Guidance is getting better, but is domestic resource mobilisation getting enough attention in the transition debate?
Aid steps in where countries can’t afford to provide for the basic needs of their people. As national economies grow, countries are better able to fulfil responsibilities to their people by delivering fundamental rights to health, education and social protection. So what do we do when economies grow but health outcomes don’t improve, governments choose not to spend money on those most in need, and the majority remain poor while the few get richer?
In a shrinking and uncertain donor landscape, every pound counts. Organisations like the Global Fund to Fight HIV, TB and Malaria, the World Bank’s International Development Association and Gavi, the Vaccine Alliance, all use criteria like gross national income and disease burden to decide which countries are eligible for funding. For some countries this will mean losing funding from multiple donors as they move from low- to middle-income status.
But higher income status is not always accompanied by improvements in health. The large number of people living in middle-income countries and persistent inequalities in wealth and access to services mean that the highest burden of many of the world’s biggest killers is no longer in the poorest countries. India and Nigeria, for example – the two countries with the highest burden of pneumonia (WHO, Global Health Observatory Data 2000-2015) – are middle-income countries.
NGOs and funding institutions are increasingly grappling with these challenges. Last week, a civil society roundtable on transition came together to discuss their work and opportunities for cooperation. Guidance for countries and donors is getting better. Results UK recently released a briefing on the impact of donor transition, Leaving no-one behind, and it’s not alone. Other organisations – including ACTION, the Overseas Development Institute and institutions like the Global Fund – are working to design safe transition strategies.
Planning the transition from external support to domestic financing of immunisation and disease responses is essential to ending epidemics of the most deadly diseases and sustaining gains made. In Romania, withdrawal of donor support for HIV programming in 2009 was followed by a rise in HIV infection rates among people who use drugs from 3.3% to 27.5% over four years. Marginalised populations, minorities and civil society organisations, which are often excluded from government funding, face real risks if the shift from donor to domestic financing is not managed with equity and sustainability in mind.
Safe transition requires forward planning to ensure continuity of funding through a shift to domestic resources for health. Yet domestic resource mobilisation seems to have fallen down the transition agenda. Instead, in the context of increased political polarisation, the growing strength of southern economies and a new aid agenda shaped by the Sustainable Development Goals and the demands of humanitarian disasters, the transition debate is turning from transitioning countries to a ‘world in transition’. While many aspects of the political and development landscape are in flux, this shift in focus draws attention away from the state’s obligation to ‘take steps to the maximum of its resources’ to progressively realise the right to health (as set out in Article 2, International Covenant on Economic, Social and Cultural Rights). Critically, it risks distracting donors and NGOs from their essential role supporting national governments to develop strategies for domestic health financing.
Domestic resources are the most reliable and sustainable source of health financing and should be at the core of transition planning research shows that to achieve universal health coverage, health systems must rely predominantly on public revenue.
The shift to domestic resource mobilisation will not be easy. Donors must assist by helping countries to develop financing strategies. States should ensure that the benefits that economic growth has brought the rich and powerful within their borders are enjoyed by all, through progressive taxation and the introduction of national health insurance schemes. Protection for marginalised groups and supported transition will continue to be important to ensure that gains made are not lost and that rights are not allowed to be neglected. The role of states and domestic financing must be at the centre of transition discussions.