Highlights and Main Points Made by Individual Speakers and Participantsa
- Donors can be smarter and more catalytic with their investments by linking funds to domestic financing and demanding clear results. (Godal)
- Improving health systems requires attention to governance, including not only the government’s ability to react to a crisis, but its accountability and responsiveness to its citizens. (Adams)
- A well-run domestic financing system will both quickly improve fiscal space and lay the foundation for future progress. (Adams)
- New pools of money for development do not exist; only the relative importance of different funding streams changes over time. More efficient management, especially in procurement, could improve the value of the money available. (Ghosh)
- Limitations in the existing tracking mechanisms and inconsistent reporting by donors make it difficult to ensure accountability or target resources to real needs. (Hohlfelder)
- Strengthening public financial management systems can support preparedness and response, as well as primary health care. (Adams, Yadav)
- Describing poor health systems and the accompanying pandemic risk in terms of macroeconomic vulnerability could help translate those concerns to a different audience. (Ghosh)
- To ensure donor coordination, partners must clearly understand their specific roles and responsibilities, as well as who will lead each aspect of the response. (Godal)
a This list is the rapporteurs’ summary of the main points made by individual speakers and participants and does not reflect any consensus among workshop participants.
In the next session, a panel of representatives from four donor organizations discussed the constraints they face, the potential for new and existing funding mechanisms, and the need for better coordination and transparency among donors and other stakeholders in a health emergency.
Tore Godal of the Ministry of Foreign Affairs, Norway, described his country’s contributions to the Ebola response. Initially, Norway responded to requests from nongovernmental organizations (NGOs) such as Doctors Without Borders (MSF) and the Red Cross who were already active on the ground. Later it provided support to the World Health Organization (WHO), because of that organization’s key role in surveillance and data provision, and to the African Union, because of its commitment to supply health workers to the three affected countries. Norway also channeled funds through the United Nations (UN) Mission for Ebola Emergency Response, the body responsible for coordinating the UN response.
In early October 2014, with cases doubling each week and the U.S. Centers for Disease Control and Prevention (CDC) projecting potentially several hundred thousand cases by early 2015, Norway decided to fund a vaccine trial. They selected the riskiest vaccine, because it was the strongest, and the most difficult country, Guinea, where the epidemic was likely to persist the longest. A clinical phase III trial began in March 2015 with support from multiple partners, using a ring-fence design rather than a randomized trial, which MSF and the Guinean government had opposed. Six days after vaccination, there were no cases of Ebola among the 3,500 people who had been vaccinated, while there had been 16 cases in those who were not vaccinated. Because of the vaccine’s clear effectiveness, those running the trial decided to vaccinate the control group as well. Experts have hailed the vaccine as a breakthrough.
Godal emphasized Norway’s commitment to financing the prevention and response to outbreaks, but at the same time, the country wants to be smart with its contributions. This has meant increasingly linking to domestic financing and demanding results for its investments, which fall into four main categories.
First, he mentioned the Norwegian investment in research and develop-
ment, an area of competitive advantage for the country. Second, Norway supports the Global Financing Facility of the World Bank, which is directly linked to ministries of finance, not health, in International Development Association (IDA) countries. Godal estimated that linking their contribution to the results through payment for performance improved efficiency by about 20 percent, allowing health workers to deliver more and better care and supporting conditional cash transfers that enable the poorest women to come to the clinic. He saw that this method of support by supplying incentives could also be applied to preventative care. In pandemics, such incentives might be used to reward the first laboratories to identify a confirmed pathogen. Norway’s third main category of health spending is in health security. Through bilateral collaboration, the Norwegian Institute of Public Health works to strengthen public health institutes in Ghana and other developing countries. Godal noted that others have developed similar partnerships, and he saw promise in them, as the African Union has set a goal of having a CDC-type organization in every country on the continent. Finally, Norway is the third largest contributor to Gavi and a major contributor to the Global Fund. In order to mobilize the resources necessary to develop robust public health systems, Godal suggested consolidating work on infectious diseases, pandemic threats, and antimicrobial resistance.
