International Development Committee: Aid Effectiveness Inquiry
Action for Global Health (AfGH) is a UK-based network of more than 50 organisations working towards a world where the universal right to health is realised. AfGH acts as the coordinator between the UK government and global health civil society, convening regular meetings and sharing learning from across our network.
The UK government’s global health overseas development assistance (ODA) is split across multiple government departments, including the Department for International Development (DFID), Department for Health and Social Care, Department for Business, Energy and Industrial Strategy and the Foreign and Commonwealth Office. Additionally, other government agencies (such as Public Health England) provide non-financial, technical support on global health issues, and decisions made by other government departments also have a significant impact on global health outcomes (eg. Department for Environment, Food and Rural Affairs and Department for International Trade).
Whilst the UK Government has a body for overseeing ODA to health, the global health oversight group, the internal objectives and line of responsibility for this group are not publicly available.
Further to this, the UK government does not have a dedicated, public strategy – or any current comprehensive document - guiding its work in global health. If the 2015 UK aid strategy is now outdated, then the last strategies issued by the UK Government focused on global health are even more so. Health Is Global – A UK Government Strategy 2008-13 is the last complete strategy document which covered the UK’s global health work and was widely considered to be an innovative model of cross-departmental collaboration. Since this strategy expired in 2013, the UK government (including DFID) have stated repeatedly that they do not plan to publish a new global health strategy, despite calls from the International Development Committee for the government to develop a global health strategy as long ago as 2014. The call for a global health strategy is supported by other notable individuals, such as the former Chief Medical Officer Sally Davies in her final report, where her first recommendation to the UK government was that they ‘publish a set of shared global health objectives as soon as possible and publish a renewed shared global health strategy by the end of 2019’.
We believe that it is essential that the UK government has a coordinated and targeted approach to global health, and that this is best articulated through a global health strategy. A global health strategy is essential because:
1). It outlines and delivers synergies that will increase the impact of the UK Government’s work across global health, improving outcomes and securing better value for money. It improves outcomes both within government departments (for example, aligning global health investments with other intersectoral issues, such as nutrition, SRHR, WASH and governance, or having a more coherent strategy for transition through both multilateral and bilateral global health spending) and across government departments (eg. across DFID, DHSC, FCO etc). In the case of the latter, a strategy could be a critical element in improving cross-departmental learning, as examined in the latest ICAI report on ‘How UK Aid Learns’.
2). It reflects the priority that the UK Government places on global health to external and internal stakeholders, as well as establishing departmental priorities for their global health investments.
3). It creates a roadmap for the UK’s role in delivering SDG3 and Universal Health Coverage by 2030, both of which they have publicly committed to achieving, as well as providing greater alignment with broader global health commitments (eg. SDG3 Global Action Plan, Universal Health Coverage Political Declaration).
4). Without a strategy and published objectives, it is impossible to hold the UK Government accountable to how well these are being achieved through their global health ODA portfolio, for example through International Development Committee inquiries.
Additionally, it is also worth noting that the need for a global health strategy is further accentuated by the delays in other significant documentation around the UK’s role in global health. A Health Systems Strengthening Position Paper has been under preparation for over four years, but no date for publication is as yet confirmed. The government and DFID had additionally recently begun work on a new Ending Preventable Deaths Action Plan but the publication was postponed due to COVID-19 with no clear timeframe of when the Plan will be made operational or commitment to publish a detailed framework. The UK has also discontinued publishing strategies or positions on specific disease areas, such as HIV and AIDS (since 2015), so a global health strategy would also set out the UK’s commitments on priority disease and/or thematic areas.
In order to improve the targeting and accountability of global health spending, Action for Global Health recommend that the UK government publish a comprehensive, cross-government global health strategy covering all UK government health ODA spend, and ensure that this will deliver against SDG 3 and towards achieving UHC. We also recommend that the UK government publish the Health Systems Strengthening Position Paper and Ending Preventable Deaths Action Plan as soon as possible.
Compared to 2010, when almost all health ODA was delivered by DFID, 2018 saw much more aid administered by other government departments. Spending outside of DFID now accounts for a fifth of all UK health ODA.
