How to find more money has dominated discussions at global health gatherings this year as the precipitous 21% fall in development assistance over the past year threatens to unravel years of hard-won gains.

There is near-universal agreement that aid-dependent countries need to pay more for their citizens’ health, and that the donors need to become more collaborative and efficient.

Many also posit the idea that the financial crisis presents an opportunity to rearrange the global health “architecture” to ensure that low and middle-income countries (LMICs) drive their own destinies rather than their donors.

But exactly how to achieve all of this is less clear.

One new vehicle is the Health Works Leaders Coalition, launched last Friday by the World Bank, Japan, and the World Health Organization (WHO). It brings together health and finance ministers, donors, business, global health agencies and civil society to promote “investments in health systems as a strategy for economic growth, job creation, and improved resilience”, according to a media release.

The coalition stresses that it is “not a funding mechanism, but rather a coordinated effort to drive bold, high-impact action on health reform globally”. It is part of the World Bank’s Health Works initiative launched earlier this year, which aims to help countries transform their health systems to provide quality, affordable health services by 2030.

“Our goal is ambitious: to help countries deliver quality, affordable health services to 1.5 billion people by 2030. No single institution, government, or philanthropist can achieve that alone,” said Ajay Banga, World Bank president. 

“But with aligned purpose and shared effort, it is possible. If we get this right, we can make real impact – improving health, transforming lives, strengthening economies – and creating jobs. This effort is as much an ingredient of our jobs agenda as it is a health initiative.”

The countries that make up the coalition are Egypt, Ethiopia, Indonesia, Kenya, Nigeria, Philippines, Sierra Leone, Saint Lucia and the United Kingdom.

Health Works is linked to three World Bank backed funds: the Health System Transformation & Resilience Fund (HSTRF), the Global Financing Facility, which focuses on strengthening primary health care to reduce deaths of women, children, and adolescents, and The Pandemic Fund, which provides financing for pandemic prevention, preparedness, and response. 

However, at last week’s World Health Summit in Berlin several global health actors acknowledged that there needed to be fewer agencies and funds.

“I do think we’re actually going to have to reduce the number of entities,” Peter Sands, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, told participants. “The system is too fragmented. There are too many underfunded institutions. There’s too much duplication. It’s too complex. That diagnosis, I think, is pretty straightforward.”

Expanding tax revenue

According to World Bank vice-president Mamta Murthi, countries need to spend $50 to $60 per person per year for a basic health package, but low-income countries (LIC) spend about $20, and for many, around half of this comes from donors.

Countries need to expand tax revenues and engage in domestic resource mobilisation, “including through better tax policy and better tax administration, and that includes health taxes”, Murthi told a discussion hosted by the Center for Global Development (CGD) at which key development leaders discussed sustainable solutions to the health financing crisis.

“The second thing that they can do is make health more of a priority in their budgets,” she said, adding that around a third of low and low-middle-income countries could allocate more to health with the fiscal conditions that they have. 

“And I don’t think they should just look at health taxes. There are lots of other things that they spend on, which don’t deliver a bang for the buck, and some of them are harmful to health. Let’s think of fossil fuel subsidies.”

In addition, it is also “shocking that, on average, about 10 to 15% of resources that are allocated for health spending don’t get spent,” she added.

However, she said the Bank is encouraged by countries presenting “compacts”– country vision statements with “asks” to the donor community, setting out what they need from development agencies to reach their goals and targets.

“I feel very encouraged by the leadership that the countries are showing… they have goals and targets in terms of accessibility, affordability, job creation that ensue from the full implementation of these compacts.”

The end of ODA?

Sania Nishtar, CEO of the vaccine alliance, Gavi, declared: “We are seeing the beginning of the end of overseas development aid (ODA).”

Gavi Leap, the platform’s reform plan, is “preparing for this future” by ensuring that countries have greater ownership and agency, and are more effective in this resource-constrained environment, said Nishtar.

Gavi is accommodating countries’ requests for more decision-making agency, quicker turnaround, less administration and vaccine sovereignty, she added.

“End-to-end digitising” will simplify and speed up the grant process, while Gavi’s support for , the African Vaccine Manufacturing Accelerator aims to “catalyse sustainable vaccine manufacturing on the continent”.

“We are speaking to our colleagues at the World Bank and other international multilateral development banks, and we have put in place what is called the MDB [multilateral development bank] Multiplier” to “unlock concessional lending for countries”.

Catalysing investment

Hitoshi Hirata, vice-president of the Japan International Cooperation Agency, said that at the Financing for Development (FfD4) meeting in Sevilla in July, partner countries had committed to expanding domestic revenue for health, particularly through health taxes.

“We would like to support health financing, and also link with existing public finance management efforts and tap domestic and private resources,” said Hirata.

The resulting Sevilla Commitment proposes concrete steps to catalyse investment in sustainable development, address the debt crisis affecting the world’s poorest countries  (three billion people live in countries that spend more on interest payments than on health),  and give developing countries a stronger voice in the international financing architecture.

The Japanese government is hosting a Universal Health Coverage (UHC) High-Level Forum in Tokyo in December, at which various countries will launch their National Health Compacts.

These are “government-led agreements that will lay out bold reforms, investment priorities, shared accountability and unlock resources for expanding access to quality, affordable health care”, according to a media release.

Strong country leadership

Wellcome Trust CEO John-Arne Røttingen warned that the “abrupt changes to the international financing environment” will result in many lives lost and worsen the global burden of disease.

But he is “optimistic” that the loss in financing will result in “stronger country leadership, supported by multilateral development banks and major bilateral donors”.

“Countries are demanding that they need to be in charge – with a one country, one plan, one budget, one monitoring approach,” said Røttingen.

“And I’m hearing commitment now from almost all big external financing agencies – the dedicated GHIs, the Global Fund, the World Bank, and the other multilateral development banks and the major bilateral donors – that signals a global moving towards empowering and also making countries responsible for delivering.”

Wellcome Trust is also supporting global and regional discussions on “reimagining the global health architecture”, which kicked off with papers on the subject written by five thought leaders.

Its motivation is to find long-term solutions to the crisis in global health that involve “more regional and national accountability and less dependence on the priorities of donors from high-income countries”. 

But Røttingen cautioned that devolving too much to country governments might reinforce the priorities and norms of undemocratic governments that could be contrary to human rights.

“There needs to be very strong transparency and the voice from civil society and different groups”, he noted, adding that positive lessons from different regions where things are working