Jennifer Adams of the U.S. Agency for International Development (USAID) explained that U.S. bilateral assistance in health is generally directed at essential interventions and priority populations (e.g., mothers, newborns, and children), and priority diseases such as tuberculosis, malaria, and HIV/AIDS. The agency tries to work in ways that help countries improve their health systems, but its ability to support health systems strengthening depends on the strength of the evidence linking such programs to improved health and on the willingness of the Congress to invest over the long term. In Adams’ estimation, they now have solid evidence of how health systems improvements benefit health.
The Ebola epidemic has drawn attention to the need for stronger health systems. Adams called Ebola a catalyst, highlighting the importance of investing in resilience, service integration, and interoperability. To support the response and rebuilding efforts, the Congress appropriated $66 million for health systems strengthening in the countries affected by Ebola, a move that Adams heralded as unprecedented.
There are challenges to building more resilient, higher-performing health systems, particularly in West Africa. One is improving governance. Adams described governance as not only the government’s capacity to mitigate the impact of future crises, but also its accountability and responsiveness to citizens. The Ebola epidemic revealed the importance of building trust between government and citizens. She also called attention to gender
imbalances, noting Ebola’s disproportionate toll on women and the critical role women will play in the recovery of their communities.
Adams expressed USAID’s commitment to working with all partners to build resilient health systems and to marshal new funds for doing so, such as the congressional appropriation for Ebola and the Global Health Security Agenda. She also saw domestic taxation as an important revenue source. In discussing taxes, she first asked whether pandemic preparedness should be considered a public good or a global public good, acknowledging that it may be both. The distinction is important because it raises the question of the relative responsibility of a country’s government and the international community for preparedness. If it is a public good, donors can still support greater domestic public spending to finance that good.
Adams described the current push for increasing domestic revenues, most recently articulated in the Addis Tax Initiative, signed in July 2015 at the Third International Conference on Financing for Development. Thirty countries and international organizations launched the initiative and signed a commitment to stop the billions of dollars lost every year on account of a narrow tax base, weak administrative capacity, poor tax compliance, and other problems with tax collection in poor countries. The signatories have committed to double technical cooperation and domestic resource mobilization by 2020. They also agreed to an agenda of policy coherence, a way to ease cooperation for international development.
USAID has been involved in projects that deal explicitly with tax administration and compliance for some time. Within its global health activities, the agency has been working with the ministries of finance and health in a small number of countries to increase domestic resources for health. To some extent, this requires expanding the overall size of the economic pie. For countries that have experienced considerable economic growth in recent years, a well-administered domestic financing system can provide immediate benefits, even as it lays the foundation for greater progress over time, Adams concluded.
Gargee Ghosh of The Bill & Melinda Gates Foundation explained that, early in the Ebola epidemic, the foundation provided rapid emergency cash grants to CDC, the United Nations Children’s Fund, and WHO. Then in September 2014, while continuing to disburse emergency grants, it announced about $60 million in grants focused on four priority areas. First, the foundation spent approximately $13 million to mobilize global organizations to accelerate their actions. Second, it invested almost $30 million in research on new interventions. Third, it devoted about $10 million to emergency operations centers in the three affected countries. Fourth, it helped bordering countries prepare for exposure and prevent the virus’ spread. She described the foundation’s role during the crisis as “providers of cash with deliberate, strategic intent.”
She pointed out, however, that the foundation avoided innovative finance tools like pledge guarantees because such mechanisms would have taken too long. Setting up a finance facility through public–private partnership takes at least 8 months, often longer. Contracts must be established in advance, Ghosh urged. Alternatively, donors could incorporate the most useful of these mechanisms into their regular practices so that they could be implemented more quickly.
