The Australian government recently released its 2015-2020 Health for Development Strategy. This comes on the back of the agriculture and food security strategy released in February. It’s great to finally see DFAT emerging from its cautionary and inward-looking emphasis of the last couple years and start to declare its priorities and vision. Many of us in the development sector have been waiting to stop talking about politics and internal machinations and get back to the ideas driving the development agenda.
The new health strategy makes for interesting reading in many ways. Explicitly stated as “the highest priority” is investing in priority countries’ core public health systems. By this they mean supporting the foundation stones of a strong, resilient system that can address a wide range of diseases and health challenges. This effort is based on the WHO building blocks and includes the health workforce, information systems (such as for disease surveillance), medicines policy, financing models (such as insurance schemes) and overall health system governance.
The focus on country-level, context-specific initiatives is not in itself new but represents a more explicit focus, moving the aid program away from regional and global approaches to addressing health challenges. AusAID previously had a focus on strengthening health services but concurrently spent a great deal of funding on regional initiatives (for example on HIV in the Pacific) and on global efforts; the new strategy positions the aid program squarely as a country partner on the detailed engagement needed to build a functioning health system.
There are two main challenges with improving health systems. Firstly, doing so is extremely difficult. Most notably, efforts over the past decades to reform PNG’s health system have achieved little amidst corruption and weak governance. Investments in health systems must be long-term and broad-based, and almost always take years to develop and to bed down. A health systems focus is presented in the strategy as a five year endeavour, but a more honest approach would be to state clearly that building a sustainable health system in PNG or the Solomon Islands is at least a 10 to 15-year endeavour. Indeed, a recent Lancet article highlighting successful health system investments used a 25-year framework and noted successes in Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu.
The second challenge is that health systems are (often perceived as) boring. I imagine many readers started to doze off as soon as I mentioned “medicines policy” or “financing models” in an earlier paragraph. Focusing on health systems moves the aid program away from high profile acute initiatives, such as polio eradication or distributing bednets to combat malaria, to complex, harder-to-sell efforts, such as strengthening Myanmar’s nursing education or supporting the development of Indonesia’s national health insurance scheme.
Lest one be underwhelmed by this soporific strategy, let’s remember that weak health systems precipitated the ongoing Ebola crisis in West Africa. Liberia, Sierra Leone and Guinea all lacked the people, policy and products to respond quickly to a disease outbreak. The second (of two) strategic outcomes in the new health strategy acknowledges that these health systems challenges are not confined to West Africa but are found in Australia’s nearest neighbours and therefore calls for efforts “to strengthen regional preparedness and capacity to respond to emerging health threats.” Clearly the country-level health systems focus and the preparedness agenda go hand-in-hand.
For those who are passionate about details on countries and funding flows, this strategy is lacking. Priority countries are not stated – beyond South East Asia and the Pacific – and the amount of funding allocated to health broadly or to any of the specific initiatives is not stated. In the context of recently announced cuts to health sector investments in Myanmar, it is unclear how health will be affected by the massive budget cuts of the last couple of years.
But it is important to note that a focus on health systems does not necessarily require the same levels of investment as a more traditional disease-focused, input-based strategy. Not to let the Australian government off the hook for the unprecedented aid cuts, but a focus on health systems does not mean buying tens of thousands of bednets or purchasing anti-retroviral medication or paying for kidney dialysis for those suffering from diabetes.
It is more about advising and supporting governments on managing decentralisation of health services, providing analytics on the impact of user fees in primary health care, sharing experience on the regulation of private sector service providers. This is a less expensive approach and one that acknowledges that some of the likely priority countries have sufficient domestic funding to implement once a suitable context-specific health system model is developed. Indeed, a successful long-term health systems investment could make the health aid sector obsolete in a few countries over the coming decade or two.
This leads to the inevitable question as to whether DFAT has the high-level expertise and capacity to engage deeply with country partners and provide advice on complex, technical, long-term issues such as financing and governance. The strategy acknowledges that the aid program will have to lean on “specialist technical assistance” that provides a clear opportunity for NGOs, consultants, universities and others to contribute to the delivery of this strategy. A return to a dependence on advisers is a big risk for the aid program in terms of image and effectiveness. Whether those advisers would be Australian is unclear, and why any of our neighbours would want to adopt Australia’s convoluted health financing model or expensive pharmaceutical policy is unclear as well. In other areas, it’s not clear that Australia has relevant expertise to offer (for example, we must assume that stated investments in “prevention of over-nutrition, drawing on Australia’s experience” are based on what not to do!).
