EU HEALTH CHEQUE - Every Last Child · Health as percentage of total Disbursements of ODA Grants...

A Review of The European Commission’sSupport to the Health MDGs

EU HEALTH CHEQUE

EU Health check report.qxp_Layout 1 06/09/2016 14:51 Page 1

Some names in case studies have been changed to protect identities.

Published by Save the Children InternationalSt. Vincent House30 Orange StreetLondonWC2H 7HHUK

First published 2016© Save the Children InternationalRegistered charity number 1076822

This publication is copyright, but may be reproduced by any method withoutfee or prior permission for teaching purposes, but not for resale. For copyingin any other circumstances, prior written permission must be obtained fromthe publisher, and a fee may be payable.

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Cover Photo: Kadija, one year old, a success story at a Save the Children-supported, government-run facility providing nutritionservices in north Nigeria

Credit: Lucia Zoro/Save the Children

Acknowledgements

This report was written by Nikita Sanaullah with support from Save the ChildrenColleagues Ester Asin, Frazer Goodwin, Jacqueline Hale, and Olivia Mertens.Additional support was provided for the analysis of health ODA by JaochimRüppel and Tim Roosen, whilst the country case study of Nigeria was greatlyfacilitated by Save the Children’s Oluseyi Abejide and produced by Seyi Olujimi.

We would also like to thank all those who contributed their time for interviews,or who attended the one-day roundtable discussion under “Chatham HouseRules”, some of whom came from other continents. Without these contributions,whether from other NGOs, multilateral agencies or the EU institutions, theresearch in this report would not have been possible.

Save the Children works in more than 120 countries. We save children’s lives. We fight for their rights.We help them fulfil their potential.


Contents

Executive Summary 4

The Story in Numbers 6

Introduction 9

Section 1 – The Check-up 11

Section 2 – The Diagnosis 13

Section 3 – The Clinical Trial – case study of EU-Nigeria Partnership 21

Section 4 – The Treatment 23

Annex 25

Endnotes 26


4

Executive Summary

This report is a review of the EuropeanCommission’s contributions as a donor toachieving the health MDGs and anassessment of the impact of its officialdevelopment assistance and developmentpolicies. The lessons in this report can beused to make health ODA more efficientand impactful so it delivers greater resultsfor the SDGs.

This review of the health aid from the EU has found:

1. EU health aid is low and its contributions do not match its economic capacity.

2. A lack of transparency remains an issue and there are discrepancies and anomalies in the official reporting of EU health aid.

3. There is a need for more predictable disbursements. Predictability of aid is particularly crucial in health where service provision levels are so dependent upon recurrent costs.

4. Better data on health ODA is critical. Without data disaggregation it will not be possible to target support and interventions to those who thus far have been left behind.

The report identifies five areas to improve theeffectiveness of EC aid to health in the future:

1. The priority afforded to development assistance for health.

2. Support for middle income countries must continue.

3. Fragmentation must be avoided.

4. Budget support must be bolstered to create strong health systems.

5. Policy coherence for development must be stronger.

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Babunie 27 gave birth to her sonEmmanuel on Christmas Day atNimule hospital. Within five minutesof arriving Babunie had given birthto a healthy baby boy with the helpof experienced midwife Jane.


5

RECOMMENDATIONSThe European Commission should:

1. Commit to prioritising health in the review process of the 2014-2020 MFF and ensure that commitments to health match the levels of funding of the previous budget.

2. Aim to invest a greater amount than the 20% of EC’s Development Cooperation Instrument in basic health and education that is the legal minimum benchmark.

3. Put UHC at the heart of EU global health policy to ensure that all health targets of the SDGs can be achieved, while prioritising access to health of children and mothers. Ensuring the transparency and predictability of the disbursements of funds will help foster UHC.

4. Review the process by which the EU sets priorities with partner countries to ensure that aid and needs are well aligned and health-sensitive.

5. Strengthen the capacity of EU delegations to engage in health dialogue by creating a team of regional advisers specialised in health.

6. Review aid graduation policy to ensure that withdrawal of support is sustainable. Identify and engage in other means of supporting MICs to achieve the health targets such as through EC role in GAVI and GF boards.

7. Prioritise sector budget support as the main means of financing the health sector and ensure that aid fosters integrated health systems, rather than fragmented projects.

8. Enforce strong policy coherence for sustainable development in all internal policy, including in trade and migration as part of SDG implementation to ensure that EU internal policy does not impede on partner countries’ ability to achieve the SDGs.

9. Urge EU member states to recommit to the 0.7% UNGA target for ODA, a critical enabler for improving human development outcomes and generating much needed additional funding to invest in global health.

10. Support the monitoring of efforts to reach the most disadvantaged and excluded populations as part of the EU´s commitment to the SDGs: support initiatives and new methods to strengthen data collection, disaggregation, particularly by age and gender, and analysis of status and progress among population groups who are excluded.

Rabia, seven months, with her mum, at amalnutrition clinic, north Nigeria

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6

The Story in Numbers

What can be done?

The health MDGs have generated substantialprogress for global health.

But still…

How does EU support measure up?

45%fewer womenand girls die

duringchild birth

44%of newborn infants now

die within the first 28 daysof life compared to

37%in 1990

40%fewer cases

of HIV areoccurring

58%fewer people

are dying frommalaria and

45% from TB

68 Millionchildren under the age

of five will die ofpreventable

causes by 2030

€3536.5million

of ODA wentto health

between 2007and 2013

Thisrepresented

7.7%of total

internationalaid fromthe EC

Only

0.007%of total EU

GNI is used asdevelopmentassistance for

health

23 out of 79– the score the EU receivedfrom partner Ministries of

Health when asked whetherit shared information plans

for at least three yearsahead with them in a 2014international performance

review (by IPH+)

of extra funding could be generated if the EU and its member statescollectively met the 0.7% UNGA target for development assistance. €41 billion


review (by IHP+)

of children under 5 dying now die within the first 28 days

of life compared to

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

11.00%

12.00%

14.00%

13.00%

2007 2008 2009 2010 2011 2012 2013

Budget of European Commission

European Development Fund

Total Net Disbursements

4

7.9%7.6%6.3%

6.7%

8.1%

7.1%

8.2%8.5%

7.7%

10.1%

7.2%

8.8%

8.0%7.6%

5.9%6.4%

6.6%

12.1% 12.0%

7.3%7.1%

400

350

500

450

300

250

200

150

100

50

0

2007

152

91

66

62

110

104

86

85

202

217

304287

348

269

317

421

213 207 263 207 316

2008 2009 2010 2011 2012 2013







400

350

300

250

200

150

100

50

0

2007

79

3 18

165161

67

83 83

228

250

70 6961

65 70 85 68 61

2008 2009 2010 2011 2012 2013

0 00

7

The Story in NumbersHealth as percentage of total Disbursements of ODA Grants Made by EU institutions by Financing Instrument

Bilateral ODA Disbursements in the form of Grants for Health Sector Programmes, in million euro

Multilateral ODA Disbursements for Health, in million euro


Deye Lomong is three years old. When he was broughtby his mother Nawii Lomong, to the stabilisation centrein Riwoto, Kapoeta North in March 2012 with cough anddiarrhoea, he weighed just 10kg – a healthy boy of Deye’sheight should weigh 13kg. After just five days oftreatment, Deye had already gained 500g. He hadprogressed from therapeutic milk to therapeutic; he wasable to sit up alone, feed himself, and had fully regainedhis appetite. Deye is from Kop village in Paringa Payam,Eastern Equatoria state.