Beyond the emergency phase of the Ebola response, the Gates Foundation has continued to support research and development of medical products for tropical diseases. They are also eager to translate the urgency people felt about the Ebola response into an urgency for health systems and primary health care. Ghosh said that a major priority for the foundation is building consensus in the global community about a core set of primary health care system indicators—that is, what constitutes a basic system that can both achieve routine functions and scale up in the event of an emergency.
Similarly, the Gates Foundation is investing in the Child Health and Mortality Prevention System, a network of data and surveillance centers around the world that are intended to support both routine service and emergency response. Starting in 6 countries, the system will eventually track child morbidity and mortality data in 20 countries. Ghosh framed the program as an investment in local capacity that could serve as a source of trainers during an emergency.
She expressed skepticism about the idea that large pools of new funds could be found for development. While the relative importance of different sources ebbs and flows over time, the pools themselves have not changed; they include domestic resources, private for-profit resources like foreign direct investment and capital flows, official development assistance, and out-of-pocket payments. Official development assistance has held steady at about $130 billion per year, with roughly 12 percent of that going to global health, a figure Ghosh did not expect to rise dramatically in the near future. She encouraged the audience to make better use of the funds available—for example, by reconsidering the cash-on-hand procurement model. In terms of domestic resource mobilization, Ghosh cautioned that improving the tax-to-GDP1 ratio by even a percentage point or two is extremely difficult.
She concluded by saying that routine preparedness must be a shared responsibility between donors and recipient countries; strengthening these systems will require a plan with clear targets. Emergency response, on the other hand, will be externally financed through the mechanisms discussed on the first day of the workshop.
While acknowledging the importance of mobilizing money, especially
1Gross domestic product.
early in the response, Erin Hohlfelder of the ONE Campaign explained that new challenges arose once the funds began to flow. She was particularly concerned with tracking pledges and disbursals and identifying the remaining gaps. It may be possible, she explained, to find information on a single donor’s contribution, but the information is collected ad hoc, preventing easy comparisons across sources. Donors’ inconsistent reporting and the limits of financial tracking tools only complicate the problem.
She described four different tracking systems used to monitor contributions to the Ebola response: the UN Office for the Coordination of Humanitarian Affairs (OCHA) Financial Tracking Service, a World Bank pledge tracker, the UN Special Envoy on Ebola’s consultant reports, and ONE’s interactive tracker for resource flows. All four mechanisms shared certain limitations, including understaffing and an overreliance on donor self-reporting. Relying on self-reports allowed for inaccuracies to be carried forward, with a false and confusing appearance of standardization. Furthermore, the different systems are obliged to track and report different information. For instance, OCHA’s Financial Tracking Service was designed to track only humanitarian flows, which do not include all kinds of assistance. During the Ebola epidemic, donors were simultaneously pledging humanitarian resources, in-kind contributions, health workforce contributions, long-term recovery functions, and research and development investments. None of these tracking systems followed the money from the pledge or disbursal to final spending. Even if such a system existed, she observed, donors might not report in sufficient detail to allow for that type of analysis.
Hohlfelder acknowledged that donor reporting on funding flows ranges widely. Some donors are very transparent and willing to work with groups like ONE to better track commitments. While a small group of donors provides intentionally misleading information, most are inconsistent in reporting not for malicious reasons, but because of poor coordination within the organization or government. Some donors report only on disbursements or only commitments, for example; they have different methods to account for in-kind contributions. Such discrepancies make true comparisons difficult. Accounting for absorptive capacity only complicates the equation, and she echoed Lelio Marmora’s observation that throwing money from an airplane is not the same as disbursement.
Hohlfelder emphasized that better tracking and accountability should not be seen as a dry accounting exercise, but rather as an opportunity to save more lives. She said that at the time of the workshop, more than 1.5 years into the Ebola epidemic, no one could accurately say how much money had been pledged or spent on the response, and this ignorance has hindered recovery. A common complaint during the outbreak was the need for more health care workers. But it was never clear where, or how many,
or what kinds of health workers were needed. It is difficult to support a solution without more specific information on the problem, but human resources flows are as hard to track as financial ones. A country might have committed to sending a certain number of health workers, but it remains frustratingly hard to count how many came or what work they did.