Those who do not do so well in this strategy include those working on more narrow disease-focused initiatives. While “health systems” is mentioned 31 times in the 20-page strategy, HIV is mentioned three times and chronic illness seven times. In the 2011 health strategy, HIV was mentioned 13 times in 11 pages, and in 2009 AusAID published a 44-page stand-alone HIV strategy.
Nutrition (along with water and sanitation) is highlighted, which provides a clear link to the food security strategy, and there is scope for closer collaboration between two of the major sectors of the aid program. Research and development into new products gets a brief mention in pillar five of the strategy around “health innovation”.
The other losers in this strategy are multilateral health actors. The language used suggests that contributions to and engagement with multilateral agencies such as WHO, UNAIDS, UNFPA and UNICEF will not strictly be a part of Australia’s role as a good global citizen but will rather be more narrowly focused on organisations that do good work in South East Asia and the Pacific. The strategy states that “we will make investment decisions that reduce fragmentation and align our multilateral and global health investments to our region’s health priorities”, and later notes that DFAT will invest in organisations that “have demonstrable, country level effectiveness in our region, particularly the Pacific” – a criterion that essentially rules out most UN agencies. My attitude on the merits of some global actors is well known, so this part of the strategy resonates with me. But I imagine that the World Bank and Asian Development Bank would be pleased given their relative expertise in health systems and financing.
Of course judgement on this strategy will have to wait until more detail is announced on health funding and specific initiatives. Strategies do not always lead to actions; often politics trumps stated objectives. A health systems focus is harder to sell to politicians and to the wider community who are already wary of aid spending. Politicians might prefer the input-based, easily-digestible, disease-focused strategies from which this strategy aims to move away.
But fundamentally, if I were a Pacific Island director of health services, I would be encouraged by this strategy and would be knocking on DFAT’s door to start an honest discussion about long-term support needs. In an earlier Devpolicy blog post by senior health officials in the Solomon Islands, this is exactly the kind of strategy they called for:
It is time to take a hard look at the way health aid is currently delivered in the Pacific and determine if it is resulting in better, sustainable care based upon improved outcomes. Is the program building health system strength from its foundation upward? Can we craft a new agreement on how to best facilitate this in countries like Solomon Islands by merging the current piecemeal aid into a comprehensive multi-national partnership with the host nation overseeing the program?
Joel Negin is Associate Professor of International Health and Deputy Head of School at the School of Public Health at the University of Sydney.
Joel, Australia’s health aid to PNG has definitely not been focused on vertical programming, but front and centre on health system strengthening. Here’s a quote we draw in the 2010 PNG aid review I worked on (see p. 24) from an ODE review:
“TA has been extensive and wide-ranging, accounting for nearly half of AusAID expenditure [in the health sector]. Although it made positive contributions, some of which have had lasting impact, the team’s judgement is that the results are not commensurate with the level of spending. Expenditure of $150 to $200 million on TA has not produced a step improvement in performance or capacity. A better balance between TA and operating costs would arguably have achieved more.” (ODE, 2009, p.40)
Joel, I don’t think it’s an adequate response to the complete failure of the multi-decade health systems strengthening approach in PNG to say that more time is needed. One wants rather to say: when you are in a hole, stop digging. Nor is it convincing to say health system strengthening has worked in Bangladesh or Thailand or Ethiopia. Likely these countries had more political will. Technical assistance and training (which is what health systems strengthening is) can work where there is political backing but will struggle otherwise. It is striking that, as you say, the new strategy doesn’t reflect on past failures in the Pacific. One of weaknesses of aid is its relentlessly forward-looking nature and its failure to learn the lessons of the past. Surely it is time to go beyond rhetoric around systems strengthening, and try to find out what approaches have worked better, and support those. In the PNG, that would mean working more with the churches, more with the private sector, and more with in-line positions.
