The second annual IHP+ inter-agency country health sector teams’ meeting took place in Bamako, Mali on 15-16 June 2009.  At the meeting, IHP+Results presented the approach that we will use to independently review progress in implementing the commitments made under the banner of the IHP+ (as set out in global and country compacts).

The meeting was a good learning forum to find out how IHP+ is working, to discuss stakeholder concerns, and review developments since the meeting in Lusaka in February 2008 and the inception of IHP+ in September 2007.

Who attended?
•    IHP+ countries: 13 IHP+ countries, including Burundi, Ethiopia, Kenya, Mali, Nigeria, Zambia and Niger, Benin, Burkina Faso, Djibouti, Ghana, Rwanda and Uganda.
•    International organisations: 8 attended from AfDB, EC, GAVI, GFATM, UNICEF, UNFPA, World Bank and WHO.
•    Bilateral partners: 5 partners from France, Germany, the Netherlands, UK and Belgium.
•    Civil society representations: from Nigeria, Ethiopia, Kenya and global representatives.

Issues that were discussed
Over two days, the meeting discussed the following:
•    progress and future challenges,
•    the role of country compacts in enhancing mutual accountability,
•    how to assess country health strategies,
•    how to reduce the time and resources required to report on progress, and
•    the funding for health plans.

On the final day, priorities for action over the next 12 months were discussed for each country.

Throughout the meeting, there was a frank debate that centred on the different expectations of IHP+ stakeholders. This included what had the IHP+ delivered? What should it have delivered?  And what could it deliver?

The meeting took place 20 months after the launch of IHP+.  Therefore, signs of progress should be clear and evident.  However, it became apparent that not all attendees believed that there was a clear view of progress.  There was a call for greater transparency and specificity to enable signatories to be held accountable for implementing their IHP+ commitments.

Calls for accountability
•    African governments made unequivocal calls for increased and transparent health financing through the IHP+ to support the implementation of costed, national health plans.  They requested that funds should be provided in ways that work better for recipient governments: funds that are more flexible, not earmarked for “vertical” (disease-specific) programmes and, most importantly, predictable.  This is one of the acid tests for the IHP+, on which it will rise or fall.

Request for input: Can you help us identify evidence of where the IHP+ has led to increased funding, or more predictable or flexible funding?

•    Real scepticism was expressed by IHP+ countries about the prospect for behaviour change by international partners – change that the IHP+ principles should have instigated.  A disconnect between headquarters and country-offices was frequently highlighted, as was the ongoing high cost for a country of doing business with so many partners.  The need to reduce these “transaction costs” was a familiar refrain.  However, the difficulties of changing reporting requirements, of using country systems (eg for procurement and budgeting) – particularly in the current economic climate – was also underlined.

Request for input: What specific actions can IHP+ stakeholders take to ensure more routine use of country systems?

•    One interesting solution put forward is to use national plans as the basis for funding decisions (eg for the Global Fund, instead of requiring separate proposals to be written).  This will enable greater use of country systems and country ownership. To support this, a mechanism for jointly assessing the quality and credibility of national plans has been developed by the IHP+ Working Group on joint assessment.  Their work includes defining the qualities that a good plan should have and an assessment tool to define the quality of a plan.  The Working Group proposed an “independent” component to the assessment, but this was strongly rejected by IHP+ countries: independence did not mean external; and any process to “validate” national plans is unacceptable.  On the other hand, this kind of assessment could help build confidence and trust, increased funding and reduced transaction costs.  But the current proposal needs more work.

Request for input: What specific actions can IHP+ partners take to promote country ownership and strengthen accountability?

•    There was also another proposal to strengthen country systems, to reduce transaction costs on IHP+ governments, and to enable a stronger focus on results.   The suggestion is that all partners should use one set of manageable indicators and one monitoring & evaluation framework.  The Global Initiative to Strengthen Country Health Systems Surveillance (CHeSS) approach works along these lines and received some support.  Investing in health information systems was also stressed, and it was proposed to fund comprehensive routine health data collection on an annual basis.

IHP+ countries spoke of efforts taken to reduce their indicators, and the pressure they experience from donors to measure many indicators (Burkina Faso had indicated that they reported routinely on over 600 indicators).  It was suggested that each country could list how many indicators it monitors, how many separate donor missions it receives, the number of programmes it had to report on, and the different reporting formats.  This could play an important role in promoting transparency, accountability and could contribute to real behaviour change.

Request for input: What other specific actions could IHP+ signatories take to ensure changes in IHP+ partner behaviours?

•    There was ongoing discussion about the need to invest in strengthening health systems.  The Taskforce on Innovative International Financing for Health Systems (HLTF) and a recent paper in The Lancet underlined how health systems had received comparatively little investment over the past decade.  Efforts were needed to strengthen human resources in particular.

Request for input: What other specific actions can IHP+ partners take to strengthen health systems?

A resolution?
These are all important areas for action.  But they are not new; they were broadly discussed in Lusaka, and the IHP+ compacts already make broad commitments to achieve progress in these areas.

Whilst an annual international IHP+ meeting is useful for sharing experiences and providing fresh perspectives, the format and participants lend themselves to broad, big-picture questions. These are issues that are unlikely to change from year to year.  This contributes to the sense that the terms of the debate hasn’t change and that clear progress is lacking.

Our IHP+Results perspective
IHP+Results believes that the meeting underlined the importance of taking action at country level – not as a matter of principle (although this is of course important) but as a practical means to ensure that we prioritise the right things in the right order and can track and communicate progress better.

The challenges faced by each IHP+ country are diverse: each has different capacity, with different partners (who also have different capacity) and are at different stages of developing and implementing health plans.

We need to make sure actions are easier to define, track and use for accountability purposes.  The necessary behaviour change will be dependent on specific transactions being executed.  The challenge is to map out and then track the actions at this level.

IHP+Results can play a role in that process, but the IHP+ community has a key role to play.  Meeting participants raised questions about whether the IHP+ process could suffer another year where specific achievements cannot be identified.

We need your thoughts, feedback and input.  Please use the links to let us know what you think.