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8


In 2000, the European Union, along withmany states and institutions, made apledge to support the achievement of theMillennium Development Goals (MDGs).Health was the most prioritised issueamong the MDGs with three of the eightgoals focused on the world’s main healthchallenges. Since the onset of the MDGs,many accomplishments have been madeamongst which:

Despite these accomplishments, none of the healthgoals were achieved by the target year of 2015. It isestimated that 68 million children under fivewill die by 2030, mainly from preventable causes,unless the international community takes bolder stepsto prevent this1.

Health is fundamental to the process of development. Inmany developing countries, health challenges arerobbing children of their opportunity to learn, to thrive,and to survive. Significant progress is still needed not

only to attain the targets set out by the MDGs, but totake on the new agenda of the SustainableDevelopment Goals (SDGs). SDG 3, the health goal,aims to ‘ensure healthy lives and promote well-beingfor all at all ages’ by tackling various global healthchallenges across the world. It includes a set of thirteentargets and a broader range of health issues such asnon-communicable diseases (NCDs), road trafficaccidents, and a target on strengthening capacity tomitigate and manage the risks associated withepidemics.

The SDGs also offer an important new target on theachievement of universal health coverage (UHC). Thistarget on UHC is important because it embodies theoverarching principle that will allow countries to meetthe rest of the health targets that deal with specificdiseases, reforms, and population groups. Put simply,having access to quality health care, for all people,regardless of where they are from and what they canpay, is critical to meeting other health challenges andraising indicators. Supporting UHC through access tofree services at the point of delivery, particularly bytargeted intervention for those groups which arecurrently excluded, such as children who are excludedby their ethnicity, gender, or by the region in whichthey live, is part of the solution to reducing the risk ofpreventable child death.

In light of the more ambitious SDG health agenda,focused on systemic change, an understanding of whythe achievement of the health MDGs has failed isrequired. This report serves as a review of the EuropeanCommission’s contributions as a donor to achieving thehealth MDGs over the 2007-2013 Multi-AnnualFinancial Framework (MFF) and an assessment of theimpact of its official development assistance (ODA) anddevelopment policies. The European Commission (EC) isan important development actor. It is one of the largesthealth donors in the world and it has the uniquecapacity to coordinate among the 28 member states ofthe European Union making it a key actor in deliveringaid more efficiently. The lessons in this report can beused to make health ODA more efficient and impactfulso it delivers greater results for the SDGs.

9

Introduction

Deaths at birth havebeen reduced by

43%Maternal mortalityhas been reduced by

45%New cases of HIV

have fallen by

40%


10

Mobile health clinic set up by Save theChildren in San Dulag, Philippines

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11

In 2004, the European Parliament (EP)adopted a benchmark to allocate20 percent of EU ODA under theDevelopment Cooperative Instrument(DCI) to basic health and education by2009. The purpose of the benchmark wasto encourage the EC to invest more onhuman development. Despite this howeverhealth has always represented less than10% of overall EU budget funding (see Table 1). Over the course of the lastMFF, the total disbursements onhealth from the EU budget totalled€3536.5 million and averaged atapproximately 7.7% of total ODA.

A key finding is that while the EU does provide largecontributions to health as the third largest providerafter the US and UK, its contributions visibly do notmatch its economic capacity. Even when health fundingfrom the EU budget is combined with health fundingfrom the European Development Fund (EDF) it stillrepresents just 0.007% of total EU GNI3. This isdisappointingly low given that development assistancefor health is facing a difficult period. Current trendsindicate that many DAC donors including EU member

states are reducing their ODA for health. This is despiteWHO estimates in 2001 that if DAC donorscontributed just 0.1% of their Gross National Income(GNI) to global health, it would be possible to deliveruniversal health coverage in almost every low incomecountry4. The only exception to this trend has been theUK, which continues to increase its funding aspercentage of GNI to the health sector5. Most EUDAC donors have failed to achieve the 0.7% GNIcommitment to ODA established in a UN GeneralAssembly resolution as well as the 0.1% of GNI targetcontributing to the underfunding of health sectors. It isestimated that the collective failure of the EU to meetthis 0.7% target has resulted in a funding gap of€41 billion for development6.

This funding gap in ODA has devastating consequencesfor the health sector. Such a disparity between thefinancial support to health and its priority as adevelopment objective has been highlighted by theEuropean Court of Auditors in its health reports. Whilemuch of current aid rhetoric has focused on domesticresource mobilisation and increased expenditure tohealth by developing states, most of the poorestcountries remain unable to allocate funds from theirbudgets, frequently due to fiscal pressure placed onthem by international financial institutions to reducegovernment expenditures, that are substantial enoughto meet even the most basic health needs, even if theymeet the 15% health expenditure target set in Abuja7.For this reason, it is crucial that European Commissioncommits itself to increasing its support for health.

SECTION 1:THE CHECK-UP

TABLE 1 DISBURSEMENTS DURING MFF 2007-2013 (IN € MILLIONS)2

Health ODA 465.3

5,768.9

8.1%

508.5

6,307.9

8.1%

458.6

7,020.7

6.5%

470.6

6,859.4

6.9%

573.2

6,616.7

8.7%

486.1

6,588.2

7.4%

574.2

6,589.3

8.7%

Total ODA

Health as% of totalODA

2007 2008 2009 2010 2011 2012 2013


12

Lack of transparency remains an issue impactinghealth and other sectors. Many of those interviewedfor the purpose of this research stated their concernsabout the differences between the EuropeanCommission’s commitments and the actualdisbursements of aid. Part of this is due to delays indisbursements on the ground, but also due to themethodology used by the EC for calculating its ownODA. The Commission uses different DAC codes in itsannual reports than those used in aid reporting to theOECD, creating large mismatches with what is reportedfrom one source to another. This creates lack of clarityabout how much ODA is really being allocated. Whenthe European Commission was contacted for thepurpose of this review, the amounts of health ODA theyreported from the EU budget totalled only €1769 million,only half of the amount that we calculated8. In order toaccount for the quality as well as quantity of spend,including to the taxpayer, there must be greatertransparency in data on aid.