I totally agree re PNG – we should try and find where things are working, try and understand why and try see if they can be replicated elsewhere. PNG is intensely political, culturally diverse and needs a nuanced approach. But there are places where things work and have improved. However, there has been scant substantive evaluation – and limited focus on really learning from past experience. When I first went to PNG in 1982 – things worked and the public service was full of expatriates in line positions. TA per se is not the problem – indeed embedded TA or inline positions are badly needed – but advisers with no accountabilities often working with public servants who don’t want the advice, are a problem. We can’t keep trying to do the same things and expect a different outcome. We truly have to start to think and act politically if we are to hope for any measure of improvement – and as Stephen says – work more in different ways with churches, private sector and the political class.
Dear Stephen and Jane,
A very good and useful discussion. One can argue whether what aid agencies have done in PNG represents good health systems engagement or not. Some would argue that it was vertical programming with a health systems fig leaf. But either way, the lack of reflection on what has worked and not worked in PNG (and elsewhere in the region) in terms of health systems is concerning. The strategy notes examples from SE Asia but scant evidence from the Pacific. That is sorely needed.
Engagement with private sector and churches is not separate from health systems. A country such as Cambodia has seen strong and regulated contracting by the public sector of the private sector. PNG could learn from that kind of model (with local adaptation of course).
Thanks Joel. I’ve been meaning to read the health strategy and your blog means I can cross it off the list. It offers a comprehensive summary.
A question. Australia has engaged with some countries over quite long time periods to strengthen their health systems, such as Fiji and the Solomon Islands. Did the strategy reflect on, or incorporate, any learning from past DFAT (AusAID) experience in this area?
Hi Jo,
That’s a very good question. As you note, DFAT/AusAID has been doing elements of health system strengthening for a long time and the evidence of positive impact in PNG and Solomons is probably limited. The strategy does not directly cite successes from the Pacific. A couple examples of positive results from Indonesia and Cambodia are noted. Others have critiqued the focus on health systems noting that the global results are not amazing – but the Lancet paper tries to address that – and I really don’t see any alternative to focusing on health systems. No one ever said it was gonna be easy!
Thanks for the summary – very useful.
I’m glad to see DFAT heading in this direction. We’ve seen some great successes in Indonesia with health systems strengthening projects, so this is quite heartening.
Thanks Joel, this is a very useful overview. It’s good to see some clarity from DFAT on current/future health aid directions. Some further thoughts:
– The health systems strengthening focus is positive. I find the multiple references to what we’ve learnt from the Ebola crisis to be somewhat ironic (including that much of the crisis could have been avoided with better health systems investment) however given that (as you’ve written before) Australia’s aid to Africa has fallen off a cliff.
– It’s positive to see chronic disease featuring much more prominently in this document. Nutrition is a good starting point, and it’s good to see tobacco control, immunisation and hypertension mentioned. The NCDs focus still feels under-developed, however. For instance there’s no mention of the role of sport/physical activity in Australia’s aid program, which on top of being a central plank of the obesity response also provides opportunities for much broader health education, women’s empowerment and disability inclusion. In the Pacific, Australia’s Sport for Development investments are among the most successful and prominent, but there’s no mention in this document. There’s a vague reference to ‘healthy lifestyle promotion’ but that’s it. Given the multisectorality of NCDs (see for instance the World Bank’s Pacific multisectoral responses paper), a much more coherent strategy is still needed if DFAT is serious about addressing the actual burden of disease, and not just infectious diseases.
– I see your point about Australia’s unfortunate world leading status in over-nutrition, but would still suggest there’s a potential role for Australian organisations in chronic disease that is being neglected. Through my work in Tonga I was able to help leverage Australia’s domestic expertise in health promotion (VicHealth) and tobacco cessation (Cancer Council/Quit) to assist with building capacity to address NCDs. Incorporating funding for such twinning/capacity building initiatives into future programming/policy would be wise.
– Research seems to be more prominent than it has been for a few years. It’ll be interesting to see how that plays out.
– On a related note, I’d like to see more reference to cross-government arrangements/collaboration. The brief reference to Health Department is a reasonable start, but what about NHMRC’s funding of LMIC research/capacity building?
Great post Joel! The part that has most resonance with me is the 25 year window needed for health systems strengthening in the Lancet article. The challenge then remains how to move from short term-ism in our development partnerships with our near neighbours, to a longer term focus on building their health systems in financially feasible, culturally appropriate and politically nuanced ways…