and who are accountable?

Seminar discussion with World Bank 26.05.05S. Møgedal

Who sets priorities

Health systems hit by AIDS:

Health Systems under pressure

• Technology and opportunity pressure– beyond the scope of public budgets – in all countries.

• HIV/AIDS pressure– on top of long term under investment (..the unfinished

agenda of 20/20)

• Reform pressure– “right” sizing of public service provision, financing,

decentralization

• Performance pressure– targeted, performance based initiatives ,

governance etc

• Health work force “leakage” pressure– Global market

Health Systems under pressure

• Technology and opportunity pressure– beyond the scope of public budgets – in all countries.

• HIV/AIDS pressure– on top of long term under investment (..the unfinished

agenda of 20/20)

• Reform pressure– “right” sizing of public service provision, financing,

decentralization

• Performance pressure– targeted, performance based initiatives ,

governance etc

• Health work force “leakage” pressure– Global market

Aggravated by multiple players and supply

drives

Aggravated by ”double messages from the

international community:

•MDG and macroeconomic governance

•AIDS scale up and a health system that delivers care for

broader basic needs

•Unclear roles in the donor architecture (who funds

infrastructure and human resources)

•Competing coordination mechanisms (AIDS)

Health Systems under pressure

• Technology and opportunity pressure– beyond the scope of public budgets – in all countries.

• HIV/AIDS pressure– on top of long term under investment (..the unfinished

agenda of 20/20)

• Reform pressure– “right” sizing of public service provision, financing,

decentralization

• Performance pressure– targeted, performance based initiatives ,

governance etc

• Health work force “leakage” pressure– Global market

PUBLIC HEALTHDISASTER

Escape

Civil Society

Need to link frameworks and go beyond the public sector

Public Sector

Helsetjenester

PRS (P)

AIDS A

CTION

3 ONES

Health Services Delivery

Need for a new ”COUNTRY-UP” paradigm

• National ownership (inclusive of NGOs, with respect for state) is the basis for The Three Ones and for Rome/ Paris OECD-DAC

• In spite of agreement, national ownership still undermined, with major consequences for sustained action

• Many of the most critical challenges require country specific solutions (both defining the bottlenecks and tailoring action)

• In-country partners have a problem solving potential that is not fully used (academic, civil society, private sector, external partners with a country presence)

• Global action must respond to and enable country level problem solving partnerships and country-up processes

The basic challenges• Action priorities that drive alignment among all

partners– Means the need to make choices and negotiate competing

interests (- what about countries that for different reasons do not deliver on this?)

• Accountability – for priorities and results to people and clients; (WDR 2004)– for alignment among partners – must be mutual – what

mechanism?– Accountability for effective use of resources

• Empowering national capacity/systems– Defining and managing effective technical support and

dealing with underinvestment and competing forces in the health work force market represent agendas undermined

• Harmonization – a tool for reducing the transaction costs and distortions of

aid, but not a purpose in itself – has possibly been too focused on donor procedures and

thereby overshadowed the critical need for priorities that an drive alignment?

Why must countries be in front?Illustration: Health work force

• A globalized world (globalized market, globalized health problems) require empowered and inclusive national governance as well as international mechanisms for dealing with common/competing interests

• Work force issues are – Multi-sectoral in nature, and therefore often fall between

many chairs– invariably political because require policy choice,

negotiation and alliance building– not resolved with blue print solutions– not resolved by money alone (training, retention,

distribution, drivers and competing forces of the internal market, regional and global market)

• Calling for a problem-solving mode ”country-up”

Challenges to partners

• What is required for countries to make the exceptionality argument?– HIV/AIDS– health work force

• How can partners enable national processes for setting priorities – based on inclusive processes (civil society and academics

+)– clear enough to drive alignment – serve as a basis for vertical and horisontal accountability

• What are mechanisms for in-country problem solving, peer review and mutual accountability?– medium term health workforce framework, work force

impact assessments? – AIDS impact assessment and health systems readiness ?– Country Action Alliances/Partnership Forums

Challenges to partners

• What is required for countries to make the exceptionality argument?– HIV/AIDS– clear enough to drive alignment – health work force

• How can partners enable national processes for setting priorities – based on inclusive processes (civil society and academics

+)– serve as a basis for vertical and horisontal accountability

• What are mechanisms for in-country problem solving, peer review and mutual accountability?– medium term health workforce framework, work force

impact assessments? – AIDS impact assessment and health systems readiness ?– Country Action Alliances/Partnership Forums

HEALTH SERVICES AIDS ACTION

PUBLIC SECTOR CIVIL SOCIETY ACTION

REQUIRE LINKING IN PLANNING; DELIVERY

PROBLEM SOLVING AND ACCOUNTABILITY:COUNTRY-UP