There is need for more predictabledisbursements. The EC has committed to being anaccountable donor through its membership to theInternational Health Partnership (IHP+), a globalpartnership of international organisations, bilateralinstitutions, and states committed to applying principlesof aid effectiveness and development cooperation todevelopment practice in health. But monitoring from thepartnership shows there is progress to be made. The

2014 Performance Review, calculated by surveyingpartner Ministries of Health, gave the Commission ascore of 79% below the target of 90% on the predictablyof the disbursements of funds in 2013. This is a substantialdecrease from the 2010-2011 period when it achieved ascore of 93%. On the indicator for whether partnergovernments had information on the Commission’sexpenditure plan for at least three years ahead, the ECscored a very poor 23% compared to the target of 79%.This is contrary to the agenda set out in the “EU’s Rolein Global Health” Communication which outlined thatEU health ODA should offer predictability of at leastthree years. While the MFF allocation reviews havepreviously remained stable, partners do not experiencethis predictability at country-level. This has hugeconsequences for a sector like health. Whether it isbuilding hospitals, training doctors or delivering bettermaternity care, predictability is key to being able toinvest in the sector for the long term.

Better data on health ODA is crucial. Currently itis unclear how much of EU health ODA goes to ruralversus urban areas or to different regions of a country,despite these being important clues into whether or notaid is reaching the most vulnerable. Monitoring this typeof information, which at the very least should includegender and age, through the development ofdisaggregated data sets, called for by Agenda 2030,would allow us to ensure that those who have the mostneed are not left behind by EU funding.

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Village doctor Ibrahim Chowdhury (60) at his small chamber at Ratnabazar, Poilarkandi, Hobiganj

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While levels of funding are important,assessing the use of those funds and theirimpact is also key. Save the Childrenconducted interviews with several actors inthe sector in Brussels and at country levelto evaluate the impact of EC policies andapproaches to global health and theachievement of the health MDGs. Theseincluded individuals working on globalhealth within NGOs and other civil societyorganisations, within the WHO, and withinthe European Institutions themselves. Thesediscussions identified five recommendationsto improve the effectiveness of EC aid tohealth in the future:

1. DEVELOPMENT ASSISTANCE FORHEALTH MUST BE PRIORITISED.

The Agenda for Change is causing a de-prioritisation ofhealth and the EU must ensure that it reverses thistrend. The Agenda, adopted in 2011, is the EU’s latestdevelopment policy framework aimed at increasing theimpact and effectiveness of its aid. Prior to the inceptionof the Agenda, partner countries could select multiplesectors to receive support in, which allowed for moreflexible and multi-dimensional interventions. Now, EUsupport is limited to no more than three prioritysectors, proving to be a key barrier to ensuring thathealth remains a priority. As a result, it is estimatedthat the Commission now only assists 19 countries inhealth within its geographical programming.

Part of the reason for de-prioritisation is that there islittle opportunity to champion health during thecooperation negotiation process. Priority-settingon cooperation is highly dependent on the expertise indelegations but there is very little capacity for healthdialogue within them. Very few delegations havepersonnel qualified in health or medicine and wheresuch experts exist, few work solely on health. MoreoverMinistries of Health are rarely invited to thenegotiation table and have a low capacity to advocatefor themselves. This reduces further the space to sethealth as a priority for partnership. In addition tothis, interviewees reported a negotiation processthat lacked local ownership. Rather than selectingpriority areas based on the domestic needs of partnercountries, they were imposed by EU delegations. Thiswas corroborated through interviews with officialsfrom the Nigerian Federal Ministry of Health whoreported the imposition of a cooperation agenda9. Thisgap between what the EU is willing to help with andwhat is needed at country level must be addressed.

Concerns about capacity for health dialogue are notnew. This issue was flagged early in the MDG period bythe Commission itself. It recognised its own lack of in-house capacity for health dialogue at country-level.There is a solution: the EU could develop a regionalteam of health specialists that could provide support todelegations and improve health capacity.

The decreasing commitment to health puts theachievement of health targets at severe risk at acritical time. DAC reporting for 2014 indicates that

SECTION 2:THE DIAGNOSIS

Policy coherence fordevelopment must be stronger.

Development assistance forhealth must be prioritised.

Support for middle incomecountries must continue.

Fragmentation mustbe avoided.

Budget support must bebolstered to create strong healthsystems.

1

2

3

4

5

13


14

the EU Institutions had only committed 2.9% of ODA tohealth (€481.58 million in current prices). Such a lowlevel of support for health is at odds with the goals setout in the European Consensus for Development andthe Development Cooperation Instrument whichoutlined the EU’s commitment to reducing povertyworldwide by assisting in the achievement of the MDGsand which prioritised human development, includinghealth, as one of the key areas of activities the EUwould work on with partner countries. The fact thathealth spending represents a slice of an overallshrinking pie is one issue: the budget for theDevelopment Cooperation Instrument in 2014 is 11.4%lower than that of the previous year at €2341.0 million.This inevitably suggests that even if the EC continues to

pursue the 20% benchmark to health and education,funding will be approximately €300.6 million less thanit was previously. yet continued funding for health iscrucial if we are to achieve UHC since many of theworld’s poorest are faced with paying out-of-pocketpayments (OOPs) in order to receive the health carethey need. Currently, OOPs are so important that indeveloping countries patient fees represent 30%of the financing for health systems, creating unequalaccess to health care in regions where need isgreatest10. It is crucial that the European Commissionrecommits itself to prioritising the right of the world’spoor to receive the health care they need andincreases its funding across countries in order to ensurethat no one is left behind in the achieving SDG3.

2. SUPPORT FOR MIDDLE INCOMECOUNTRIES MUST CONTINUE

EU financial support to middle income countries isdecreasing but the EU must look at other means ofsupporting MICs to achieve their health targets. Underthe Agenda for Change, grant-based bilateral aid to‘more advanced developing countries’ was consideredno longer viable and led to the introduction of theprinciple of differentiation. Under this principle, upper-middle income countries are beginning to graduatefrom EU support and EU focus is shifting towards lowincome countries with the view of having greaterimpact and to promote poverty reduction.

The problem with this shift is that it contradicts theAgenda for Change’s focus on poverty reduction given

that up to 80% of the world’s poor live in MiddleIncome Countries (MICs)11. The 19 countries initiallyselected for graduation, three of which were later‘saved’ by the European Parliament in its negotiationson the Agenda for Change, represented an estimated79% or 751 million of the DCI’s poor in 2009,suggesting that the DCI already had a strong pro-poorfocus before differentiation came into play12 By relyingtoo heavily on traditional income indicators like GNI todetermine who should graduate from support, the EChas shifted itself away from a multi-dimensionalunderstanding of poverty that incorporates thevariations in wealth distribution, country needs, andcountry capacity. Whereas the distribution of healthassistance was already favourable to low incomecountries (LICs) and least developed countries (LDCs)before differentiation was introduced.

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FIGURE 1 DISTRIBUTION OF SUPPORT BEFORE AGENDA FOR CHANGE (2010)

Differentiation based on a country’s income status isalso problematic because it means dismissing thedifferences in political space within graduatingcountries. Some of MIC states are not willing to providesupport for contentious health issues, most notablysexual and reproductive health (SRHR) and HIV/AIDSdue to the stigma and cultural taboos still attachedto them.

