches

Multilateral organizations present a promising mechanism for global coordination of health aid, but while grasping a larger share of the political spotlight, they still comprise less than a third of overseas development aid (ODA) for health. Multilateral aid for health totalled 3.45 billion euros in 2007, compared with 8.1 billion in bilateral aid. At the same time, the share contributed by the UN and the World Bank has actually external pagedecreasedcall_made from one third to one sixth, and has increasingly targeted specific programs.

As the EU external pageworking documentcall_made presented: "Aid is not being used to support comprehensive national health plans. Instead, it is becoming increasingly fragmented, with the bulk of new health aid now outside government accounts and, for the most part, neither recorded by countries' planning authorities nor connected to national health plans."

Comparatively new approaches, including coordinating mechanisms such as sector-wide approaches (external pageSWApscall_made) and compacts advocated by the International Health Partnership (external pageIHP+call_made), have been widely touted, but reports over progress have been external pagemixedcall_made. The deliberation over approaches has led some to advocate for hybrid approaches, such as the 'external pagediagonal approachcall_made' popularized by discussions at the WHO and the Global Fund.

Follow the money

Ultimately, both practitioners and policy-watchers would be wise to follow the funding trail. The growing need for 'austerity measures' will ensure that donor governments strategically consider their aid funding and the dollars to greatest political effect. As external pagenotedcall_made in The Lancet medical journal: "The probability that these complex efforts will have a major impact on the behaviour of donor agencies and their interactions with developing countries will be greater if they come with new resource commitments." In other words, talk is cheap.