The UK committed to developing more of a cross-government approach in their 2015 Aid Strategy, delivering more aid outside of DFID, and developing a number of cross-government funds. This decision has been contentious; the International Development Committee (IDC) 2018 inquiry found that spending ODA outside of DFID creates inherent risks in terms of coherence and transparency across ODA investments, as well as the UK ODA’s poverty reduction focus. The IDC found that spreading spend across Whitehall raises concerns over some ODA programmes duplicating or even contradicting others. Additionally, Publish What You Fund’s aid transparency review found that DFID and DHSC were the only UK government departments ranked as ‘very good’ for transparency of aid spending. Weaknesses in the transparency of aid spending risks undermining the UK’s proud record on aid accountability and damages public trust in aid.
Experience from previous countries that have undergone a merger between international development and foriegn affairs departments show us that mergers do not guarantee effectiveness in delivering impact or value for money and can result in development interests becoming side-lined in favour of commerce and foreign policy objectives. The coronavirus crisis has shown us that global cooperation and a joined-up, values driven approach to international development and foreign policy are more vital than ever, however, this must not come at the expense of effective, transparent aid spending for the most in need.
As such, Action for Global Health recommends that the Department for International Development remains an independent department (with a Cabinet-level Secretary of State) and oversight for all health ODA, and its expertise and reputation in global health maintained.
The cross-government Prosperity Fund is explored further in a case study below.
Case study: Prosperity Fund’s ‘Better Health Programme’
The Prosperity Fund is a joint initiative across UK government departments. The following departments are active in the Better Health Programme: Foreign and Commonwealth Office, Department of Health and Social Care, Department for International Development, Department for International Trade. The programme is led by the Foreign and Commonwealth Office and oversight of the Prosperity Fund across government is provided by the Joint Funds Unit under the Cabinet Secretariat.
The Better Health Programme (£79.3 million) of the Prosperity Fund will invest in tackling non-communicable diseases in eight countries, through helping partner governments to develop strategies and guidelines to develop and treat NCDs, providing training for primary and secondary care providers, and supporting research and development partnerships.
While the Better Health Programme is in its implementation phase, a 2017 ICAI rapid review raised significant concerns in relation to the Prosperity Fund more broadly; ICAI highlighted that the expected speed of implementation of the Fund’s programmes risked compromising delivery, and that the initiative lacked transparency. The UK parliament’s International Development Committee (IDC) has since raised grave concerns about the Fund’s business focus, stating that ‘the heavy emphasis of the Prosperity Fund upon promoting UK trade risks losing the rightful emphasis of the Fund upon the primacy of poverty reduction, and is a step towards the return of tied aid’. Apart from a commitment to promote more equitable health outcomes and integrate a poverty-sensitive approach, the Better Health Programme does not make clear how it will guarantee that public health needs will be prioritised over business interests in its interventions, or how it will ensure people in poverty see no increase in healthcare costs resulting from its activities.
As recent months have shown through the Covid-19 pandemic, the health of people globally is interconnected and indivisible. Investments in global health, such as strengthening health systems, investing in health workers globally, and health research and development, positively influence the health of people everywhere, including the UK. Health challenges are global issues, and as such can only be tackled through global cooperation and coordination. In the UK and globally, skills, expertise and resources from across development, health, foreign, and defence sectors are needed to be able to deliver sustainable solutions to global health challenges.
The UK is the third largest international aid donor, and as such has the opportunity to play a leading role in multilateral coordination, working with others to build a framework for the international system that can produce mutually beneficial solutions to global challenges in ways that address longstanding disparities afforded to people around the world. The danger is that narrow, short-term self-interest will continue to set the policy agenda, ultimately to the detriment of the UK, it’s standing in the world, and international development objectives. Narrow economic self-interest has no role to play in the targeting of UK aid and co-opting development assistance to secure trade deals will only serve to undermine the effectiveness of UK aid and ultimately weaken the UK’s influence in the world.