While middle income countries should be able takecare of their own populations and respond to theirhealth needs, in practice their capacity to do so varyfar too much. Many MIC income countries, includingthose who have recently been upgraded to upper-middle income status are still struggling to develop orsustain strong health systems. In Latin America and theCaribbean for example child mortality varies greatlydepending on parental socio-economic status. Childrenfrom low income homes are five times more likely todie before their 5th birthday13. Access can vary vastlydepending on rural or urban settings, which region of acountry a person lives in, what gender they are, whatreligion or caste they belong to, their migration status,among others. With the wealthy able to buy healthservices not publically available, it is the poor and thosemost in need that are left vulnerable.

Data projections on where the poor will be in thefuture appear to be conflicting; some studies suggestthat more of the poor will live in LDCs, while someforecast that the number of poor living in MICs willcontinue to grow as more LICs enter into middleincome status14, 15, 16. This lack of clarity serves to

further emphasise the need for the Commission tofocus on equity, regardless of changing income status inits future development policy for health.

During graduation negotiations the EC had promisedthat aid to upper-middle income countries would bephased out over time; in reality no transition policy wasput into place and aid was cut abruptly putting theprogress made in those countries at risk. Thispremature withdrawal has been problematic forcountries where the decrease in aid has not beenmatched by a rise in tax revenues to immediately fillthe gap17. Additionally MIC status means that certaincountries’ accessibility to more lenient external loanterms is very low, particularly as multilateraldevelopment banks have not increased theopportunities for funding, despite the growing numberof countries eligible for them18.

Some interviewees reported that there has beenrecognition from within the Commission recently thatthe implementation of this withdrawal strategy hasbeen problematic and that it is looking at ways toprovide support for graduate countries that goesbeyond financial assistance. The Commission should useits position on the boards of the Global Fund to FightAIDS, Tuberculosis and Malaria and the GAVI Alliance inorder to ensure that graduating countries wouldcontinue to receive immunisations at discounted pricesor be eligible for funding from these organisationswhere appropriate. This non-financial support isimportant to empower all MICs to achieve the healthSDG targets.

12%(€46 million)

45%(€168 million)

36%(€135 million)

Least Developed Countriesand Low Income Countries

Low-Middle Income Countries

Upper-Middle Income Countries

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3. FRAGMENTATION MUST BEAVOIDED

The EU commits a high proportion of its support forhealth to multilateral organisations. These accountedfor 15.7% of total health ODA with the bulk of thatgoing to the Global Fund to Fight AIDS, Tuberculosis andMalaria (GFATM). Disbursements to this organisationtotalled €367 million over the seven years of the lastMFF19. The EU member states individually alsocontribute significant amounts to GFATM with eight ofthem figuring among its top 15 donors. Together withthe Commission, they represented 45.8% of pledges inits previous replenishment round for 2011 to 2013,making the EU a significant contributor to globalinitiatives or vertical funds20.

Global initiatives have had a significant impact on theMDGs. They became a useful instrument for rapidlygenerating attention and resources for some of themost pressing health problems from the early 2000s.Despite the successes of this type of funding however,views on its benefits shifting in the post-2015 contextand many are beginning to express their concernsabout vertical funding and the barriers that globalinitiatives create to health systems strengthening (HSS).

Because of their narrow focus on specific diseases,vertical funds require separate strategic plans, separatemonitoring mechanisms, separate funding streams andseparate implementation streams21. Such programmesilos lead to duplication and the creation of parallelstructures within national health systems that add tosystem and transaction costs and make the task ofgovernance increasingly difficult for countries whichalready suffer from low capacity22. Vertical initiativesinvest little in developing an integrative system thataligns their programmes with strengthening the healthsystem and because they aim primarily at diseasecontrol they do not encompass the ‘bigger picture’ ofHSS in their approaches. According to Warren et al, anestimated 37% (€341 million) of Global Fund’s Round 8budget went to HSS, but of this 62% (€210 million) wentto disease-specific system strengthening rather thanintegrative HSS. Alarmingly, vertical funds also tend topromote the exodus of health workers from the publicsector into vertically-funded programmes run by NGOs

as a result of large differences in salaries between theircontracted staff and those of public health workers23.

The focus on disease-specific funds that target MDG 6(the goal to combat HIV/AIDs, malaria, and otherdiseases) has also too frequently translated into theneglect of other health challenges. MDG 6 is estimatedto have accounted for 58% of all ODA that excludedbudget support while only an estimated 10% of globalhealth ODA went to addressing MDG 5 which aimed toreduce maternal mortality and was the most off-trackof the health goals24. The heavy focus on globalinitiatives is leading to a funding gap for sexual andreproductive health that will only increase as verticalfunds become increasingly popular. Many EU donors areturning to multilateral organisations as their mainsource of health funding: in 2013, France gave 73% of itshealth ODA to multilaterals, mainly GFATM; Germanygave 61%, and the UK gave 44%25. As one of the newtargets of the SDGs is universal access to sexual andreproductive services, the EC must take steps to ensurethat this does not happen. The key is maintaining ahealthy balance between funding to global initiativesand other types of funding.

In March 2016, the Commission announced that itwould contribute €470 million to the GFATM over 2017to 201926. This is an increase of €100 million comparedto the previous funding cycle. The Commission has alsopledged €200 million to the GAVI Alliance for 2016 to2020. While the MDG framework encouraged thedevelopment of siloed approaches, the SDG targets aremuch more interlinked and interdependent. The SDGsdemand a more integrated and holistic approach27.Coordination is one of the core principles of the Agendafor Change, it emphasises avoidance of fragmentationand the need for a simpler and faster programmingprocess. The EC must champion this approach and it canuse its position on the boards of GAVI and the GlobalFund to shape these mechanisms into more integrativetools for better results for HSS. Moreover while verticalfunds might be efficient from a donor perspective, it isimportant that the EU recognise their limitations andthat it allocates aid to them accordingly. We cannotguarantee universal coverage of health care andresilient approaches to future health crises if we helpbuild narrow systems that are only equipped to tacklespecific health issues28.

TABLE 2 MULTILATERAL FUNDING DURING 2007-2013 MFF (IN EURO MILLIONS)

EU budget 79.5

17.1%

64.9

12.8%

66.5

14.5%

70.2

14.9%

85.4

14.9%

68.3

14.1%

60.7

10.6%As % of totalhealth ODA

2007 2008 2009 2010 2011 2012 2013

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4. SECTOR BUDGET SUPPORT MUSTBE BOLSTERED TO CREATE STRONGHEALTH SySTEMS.

The EU and its member states must not use verticalfunds as an alternative to budget support, whichremains the most effective method of building stronghealth systems. As untied aid, budget support allowsassistance to be aligned with national developmentstrategies, fostering greater country ownership anddecision-making power in allocating the funding.Crucially, budget support offers greater predictabilityfor recipient countries as well, allowing them to budgetfor several years. All these elements serve to makestrong budget support a necessary component ofhealth system strengthening.