The information problem Hohlfelder described got in the way of donor coordination during the Ebola epidemic, hurting the response. Without a shared, real-time understanding of the gaps, these problems have lingered. She praised the Mano River Union Marshall Plan to rebuild Guinea, Liberia, and Sierra Leone, but saw challenges in determining what remaining emergency funds could be repurposed for recovery, as well as what funds represent new commitments, rather than money bilateral donors were already planning to spend in these three countries.
Hohlfelder emphasized that the push for accountability comes not only from international organizations like ONE, but also from local civil society groups. Activists in Guinea, Liberia, and Sierra Leone are eager to change their countries’ reputations for mismanagement; they want to hold people accountable for delivering services. A lack of reliable information gets in the way of translating such sentiments into action.
Some donors abuse the lack of transparency, pledging funds to the Ebola response that otherwise would have gone toward malaria, HIV/AIDS, or child immunization. They get credit for supporting the response when, in fact, their actions damage the larger global health effort that is critical for recovery, Hohlfelder said. Even journalists have found it difficult to obtain sufficient, good quality information about funding for the Ebola response. Some end up conveying misleading information based on the limited data they find; others give up entirely and do not write a story.
Acknowledging the scope of the problem, Hohlfelder once again emphasized the opportunity to develop a better system. In the run-up to the new Sustainable Development Goals, momentum has grown for a data revolution. Better data could give a more accurate picture of returns on investment and provide a stronger foundation for the risk modeling, insurance schemes, and other financing mechanisms discussed during the workshop.
In the question-and-answer session that followed, Prashant Yadav suggested that enabling public financial management systems to have greater agility, or cash velocity, is an often overlooked investment that could benefit both preparedness and response. Adams agreed that improving this agility is an important goal, but not something to do in the midst of a pandemic. Over the past few years, the USAID health program has been working with the ministry of finance and the ministry of health in Liberia on how the finance ministry releases funds to the health ministry to support primary health care throughout the country; USAID then provides funding based
on a results framework. Health experts tend not to have much experience with finance, so the program has involved a lot of mutual learning as USAID health staff learn the constraints on the ministry of finance. They then work with the ministry to address these issues. Under the program, the Liberian government has supported both public-sector health services and primary health care services provided by other organizations in the country. As such, it may serve as an effective model in emergency situations when responders include the private sector, civil society, and NGOs, in addition to the government.
Ghosh was more pessimistic about the prospects of public financial management for pandemic preparedness, saying that the solution must be more comprehensive. But improving public financial management overall remains a challenge. She added that more should be done to communicate the economic impact of health risks. Describing poor health systems and the accompanying pandemic risk in terms of macroeconomic vulnerability could help translate those concerns to a different audience.
Daniel Hanna of Standard Chartered Bank asked about the balance between creating new sources of money and building agile systems, at both the donor and country levels, that can harness existing sources in the right place at the right time. Switching from cash procurement to supply chain financing could help improve agility, but donors may lack the risk tolerance for such a move. The Gates Foundation, along with the Norwegian government and UK Department for International Development, has been trying to identify mechanisms that could balance these concerns with the need to procure products quickly. Ghosh repeated her earlier assertion that there are no new sources of financing; rather, the focus should be on developing mechanisms that can tap into these sources quickly for an emergency response.
Throughout the discussion, a number of panelists and workshop participants returned to the problem of donor coordination. Godal suggested learning from the response to earthquakes and other natural disasters, which happen more frequently. In those relief efforts, partners clearly understand their specific roles and responsibilities, as well as who will lead each aspect of the response. This ensures better coordination. Country leadership also plays an important role, and he encouraged the group to consider this when thinking about financing tools.