In international development, and particularly in global health, a values-led approach is best manifested by maintaining the primacy of poverty and inequality reduction as the guiding principle behind development assistance. In 2015, the UK Government joined other countries in making a commitment to development that leaves no one behind with the adoption of the 2030 Agenda for Sustainable Development. Five years on from the agreement of the Sustainable Development Goals (SDGs) as the framework for delivery, there are critical gaps in the UK’s own policy, programming and political commitment to implementing them. These gaps were made evident in the UK’s first Voluntary National Review (VNR) in 2019. There have been repeated calls for the UK government to establish a Cabinet level position which would have oversight of the UK’s delivery against the SDG portfolio both domestically and internationally. The UK Government should ensure that ODA is completely focused on poverty eradication and reducing inequalities, and reverse approaches to spending aid through other government departments or “in the national interest” where this is not the case.
Case study: Covid-19
Roughly one-third of hospitalised patients with coronavirus need intensive care. For many countries, responding to this need through existing health systems will be impossible. Tanzania, for example, has just 1 doctor for every 30,000 patients, while most African countries have less than 20 ICU beds for their entire populations. Not only will the virus be more difficult to contain, but the ability to care for those infected is severely limited.
Investing in health workers worldwide, as well as providing adequate protective equipment and other essential medicines helps prepare low and middle income countries to deal with the immediate threat of Covid-19 and avoid thousands of preventable deaths. But these investments are also critical if we are to emerge from this crisis with health systems that can effectively respond to future outbreaks. We are only as strong as our weakest health system.
According to the WHO at least half the world’s 7.6 billion people cannot access the essential healthcare they need even in normal times, and now many are facing financial barriers to accessing testing and treatment of Covid-19. It is essential that free, universal public healthcare is central to short and long term UK aid efforts. In the immediate, the UK should encourage countries to utilise all private healthcare facilities to increase capacity to treat and care for infected patients and to meet ongoing essential health needs generated by Covid-19.
The pandemic has also re-confirmed the vulnerabilities women and girls face in crises, particularly because of heightened exposure due to over-representation in the healthcare sector, but also because of the unequal care burden rooted in gendered social norms, and the increase in gender-based violence. More than ever, a robust, gender-responsive approach to global health is needed. As outlined in the International Development (Gender Equality) Act 2014, ODA should consider how it can contribute to reducing gender inequality including taking into consideration gender-related needs in humanitarian assistance.
 ‘…a global health oversight group, convened in 2016, with representatives from DFID and DHSC. It oversees global health policy and programming of mutual interest between government departments, including the cross-government response to global health threats. However, formal accountability for global health security programming lies with individual departments.’ Independent Commission for Aid Impact (2018), The UK aid response to global health threats, available at: https://icai.independent.gov.uk/html-report/global-health-threats/
 International Development Committee (2014), International Development Committee – Fifth Report. Strengthening Health Systems in Developing Countries, available at: https://publications.parliament.uk/pa/cm201415/cmselect/cmintdev/246/24602.htm
 UK Government, ‘Annual Report of the Chief Medical Officer, 2019’, available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832948/annual-report-of-the-chief-medical-officer-2019.pdf, summary p.8.
 2018 spending via seven government departments accounted for £267 million of health ODA, with the remaining £1.056 million spent via DFID.
 HM Treasury and DFID (2015) op. cit.
 UK Parliament International Development Committee, (2018), Definition and administration of ODA inquiry, available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmintdev/547/54702.htm
 Publish What You Fund, How Transparent is UK Aid? (2020), available at: https://www.publishwhatyoufund.org/wp-content/uploads/dlm_uploads/2020/01/How-Transparent-is-UK-Aid_Digital.pdf
 ODI, Merging development agencies (2018), available at: https://www.odi.org/sites/odi.org.uk/files/resource-documents/11983.pdf
 UK Government Development Tracker, ‘Better Health Programme’, and ‘Prosperity Fund business case: Better Health Programme’, available at: https://www.gov.uk/government/publications/better-health-programme
 ICAI (2017), Report: The cross-government Prosperity Fund. An ICAI rapid review, 7 February 2017.
 UK Parliament International Development Committee, (2018), op. cit.
 UK Government, Prosperity Fund business case: Better Health Programme’, available at: https://www.gov.uk/government/publications/better-health-programme