Despite its importance to HSS however, budget supportis rarely sufficient enough to be used as funding forhealth. This is largely due to the fact that countries useup to 70% of general budget support (GBS) to pay offdebt29. Budget support is not currently enough toexpand the fiscal space to cover both sector budgetsand national debts, so governments in developingcountries are forced to pick and choose where they willallocate these funds. Save the Children’s analysis of GBSrevealed that only €146.1 million of EU GBS grants(0.32% of total ODA), went to health over the sevenyears of the last MFF30. These figures are clearly toolow to have a substantial impact on the budget ofHealth Ministries. Sector Budget Support (SBS) faresbetter. SBS, denoted in the table above as ‘health sectorprogrammes’, represents the largest chunk of healthODA at €1558.6 million but still represents only 3.4%of all ODA.

Sufficient and impactful budget support isneeded for health system strengthening. Thereare concerns about whether bilateral support has hadreal impact after the Ebola crisis. Sierra Leone received

€22.85 million in ODA grants from the Commissionover 2007 to 2013, Guinea received €2.37 million andLiberia €20.35 million, yet none could manage the crisis.The combined efforts to fund the Ebola response costthe EC €869 million, leading to questions about howmuch money could have been saved had health ODAbeen more effective in creating strong, sustainable, andresilient health systems. The crisis also highlights theneed to stop de-prioritising health as the refusal to puthealth at the centre of external priorities runs the riskof leaving countries vulnerable to similar diseaseoutbreaks in the future and risks periodic spikes inhumanitarian aid that could be prevented. The Ebolacrisis was an important moment in global healthbecause it showed up the deep impact that weak healthsystems have on development. The affected regionsuffered not only the health impact, but local trade andtourism plummeted with devastating consequences forGDP growth and population income. The World Bankestimated that the crisis has had an epidemiologicaland economic impact of $2.8 billion since 2014 and thatGDP per capita has been reduced by an average of$125 per person. In Liberia there has been a 40%decrease in those working since the onset of the crisis,mostly women who worked before the crisis. In Guineanearly 10% of households have stopped sending theirchildren to school31. The consequences of a weakhealth system impacted education, gender equality, andmany more important components of development andstability.

The role of sector budget support is important becauseforeign aid remains an important source of funding forthe health sector, representing as much as 40% of publicexpenditure in countries which have a per capita grossdomestic product of less than $200032. The EC’s supportis vital to the health systems of its partners indevelopment. Whether support takes the form of SBSor GBS, support must be high enough to increaseexpenditure to social support sectors, including health.

17

TABLE 3 BILATERAL ODA GRANTS FOR HEALTH IN MFF 2007-2012 (IN EURO MILLIONS)

Health sectorprogrammes

151.5

10.3

356.0

212.7

9.8

408.8

202.2

16.6

363.4

206.7

41.7

373.6

262.5

23.5

453.6

206.7

28.3

391.0

316.3

15.9

194.2 186.3 144.6 125.2 167.6 156 146.9

479.1

GeneralBudgetsupport(health)

Other –Issue specific

TotalBilateralsupport

2007 2008 2009 2010 2011 2012 2013

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TABLE 4 ISSUES SPECIFIC INTERVENTIONS BILATERAL HEALTH GRANTS IN MFF 2007-2013(IN EURO MILLIONS)

HIV

Reproductive Health

Child health

Immunisation

Other

243.2

176

310.6

25.5

365.6

0.53

0.38

0.68

0.06

0.80

Total % of total EU Budget ODA

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Laxmi, 23, cradles her 3-day-old 2nd child, in the Bardiya District Hospital one hour's walk from her village inBardiya, mid-Western Nepal.

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5. POLICy COHERENCE FORSUSTAINABLE DEVELOPMENTMUST BE STRENGTHENED

The European Commission must ensure that EUemployment policies and member state health policiesmatch the commitments it has made to development inboth the European Consensus on Development and theAgenda for Change. Better policy coherence wouldhelp alleviate the human resources for health (HRH)crisis in developing countries. Currently, 61 countriesfail to meet the WHO threshold for the minimumamount of health workers needed to provide basichealth services (23 per 10,000 people)33. Many healthworkers are migrating out of developing countries intoEurope and as a beneficiary of this migration the EUhas a responsibility to support the countries of origin.

Intakes of health workers from developing countriesare a result of the EU’s own shortage of healthworkers. International recruitment is an attractivesolution given that member states are able to acquiremore staff, while incurring no training costs. Memberstates like the UK, Ireland, and Germany continue toheavily recruit from developing countries despite statedefforts to stick to the letter of the WHO Code onhealth workforce recruitment34. This is particularlyproblematic for Africa, which has the highest diseaseburden in the world but the lowest proportion of healthworkers (0.8 for every 1000 person)35. Each year anestimated 20,000 health workers emigrate from theregion36. These shortages impact on the quality of care,cause origin countries to be burdened with the cost oflost education, the additional costs of recruitingreplacements, and creates low morale among staticstaff who stay behind as their workload drasticallyincreases37. These problems are likely to continue togrow as the EU deals with an ageing population that isrepresenting an increasingly large portion of societyand further recruits foreign medical professionals tocare for them.

The EU’s political commitment to tackling the crisis hasbeen strong and has included the EU Strategy forAction on the crisis in 200538, the Programme forAction39 in 2006 and the adoption of the WHO Codeof Practice on International Recruitment of HealthPersonnel. The EC also developed the Action Plan forthe EU Health Workforce, promising to supportmember states’ implementation of the WHO Code. Still,little progress has been made in adopting measures toease the crisis and according to its own PCD report,there is little evidence that the EU has contributed toreducing the migration of health workers to the EU. Thelack of progress is partially due to the voluntary natureof the WHO ethical recruitment code. A first step thenwould be to make its integration into the EU ActionPlan legally binding for all member states.

Secondly, ethical recruitment codes must apply to theprivate sector. Currently private sector organisationsand private recruitment agencies can bypass rules onethical recruitment adopted by the state. The sectormust be better regulated in order to ensure that thecode is implemented in both the public and privatesector recruitment.

Thirdly, better data on health workforce migration isneeded. Only 13 EU member states contributed morethan five years’ worth of data on health workforcemigration to the OECD. That data only measuresforeign-trained doctors, and does not differentiatebetween doctors from within the EU and doctors fromdeveloping countries. Moreover it does not take intoaccount doctors from developing countries that receivetraining within the recipient country. Data on theoutflows of foreign-doctors is also not measuredthough this is needed to determine to how manymigrant health workers are returning home where theorigin country can benefit of any new skills or trainingthey received in the EU. Better data is crucial tounderstanding the scale of the problem and to betteraddressing it.

Finally, the EU must tackle the root causes of its ownshortages to avoid recruiting large amounts of doctorsfrom developing countries. By investing in EU healthworkers such as by improving work conditions,combatting underpayment, cutting overtime hours, andproviding better career progression structures, the EUand its member states can not only resolve their ownhealth worker shortages but contribute to decreasingbrain drain. Creating more incentives to study medicine,training more doctors and improving technology andtraining opportunities at member state level could playa preventative role in overcoming the lack of healthpersonnel40.