Hans Troedsson brought up the related issue of earmarking funds, highlighting the burdens that earmarks place on the recipients, including WHO; these burdens have financial implications and work against donor coordination. According to him, placing restrictions on how money can be spent impedes recipients’ ability to get the job done. Godal suggested that recipients could encourage less earmarking by improving accountability and reporting on results. Insufficiency in these two areas has pushed Norway
away from budget support and sector-wide approaches and toward earmarking funds.
Adams pointed out that, even within the U.S. government, coordination remains a major challenge. USAID’s Office of U.S. Foreign Disaster Assistance (OFDA) is the first responder in emergency situations, generally natural disasters. In the case of Ebola, a health emergency, OFDA had to work with many other government agencies, including CDC and the U.S. Department of Defense. When OFDA ran out of money, it had to borrow money from the general USAID development budget. The supplemental congressional appropriation, out of which OFDA repaid that loan, involved four different funding streams and a requirement to report to the Congress every 30 days. Tracking this funding requires a lot of work, which must be done by people whose attention is consumed by the emergency response itself. Coordinating and tracking contributions across donors only adds to the complexity.
Reflecting on the difficulty that ministers of finance face when they cannot account for donors’ activities, Ann Marie Kimball of Chatham House asked whether donors might consider establishing a code of ethics to improve transparency. Adams praised the idea, but noted that structuring such a code would be complicated. Nevertheless, it could help donors align with country plans and orient them toward strengthening health systems, down to the level of implementation. She suggested that this could be a good time to put something in place, building on the information and experience that has come out of the Ebola response.
A code of conduct is not the only way to achieve greater transparency. If better information would help donors make better decisions about how to allocate scarce resources, there could be a market- or incentive-based solution. Staci Warden described a solution to the information problem in bond markets. Financial institutions submit the price and volume of their trades to Markit, a financial information services company, allowing them access to the aggregate data of all other contributing institutions. Something similar might work for donor funding.
Adams and Hohlfelder cautioned that this information has many different audiences, and data transparency may take different forms according to the end users. USAID now puts all of its expenditure data on a publicly available platform called the Foreign Assistance Dashboard, but many of the agency’s partners still prefer to get that information directly from the local USAID office. Other interested parties, such as civil society groups, may not have the benefit of such close relationships. One big data portal will not necessarily fix the problem, Hohlfelder said, noting that the solution must be systemic. The quality and availability of data have serious implications for modeling risk and implementing the various financing tools discussed at the workshop.
Ghosh added that the data problem goes well beyond transparency, which has actually improved, and more attention should be paid to reporting results. Poor measurement methods make comparisons difficult even when donors are spending on the same thing.
Adam Bornstein proposed separating the response and the recovery efforts, especially when thinking about how to distribute resources. The response to a pandemic represents a global public good and could be accomplished somewhat easily, he argued. As evidenced by the Ebola response, the military possesses the capacity to respond quickly. Prequalifying the military to serve as a quick response team for epidemics might be an effective solution and, at least from the perspective of allocating funds, a simple one. Donors would then focus on the long-term rebuilding efforts, maintaining their systems as usual. But Godal objected to the suggestion that the military could be used as a first responder in all situations. Politically, that would not be feasible. Deploying the military should be seen as a last resort, he said, and even then, regional mechanisms like the African Union may offer a better solution.
Godal also disagreed with the distinction between public goods and global public goods: the responsibilities, and the financing, necessarily overlap. Rather than try to divide the available resources, donors should think about how to use them catalytically, he said. Building on this point, Hohlfelder talked about the pressures that governments face to justify their foreign aid budgets, however small they may be. Specific, measurable outcomes provide a more compelling case than long-term investments like health systems strengthening, which are hard to measure and to communicate. The health systems story may be best told in parts, Godal suggested—focusing on management, supply chains, human resources, or surveillance, etc., rather than talking about health systems strengthening. Disaggregating in this fashion could also give donor organizations a way to leverage their resources for building health systems. For example, Gavi might choose to focus on supply chains; the Global Fund might take on responsibility for surveillance and response.