BERLIN, Germany — Speaking to a crowd of African entrepreneurs in July, World Health Organization Director-General Tedros Adhanom Ghebreyesus emphasized the need for greater investments in Africa's health care systems.
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"Health is the foundation for the dynamic and prosperous Africa we all want to see," he told the audience at the Tony Elumelu Foundation Forum in Abuja, Nigeria. "Health enables people to learn and earn, to start businesses and to thrive. Health creates jobs. It drives productivity. It stimulates inclusive growth. And it protects economies from the impacts of outbreaks and other emergencies."
Tedros could just as easily have been talking to donors or domestic governments. At budget debates and investor pitches, alike, leaders of the global health architecture are increasingly eager to frame health funding as a capital investment. And it is central to the case for domestic financing for universal health coverage — the idea that now dominates the global health agenda and has earned its own high-level meeting during the September United Nations General Assembly.
The upcoming meeting in New York raises questions about the implications of positioning health financing as an investment, including whether that approach aligns with the vision of inclusive health services that is at the core of UHC and whether it can guarantee sustainability given the political reality that governments often prize investments that offer more immediate returns.
Failure to translate commitments into budgets
Governments have traditionally been happy to sign international agreements to uphold the right to health.
There are 170 state parties to the 1976 International Covenant on Economic, Social and Cultural Rights, which obliges them to provide "the highest attainable standard of physical and mental health." Thirty-nine years later, nations rallied around the Sustainable Development Goals, which places UHC within the broader goal of ensuring healthy lives and promoting well-being for all ages. By 2014, a year before the SDGs were ratified, 88% of countries had written some kind of aspiration to or guarantee of the right to health into their constitutions, according to the World Policy Center.
However, those commitments rarely appear on budget lines.
The 2001 Abuja Declaration, which compelled African Union governments to spend at least 15% of its annual budget on improving the health sector, is one of the highest-profile attempts to put an actual figure on the right-to-health aspirations. While WHO reported in 2016 that most African countries had increased their spending on health in the intervening 15 years, less than half of the governments actually met the target in any given year, according to 2016 research from the ONE Foundation.
"The spirit of human rights declarations and covenants runs up against government's reluctance to feel obliged to live up to these standards and principles they've signed up to and ratified," said Paolo de Renzio, a senior research fellow at the International Budget Partnership, who has written on equity and justice in budgeting.
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There is no real international mechanism to enforce any of these covenants or agreements, though the World Bank’s human capital index, first published last year, is attempting to quantify how much governments are spending on human capital in a bid to spur government investments in health and education. And while some civil society groups in places as varied as Colombia and Uganda have tested the justiciability of these agreements domestically with varying degrees of success, domestic advocacy efforts to hold executives accountable for their global commitments have been inconsistent.
The result, de Renzio said, is that "there are few, if any, governments that remotely mention human rights in their budget speeches or criteria to develop fiscal policy or take budget-related decisions."
Shift to ministers of finance
No wonder then, that the global health community shifted its focus to ministers of finance, who they recognize as the brokers of budgetary power. And they tailor their arguments to those officials' priorities, including fiscal responsibility and economic growth.
"Ministries of finance recognize that they should pay attention to health," said Maxwell Bruku Dapaah, senior governance specialist with the World Bank and the former co-lead of the UHC2030 secretariat. "At the same time, they also want the health sector to demonstrate that it's worth investing in." Which is why global health advocates began encouraging ministries of health to learn the language of the finance ministry and, as Dapaah said, position health financing not as a recurrent expense, but as a capital investment — the approach Tedros deployed in his July speech.
As part of the USAID-funded Health Finance and Governance project, Jeremy Kanthor of global development firm DAI helped create a toolkit published in 2013 to help ministries of health work with ministries of finance.
"The idea was to look at things that were happening and try to provide some easy and practical guidance around that," said Kanthor, DAI's vice president of governance. The toolkit guides health officials to assess their efficiency, to identify key performance indicators, to set internal controls, and to use these assessments to evaluate the strengths and weaknesses of the health sector as a whole.
Even with these resources, it's not clear this strategy has been any more effective than orchestrating high-level agreements.
Though impossible to disentangle the specific impact of a ministry of finance-friendly case for investing in health from other influences, health funding has not become a priority since that approach emerged as the dominant strategy for increasing domestic financing.
An evaluation of global health financing trends by the British Medical Journal earlier this year concluded that government spending on health is rising, though it is the result of overall economic growth and fiscal expansion and not budgetary prioritization. And between 2000 and 2016, low-income countries actually became more reliant on official development assistance for health.
Rights-based approach to health
Amid the campaign for UHC, advocates of a rights-based approach to health financing see an opportunity to re-evaluate the framing of that funding as an economic imperative. Particularly the issue of whether it is even suited for that push, given that UHC is rooted in equitable access to health services.
"The human rights approach is very much about equity, about equality, about protecting, respecting the rights of everybody and prioritizing those who are most marginalized," said Mariska Meurs, a global health advocate with the health-focused civil society organization, Wemos. "Those are not the groups you reach first when you're talking about returns on investment."
There may also be financial advantages to reorienting the funding discussion around human rights commitments, Meurs said. It disentangles health budgets from politics, which is significant, because these "are not investments that will materialize within a couple of years," she said. "Also not within one election cycle. This requires a longer-term vision."
It also links demands for health expenditures to a broader rights-based discussion around how to expand government resources outside of a singular focus on economic growth. That includes campaigns to end tax avoidance and discussions around increasing corporate tax rates, which could increase domestic revenue.
Whether this approach takes hold may no longer rest on high-level political declarations, Meurs said, but the effectiveness of a grassroots movement that was lacking in the past. Political leaders "have already made commitments," she said. "Now we're calling on them to live up to those commitments."
Experts on effective budget strategies acknowledge the potential for a more central role for rights-based advocacy, while cautioning that there is no singular approach.
Officials with the Inter-Parliamentary Union, who work with parliamentarians around the world to strengthen their budget oversight capacity, told Devex that it has seen receptivity to both the economic case — and particularly evidence of efficiency — but also to rights-based arguments. And Japan's Finance Minister Tarō Asō emphasized in a 2017 Lancet commentary that finance ministries will be deeply involved in any efforts to achieve UHC, even if advocacy for funding shifts to other targets, so the ability of ministries of health to work effectively with those counterparts will remain useful.
"As with anything, it's a combination of things," de Renzio said. "There's not one approach that's likely to deliver any answer."
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