The WHO estimates that there is a shortage of over7.2 million health workers across the world41. Withoutmedical professionals, it is impossible to deliver UHCand HRH is crucial to achieving the health targets. Thisis why the SDGs feature a target on HRH which aimsto “substantially increase health financing and therecruitment, development, training and retention” ofhealth workers in developing countries. As the terms‘substantially increase´ are vague, it is important thatthe EC defines its own measurable endpoint for thistarget and puts more emphasis on policy coherence fordevelopment. With strong PCD, the EU can make itsaid more impactful and efficient and ensure that everychild has access to a health worker.

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TACKLING POVERTy-RELATEDAND NEGLECTED DISEASESWITH EU RESEARCH ANDDEVELOPMENT POLICy

The EU can play a direct role in tackling thediseases that affect children living in povertythrough its allocations to research anddevelopment (R&D) of medical innovations andimmunisations. Children are the most vulnerableto poverty related and neglected diseases(PRNDs) which affect over 1 billion people,primarily in developing countries44. yet during theMDG period only 4% of new drugs and vaccinesto reach the market were developed to take onthese diseases45. The EU has taken strong stepsto addressing this gap as the third largest publicfunder for this sector46. There are however otherways in which the EU could contribute topreventing, managing, or curing these diseases.

The EU can help by:

1. De-linkage – High costs of medicines are often the result of R&D investments made by pharmaceutical developers. The EU can help find an alternative to de-link research costs from the price of a product by allowing developers to immediately recoup their costs such as by offering prizes to encourage development.

2. Open innovation – The EU can help ensure that information sharing such as technical expertise, know-how and platforms happens to stimulate the development of new products. This can happen by creating structures such as open laboratories where relevant stakeholders can participate equally in sharing their knowledge.

3. Licensing for access – The EU can create pooling mechanisms for proprietary rights so that interested parties who do not own patents on certain compounds can use them to generate new products or combinations that are suited to children and to particular needs in different contexts47.

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SAFEGUARDING ACCESS TOMEDICINES THROUGH EU TRADEPOLICy

Achieving UHC will only be possible if the costof medicines and immunisations remainscompetitive and safeguarding access toaffordable essential medicines and respecting theTRIPS agreement is now part of SDG 3. Morethan 40 million already fall into poverty in Indiadue to the cost of drugs42. Ongoing EU freetrade agreement (FTA) negotiations between theEC and India are jeopardising access to low-costdrugs. India is the most important supplier ofaffordable generic drugs for the developingworld and the EU has promised that it wouldkeep to its commitments to safeguard access tomedicines agreed in the Doha Declaration onTrade-Related Aspects of Intellectual PropertyRights (also known as the TRIPS agreement).Reports indicate however that thesenegotiations have not concluded preciselybecause of the EC push for strict intellectualproperty rights (IPR) enforcement and dataexclusivity which puts the production anddistribution of generics at risk. The EC has onseveral occasions chosen to push for IPRprovisions that are more rigorous than those setin the TRIPS agreement. Such strict terms havethe greatest impact on the poorest countrieswhich lack the capacity to mitigate the effects ofprice inflation, putting the affordability and theaccess to medicines of those living in poverty athigh risk43. When negotiations move forward,the European Commission must ensure that itstrade policies do not undermine access toessential medicines required for maternal andchild care in developing countries byunnecessarily pushing for TRIPS plus provisions.

Tsahara brings her son Habou, three, to see the doctor at theirlocal health centre in Kentche, Zinder region, Niger.

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Nigeria made remarkable strides during theMDGs. The country has managed to reduceunder-five child mortality by 49%. Maternalmortality has also seen a dramaticreduction. Despite this progress, all of thehealth targets could not be achieved andthe country still has one of the highestmaternal and child mortality rates in theworld.

EU COOPERATIONEU bilateral contributions to Nigeria in ODA grantsfor health from 2007 to 2013 totalled €102.56 million,of which €19 million came specifically from the EUBudget specifically48. The Nigerian government´s owntotal expenditure to health as a percentage of thecountry’s GDP was only 3.7% in 2014 and its totalexpenditure per capita was €183. As a result of lowstate health expenditure, 60% of health expenditurescome from OOPs.

EU support to the health sector in Nigeria during theMDGs focused on immunisation. There are four areas inwhich it provided support:

1. Management capacity building

2. Infrastructure (eg.: building cold rooms and rehabbing health facilities)

3. R&D including data analysis and interpretation

4. Polio eradication

Health projects supported by the EU are implementedthrough the state, NGOs, and internationalorganisations. Implementing partners include WHO,UNICEF and the National Primary Health CareDevelopment Agency (NPHCDA) of Nigeria to whomthe EU provided funding for three different projects.

IMPACTProgress has been made in vaccination coverage forchildren, which has increased by 12.5% in ten years, butthe greatest impact has been on the fight to eradicatepolio in Nigeria, which the EU has been a significantpartner in addressing. The last case of the disease wassignalled in July 2014 and interviewees felt that EUsupport, along with that of other donors, hadcontributed to this progress. The goal now is to reachthree years without another case in order to be eligibleto become a certified polio-free country. The WHOpolio eradication campaign focuses on deliveringvaccines to children below the age of five. Childrenunder one also get screened for other commondiseases and receive routine immunisations, providingan integrated service that targets vulnerable children.Part of the success related to polio eradication push islikely partially due to the strong in-house capacity forhealth dialogue from the EU delegation in Nigeria. TheHealth Unit has many staff members who come from abackground in medicine or health planning.

SECTION 3:THE CLINICAL TRIAL – CASE STUDYOF EU-NIGERIA PARTNERSHIP

Under-Five Deathsper 1000 live births

• 1990: 213 • 2014: 89

Deaths per100,00 live birth

• 1990: 1000 • 2014: 243

Vaccination coveragefor children aged 12-23

• 2003: 12.9% • 2013: 25.4%

MDG 4: Child Mortality

MDG 5: Maternal Mortality

MDG 6: Malaria, TB, HIV/AIDS

PROGRESS TOWARDS HEALTH MDGS


COUNTRy OWNERSHIPEU bilateral funding goes through the Federal Ministryof Budget and National Planning which then transfersthe funds for immunisation projects to the NationalPrimary Health Care Development Agency. There is nocoordinated entry into the health sector and the EUgoes directly to the activity. Proposals for the healthsector come from the Budget and National PlanningMinistry whom must cite specific activities in order tomake a request for funding to the EU Delegation. Theproposals then return to the Planning Ministry beforefinally arriving at the NPHCDA. This means that theMinistry of Health bares no direct role in developinghealth sector proposals with the EU. Interviewees at theNPHCDA also acknowledged that projects aredesigned by the EU, which prefers to focus on oneaspect of health and to have more control over aprogramme. As a result, officials from the FederalMinistry of Health (FMOH) reported feeling bypassedand there was little sense of country ownership fromthem over the projects.

