Global Health Governance: Funding and Accountability

This week’s readings discussed the plethora of actors and agencies involved in global health, including, e.g., the World Health Organization, donor governments, multilateral organizations and IFIs, the private sector and more. In fact, in 2008 there were more than 40 bilateral donors, 26 UN agencies, 20 global and regional funds and 90 global health initiatives1 – which of course does not include the countless NGOs also active in the health arena in low and middle income countries. According to Sridhar, “the current landscape is characterized by fragmentation, lack of coordination, and even confusion”1 (pg. 460).

Significant portions of the budgets of some of the poorest countries with arguably the greatest needs are financed by donors – including a full 30 percent of the health budgets of 23 countries, as reported by WHO. Unfortunately, developing countries, with the most at stake, are underrepresented in decision-making at all levels. Donor governments and agencies tend to act and spend according to their own agendas and priorities rather than those of the countries receiving funds, which can serve to undermine existing health systems and national health plans. Furthermore, donors are generally held accountable to external entities (e.g., USAID is accountable to the U.S. Congress), rather than the recipient governments1 and certainly not to the intended beneficiaries – the people living in the country. In this context, many steps must be undertaken by all stakeholders to improve country ownership of health and development as well as health outcomes for individuals and communities in developing countries. One aspect that I will look at more closely here is information and data provided by donors to recipient governments.

There is a widespread lack of information-sharing regarding funding streams and health financing as well as service provision and outcomes funded and in many cases implemented by these external actors. According to Sridhar and Batniji,2 funding disbursements from donors are not systematically tracked, and the data that is available is often of poor quality and not standardized. In addition, some donors disburse funds primarily to NGOs rather than governments. As a result, governments often lack information about where funding is going, what services are being provided, and what programs are successful, which serves to inhibit effective planning. In this (highly recommended) presentation, Owen Barder from the Center for Global Development provides one example of what can happen under these circumstances: a ministry of health employee in Malawi struggled over where to locate health clinics because no information was available regarding NGO, PEPFAR and other donor activities; the official essentially had to guess where their services were being implementing in order to avoid overlap and the wasting of scarce resources. Situations such as this lead to underserved communities and lack of access to healthcare services.

Moreover, data gathered by donors that implement programs in developing countries is not always shared with the recipient government or with others active in the field. These agencies would provide more efficient and potentially higher quality services if they improved information coordination with each other and with the national government. Governments could use data collected regarding the populations being served and program outcomes to coordinate planning. Agency-to-agency coordination would help avoid overlap in service provision and potentially help agencies to fill service gaps. In the presentation referred to above, Owen Barder provides another local example of the consequences of this lack of information-sharing – communities in which children were vaccinated against measles three different times in campaigns run by different organizations. This not only again wasted scarce resources but also could have endangered the children who received the multiple vaccinations.

Ultimately, there is a great need for transparency and accountability in donor financing and activities. Developing countries will likely struggle to develop and implement health plans and policies that effectively respond to national and local needs and realities if donors undermine them by withholding information and financing competing interests and agendas. Governments furthermore cannot plan effectively without knowledge of the programs that are being implemented on the ground. As quoted in Sridhar and Batniji,2 one minister of health stated that donors “like to monitor activities, but they do not like to be monitored and evaluated” themselves (pg. 1190). The authors call for standardized reporting of funding streams that is accessible to the governments and the public of developing countries, and a move toward decision-making based on the needs of the recipient countries, in line with the Paris Declaration. The 2005 Declaration calls for donors to respect the leadership and ownership of recipient countries in the development process, align and base their support on countries’ national development strategies and to work in a transparent manner. The international community has not yet lived up to the rhetoric of this declaration. In the meantime, there are other initiatives to enhance transparency among donors. The International Aid Transparency Initiative, for example, described in more detail in the aforementioned presentation, is an online database that enables decentralized coordination and information sharing using a common data format. Many donor governments and agencies have signed on to this project, which is fairly new. It seems like it is a step in the right direction.


1. Sridhar, D. (2010). Seven challenges in international development assistance for health and ways forward. Journal of Law, Medicine & Ethics, 38 (3), 459-469.

2. Sridhar, D. and Batniji, R. (2008). Misfinancing global health: a case for transparency in disbursements and decision making. The Lancet, 372 (9644), 1185-1191.


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