Stephanie M. Topp (Centre for Infectious Disease Research in Zambia and Divisions of Infectious Disease, University of Alabama at Birmingham); Kurfi Abubakar Muhammed (National Health Insurance Scheme, Nigeria); Charles Birungi (School of Accounting, Economics and Finance, University of KwaZulu-Natal, South Africa) & Natalie Eggermont ( Institute of Tropical Medicine, Antwerp )

StephanieMTopp_HighRes  DSC_2270 Charles Birungi_EV4GH2013 natalie eggermont

Over the past half century the global health elite has excelled in setting lofty goals and making aspirational comments, as part of a broad – if often ill-defined – movement towards global improvements in disease prevention, diagnosis and treatment.  Some of these goals have been met (notably small-pox eradication and substantial reductions in child mortality), while others have been less successful.   None have been so grand and so vigorously pursued as those relating to HIV and AIDS.  Indeed, with new HIV infections at their lowest levels since the early 1990s and a 21% fall in AIDS-related deaths globally in the past decade the UN catch-cry ‘Zero New Infections, Zero Stigma and discrimination and Zero AIDS related deaths reflects an increasing focus amongst global health activists and policy makers on achieving an AIDS-free generation and bringing about ‘the end of AIDS’.

While aspirational statements can play a role in helping to galvanise policy makers, funders and health workers to further action, they can also serve as a distraction by encouraging an over-simplistic assessment of the challenge(s) at hand.  Within the global health and HIV/AIDS communities, for example, the need for strong health systems and strengthened national ownership of HIV/AIDS responses is now widely recognized (and correctly so), and yet comparatively little attention is being paid to the political and structural conditions that are required to enable such ‘ownership’ to evolve.

The global political economy has a significant, and not always positive effect on the structure and impact of domestic policy-making and investment in health.  Evidence from one recent report – Illicit Financial Flows from Developing Countries – demonstrates that for every dollar of official development assistance (ODA) coming into sub-Saharan Africa in 2010, ten dollars exited the region via the illicit financial flows of a global ‘shadow economy,’ comprising tax havens, secret jurisdictions, disguised corporations, trade mispricing and money laundering.  A growing body of literature (see: Oxfam’s Working for the Few’ / Aidwatch’s Global financial flows, aid and development) and various commentators (e.g. Alex Cobham / J. Ball) suggest that ODA may help to mask the effects of illegal financial flows by unintentionally crowding out domestic spending, weakening the need or resolve of local governments to invest in human services, or, by propping up service sectors undermined by corrupt officials or governments.  These assertions are supported by the work of Lu et al, amongst others, who demonstrate that in many sub-Saharan African countries, health-specific development assistance provided direct to governments, has had a significant negative effect on domestic government spending on health (a reduction of between $0.43 to $1.14 in government health expenditure from domestic resources, for every US$1 of health-specific development assistance disbursed).

So why do global health donors not simply pack up their bags and leave?

ODA has been an almost permanent feature of the post-independence landscape of sub-Saharan Africa and many assume that a withdrawal of aid would result in widespread collapse of institutions that provide basic services.  Providing a counterpoint to this assumption, a recent study on Somaliland – which seceded from Somalia in 1991 and as a result has been largely ineligible for international aid – provides an example of how ineligibility for aid may actually facilitate the development of more accountable political institutions and the re-emergence (albeit gradual) of a local service sector.  Although clearly describing a specific context, the study shows how in the absence of external funding the Somaliland government had to turn to its citizens, especially the business community, for revenue by means of taxation.  This provided a source of financing but also a critical mechanism of government accountability, with negotiation over government spending of those taxes an essential part of the social contract.

The debate surrounding the potential negative impact of ODA is not new and the Somaliland example remains an isolated one.  Nonetheless, in the context of a debate on strengthening country ownership of the HIV/AIDS response, this case, combined with the data on illicit financial flows, help to focus attention on the importance of not how much money is spent, but who controls it and how accountability is institutionalized.  Recent debates in Davos and the declarations coming out of the G8 and G20 meetings similarly demonstrate a growing international recognition of the need to support LMICs to strengthen the social contract and institutionalize government accountability.

Within the global health community, however, there remains a disconnect.  The rhetoric of improved governance and accountability is not matched by any genuine commitment to shift from the neoliberal status quo that underpins the global shadow economy (see for example Microsoft’s Tax record) or (as demonstrated during recent Global Fund replenishment discussions) away from traditional forms of ODA that may actually undermine, instead of strengthening the social contract.  To be fair, there has been a shift within some sections of the global health community with growing momentum towards Universal Health Coverage  (UHC) and an associated emphasis on public financing.  Nonetheless, progress is slow; too slow, with many global health experts seemingly hardwired to consider ‘value for money’ (e.g. twitter hashtag: #BestBuys4GH) while ignoring fundamental structural and political issues.

As the post-2015 discussions continue, key questions that should be considered include whether the global health community can truly contribute to strengthened ownership of the HIV/AIDS response, or indeed, UHC, given its strong preference for global health financing strategies that (even as they advocate for increased domestic inputs) tend to ignore the underlying and systemic inequity of the global political economy.  The Lancet Governance for Global Health Commission represents a recent and welcome exception to this selective blindness although some remain skeptical as to its capacity to truly influence the real financial players in this domain.


** The views expressed in this editorial are those of the authors and not their respective affiliated organizations.  You can follow any of the authors on twitter at:  @globalstopp / @abukurfi / @C_Birungi / @neggermont.



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