The FMOH stated that because priority settingnegotiations take place between the EU and theMinistry of Budget and National Planning, there is an

in-house issue of lack of push for prioritisinghealth. Though this has been signalled to therelevant stakeholders, this has not changed andthe FMOH is still not invited to the negotiationtable. When questioned about this, an officialfrom the EU delegation expressed the fact thatthey believe the EU should support the FMOHonly on policy and regulation, not onprogramming and that they see it as the FMOHand NPHCDA’s role to information-share withthe Budget and National Planning Ministry onEU cooperation.

TRANSPARENCyTransparency failings mark the currentapproach: of the six officials interviewed fromthe Federal Ministry of Health, not one wasaware of the amount of financial support theEU gives to Nigeria for the health sector.According to them, EU funding and support, likeother development partners, goes directly to theprojects they are meant. They stated that whileother donors occasionally provided support tohealth without the involvement of the FMOH,the EU was the most pronounced case.

DELAyS IN RELEASING FUNDSDisbursements of funds from the EU wereinconsistent and there are often delays. In oneinstance, a project, EU-SIGN, was approved fromBrussels in 2009 but funds for implementationwere not released until May 2013. Finally, theimplementers were only able to withdrawmoney from the project account in August 2013.Despite these delays that were out of the handsof the local government the EU refused to allowan extension to cover the delays.

REMEDIAL STEPSThe lack of a role provided to the FMOH inEU-Nigeria cooperation suggests that there isurgent need for a better flow of communicationfrom all parties with the Federal Ministry ofHealth. EU support to Nigeria, though impactful,is very much led by the EU itself. The FMOHmust a bigger part in the planning process if EUcooperation is to achieve the long term goal ofbuilding a strong self-sufficient health system.Officials at the FMOH emphasised their desireto see support take the form of health systemstrengthening and to see a move towardsbudget support, which would put fundingallocations through the national budget insteadof separate agencies. This would also allow theNigeria health ministry to develop its ownprojects to improve the health system, giving itgreater ownership.

22

Alia, two years old, has just arrived at a Save the Children-supported, government-run facility providing nutrition services.

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The European Commission mustcontinue to fund health adequately.The new SDG framework offers us a newchance to create positive and lasting impacton health in developing countries. It isimportant to remember that the healthMDGs sought to take on preventabledeaths. This means we already have thetools necessary to significantly reducedeath rates, including maternal and childmortality. Strong financial and politicalsupport from donors like the EuropeanCommission can create meaningful changeto tackle these problems. The EuropeanCommission should no longer toleratepreventable deaths and as a major donor itmust play its role in bridging the fundinggap for health.

With its international cooperation and developmentassistance, the EC must show strong commitmentto UHC in particular. Commitment to UHC in bothpolicy and programming is crucial to achieving thehealth targets of the SDGs. The EU can ensure thatchildren survive by accelerating the progress towardsachieving the universal coverage of health, including bysupporting national UHC plan. The EuropeanCommission should show leadership and invest in UHCby contributing strong and impactful health systemfinancing to increase health services and to abolishOOPs, creating the provision of services that are freeat the point of delivery, particularly for the mostvulnerable including pregnant women and children sothat they can access essential quality care withoutfinancial hardship. This is the crucial step to reducingpreventable child and maternal mortality wherepossible.

The progress we have seen with the MDGs is the directresult of continued commitment and the engagementand actions of multiples stakeholders, which includenational governments, civil society, and the

international community including donors. Thiscommitment must continue into the SDGs so evengreater progress can be made. Since 2000, 48 millionlives of children have been saved. The responsibility andthe ability to save even more over the next fifteenyears rest with donors like the European Commission.

RECOMMENDATIONSWe are at a critical juncture in the quest to improveglobal health, so that we have adequately resourcedand strengthened health systems to meet the SDGtargets, including the aim to end preventable deaths,and secure a future in which no one is left behind.

The European Commission should:

1. Commit to prioritising health in the review process of the 2014-2020 MFF and ensure that commitments to health match the levels of funding of the previous budget.

2. Aim to invest a greater amount than the 20% of DCI in basic health and education that is the legal minimum benchmark.

3. Put UHC at the heart of EU global health policy to ensure that all health targets of the SDGs can be achieved, while prioritising access to health of children and mothers. Ensuring the transparency and predictability of the disbursements of funds will help foster UHC.

4. Review the process by which the EU sets priorities with partner countries to ensure that aid and needs are well aligned and health- sensitive.

5. Strengthen the capacity of EU delegations to engage in health dialogue by creating a team of regional advisers specialised in health.

6. Review aid graduation policy to ensure that withdrawal of support is sustainable. Identify and engage in other means of supporting MICs to achieve the health targets such as through EC role in GAVI and GF boards.

7. Prioritise sector budget support as the main means of financing the health sector and ensure that aid fosters integrated health systems, rather than fragmented projects.

SECTION 4:THE TREATMENT


24

8. Enforce strong policy coherence for sustainable development in all internal policy, including in trade and migration as part of SDG implementation to ensure that EU internal policy does not impede on partner countries’ ability to achieve the SDGs.

9. Urge EU member states to recommit to the 0.7% UNGA target for ODA, a critical enabler for improving human development outcomes and generating much needed additional funding to invest in global health.

10. Support the monitoring of efforts to reach the most disadvantaged and excluded populations as part of the EU´s commitment to the SDGs: support initiatives and new methods to strengthen data collection, disaggregation, particularly by age and gender, and analysis of status and progress among population groups who are excluded, extremely poor or not covered by conventional household surveys, such as displaced persons, street children, slum populations and persons with disabilities.

This is 18-year-old Maria's first child, a baby girl unnamed. The baby is approximately 1 hour old. She gave birth ina clinic in Salala about half an hour drive from CH Renniehospital. She had a postpartum hemorrage. The baby was feverish.Maria had been admitted three times in the previous weeks foranemia and malaria. Both mother and baby were held for tests.

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3. ANNUAL HEALTH DISBURSEMENTS TO NIGERIA

25

ANNEX

TABLE 5 GFATM FUNDING DURING 2007-2013 MFF (IN EURO MILLIONS)

EU budget 62.0

62.0

50.0

50.0

50.0

150.0

200.0

50.0

50.0

65.0

165.0

230.0

50.0

50.0

40.0

40.0

EDF

Total

2007 2008 2009 2010 2011 2012 2013

Non-EDF 269

423

268

468

335

75200154 161233405

410

274

679

85

156

241

187

420

351

512

1384

1769

3153

EDF

Total(€ million)

2007 2008 2009 2010 2011 2012 2013 Total

TABLE 6 HEALTH ODA TO NIGERIA DURING 2007-2013 MFF (IN EURO MILLIONS)

EU budget 0.81

14.92

15.73

1.29

21.92

23.21

2.70

9.32

12.02

1.90

2.25

4.15

4.46

16.39

20.85

4.38

7.74

12.12

3.46

11.02

14.48

EDF

Total

2007 2008 2009 2010 2011 2012 2013

1. CALCULATION OF EU ODA SPEND TO HEALTH DURING THE2007-2013 MFF AS RECEIVED FROM THE EUROPEAN COMMISSION

2. ANNUAL HEALTH DISBURSEMENTS TO GLOBAL FUND TO AIDS,TUBERCULOSIS AND MALARIA


26

ENDNOTES1 UNICEF (2015). “Progress for Children. Beyond Averages:Learning from the MDGs”, Number 11, 23 June.2 Please note that this study looked specifically at the ODAcoming from the EU budget as this is directly controlled andset by the Commission, and does not include the EuropeanDevelopment Fund (EDF), which is covered by its own financialrules and from which funds are contributed directly by themember states in accordance with a contribution key, unlessotherwise stated. All figures indicate disbursements and are incurrent prices.3 Ibid.4 Action for Global Health (2015). “Health Financing:Unpacking trends in ODA for Health – Cross EuropeanAnalysis”, Briefing Paper, June 2015.5 Action for Global Health (2015). “Who pays for Health?Trends in ODA for Health”. Advocacy Report, January 2015.6 CONCORD (2014). “Aid Beyond 2015: Europe’s role infinancing and implementing sustainable development goalspost-2015”, AidWatch 2014.7 Action for Global Health (2012). “Results or rhetoric? Whatyou didn’t know about Europe’s aid for health”, AdvocacyReport, November 2012.8 See Annex 1.9 See Nigeria case study in Section 3.10 Action for Global Health (2015). “Who Pays for Health?Trends in ODA for Health”, Advocacy Report, January 2015.11 Sumner, Andy (2012). “Where Will the World’s PoorLive?”, IDS.12 Herbert, Sian (2012). “Reassessing aid to middle-incomecountries: the implications of the European Commission’spolicy of differentiation for developing countries”, WorkingPaper 349. London: ODI.13 World Bank (2013). “Latin America: unequal access to healthcare is still no. 1 killer for moms and kids”, Feature Story, 11September. 14 For example, ODI “Horizon 2025: Creative Destruction inthe Aid Industry” study from 2012. 15 Numerous studies for this include Chandy and Gertz (2011).16 An IDS study projects that even with growth, the amount ofpoor living in LICs and MICs will be equally split.17 Save the Children (2012). Immunisation for all: no child leftbehind. London: Save the Children.18 Kharas, Homi; Prizzon, Annalisa; and Andrew Rogerson(2014). Financing the post-2015 Sustainable DevelopmentGoals. London: ODI19 See Annex 2.20 Rivers, Bernard (2012). Donors to the Global Fund: WhoGives How Much? Nairobi: Aidspan.21 WHO (2015). Health in 2015: From MDGs to SDGs. Geneva:WHO.22 Ibid.23 Mussa, Abdul H.; Pfeiffer, James; Gloyd, Stephen S; andKenneth Sherr (2013). “Vertical funding, non-governmentalorganisations, and health system strengthening: perspectives ofpublic sector health workers in Mozambique”, HumanResources for Health, Vol 11. 24 SAFPI (2013). “Is Health ODA falling?”, 16 May 2013. 25 Action for Global Health European Health ODA profiles.

26 http://europa.eu/rapid/press-release_IP-16-522_en.htm27 Save the Children (2016). From Agreement to Action: Deliveringthe Sustainable Development Goals. London: Save the Children. 28 Save the Children (2015). A Wake Up Call: Lessons from Ebolafor the World’s Health Systems. London: Save the Children.29 European Court of Auditors (2008). “EC DevelopmentAssistance to health services in Sub-Saharan Africa”, SpecialReport 10. 30 General budget support grants that went to health werecalculated on a country-by-country basis by analysing relevantprojects and comparing them to annual national healthexpenditures.31 World Bank (2016). “2014-2015 West Africa Ebola Crisis:Impact Update”. Washington: World Bank Group.32 Bendavid, Eran; Duong, Andrew; Sagan, Charlotte; andGillian Raikes (2015). “Health Aid is Allocated Efficiently, ButNot Optimally: Insights From a Review of Cost-EffectivenessStudies”, Health Affairs, 34 (7).33 Save the Children (2011). “No Child Out of Reach: Time toEnd the Health Worker Crisis”. London: Save the Children.34 Buchan, James (2007). “Health worker migration in Europe:assessing the policy options”, Eurohealth, 13(1).35 Hudson, Alan (2006). “Case Study: EU Strategy for Actionon the Crisis for Human Resources for Health in DevelopingCountries”, ODI Annual Reports.36 Stilwell et al (2004). “Managing brain drain and brain wasteof health workers in Nigeria”, WHO Bulletin. 37 Buchan, James (2007). “Health worker migration in Europe:assessing the policy options”, Eurohealth, 13(1).38 EU Strategy for Action on the Crisis in Human Resourcesfor Health Developing Countries – COM(2005) 642.39 A European Programme for Action to tackle the criticalshortage of health workers in developing countries (2007-2013) – COM(2006) 870.40 Many similar recommendations were made in an EC fundedstudy: European Health Management Association (2015).“Recruitment and Retention of the Health Workforce inEurope”. 41 Global Health Workforce Alliance and WHO (2013). A Universal Truth: No Health Without a Workforce. Geneva: WHO.42 Rockefeller Foundation, Save the Children, UNICEF andWHO (2013). Universal Health Coverage: A commitment to closethe gap. London: Save the Children.43 HAI and MSF (2015). “Empty gestures: the EU’sCommitments to Safeguard Access to Medicines”, Review ofthe European Union´s Trade and Investment Policy, September2015.44 WHO estimates that more than 70% of countries affectedby PNRDs are low income or low middle income countries.45 SEEK Development and Policy Cures (2016). “Assessing EUFunding for R&D for Poverty-Related and NeglectedDiseases”. EACH Coalition.46 The EU contributed 3.7% of global financing for PRNDR&D between 2007 and 2014.47 Save the Children (2016). Small Doses: Finding and makingthe medicines children need. London: Save the Children.48 See Annex 3.


27

Princess, 20, gave birth to Jallah, 3 days old and herfirst child at CH Rennie Hospital. She had to havea c-section because Jallah was so large. Her motherAfua shows her daughter how to breastfeed.

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In light of the ambitious SustainableDevelopment Goal health agenda, focused onsystemic change, an understanding of why thehealth Millennium Development Goals failedto be achieved is required. The European Commission (EC) is an important development actor.This report serves as a review of the European Commission’scontributions as a donor to achieving the health MDGs over the2007-2013 Multi-Annual Financial Framework (MFF). The EU’s recordon health can provide an insight into the impact of EU’s officialdevelopment assistance (ODA) and development policies.

The lessons in this report can be used to make health ODA moreefficient and impactful so it delivers greater results for the SDGs

The report urges an increase in the priority afforded to developmentassistance for health.

Outlines why and how support for health for middle income countriesmust continue.

Details why and how fragmentation in the health sector must beavoided.

Recommends that budget support be bolstered so as to create stronghealth systems.

Provides specific recommendations on how EU policy coherence fordevelopment (PCD) must be stronger for health.

The ten specific recommendations of the report are important at atime when the EU is revising its Consensus on development, devising itsstrategy to implement the SDGs and undertaking the mid-term reviewof its long term budget – the MFF.

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EU HEALTH CHEQUE


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