University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham, B18 6QH, England
Despite increased global aid for development and health - from 5.6 billion United States dollars (US$) in 1990 to US$ 21.8 billion in 20071 - donors and wider society have become sceptical about the benefits of this aid. This is reflected in a call recently issued by the Bill and Melinda Gates Foundation's Grand Challenges Explorations programme for innovative ways to better convey to the public the benefits of global aid.2 Poor tracking of programme outcomes and of funding for global health by both donors and recipients, a problem widely recognized, contributes to the growing doubts.3-4
A United Nations High Level Meeting (UNHLM) held in September 2011 focussed attention on noncommunicable diseases (NCDs).5 Almost two thirds of all deaths in the world are caused by NCDs, many of which are preventable,6yet NCDs have received relatively little attention and funding.7 They were excluded from the Millennium Development Goals.8 Although the lack of measurable "hard" outcomes (e.g. targets for reduction in mortality or increased access to medicines) emanating from the UNHLM disappointed many, media coverage of the meeting undoubtedly put the spotlight on NCDs.
Encouragingly, the UNHLM revealed singularity of purpose across the global health community.5 Participants agreed that identifying common NCD risk factors and integrating approaches for NCD control are crucial, but saw as the greatest challenge the implementation of broader health system changes in low- and low-middle income countries to produce more sustainable, long-term effects.5-6 Failure to learn from the past and to scrutinize the factors currently hindering efforts to control communicable diseases and improve maternal and child health, including non-transparent tracking of programme funding and finances, will undermine efforts to combat NCDs. Better metrics and improved monitoring and reporting of health outcomes, funding and finances will facilitate programme success.
NCD control and monitoring of programme funding should occur at the country and regional levels, since insufficient data on global health financing makes comprehensive auditing of funds nearly impossible. On a global scale, reported increases in health funding may be overblown and there may be no way to know whether the funds really reach the intended recipients.3The shaky economy may lead to reduced health aid for several countries and create the need for improved monitoring and efficiency.3,4 There are also potential conflicts of interest among the many parties involved in the multi-billion dollar industry that global health represents.4 When Sridhar & Batniji tracked funding from the major global health donors, such as The World Bank and the Global Fund, they found that "the pluralism of global health institutions and the informal alliances on which power in global health rests make a unified and fully coordinated health system highly unlikely".3 Inadequate coordination and bureaucracy have plagued global health aid and the NCD community must take heed. Lessons can be more widely shared and previous mistakes more easily avoided through coordination of methods and data across countries. New efforts to control NCDs should be worked into the existing health-care infrastructure and global programmes.7
Transparency in funding, programme delivery and outcome data, as well as local ownership, will enable improved monitoring and a global health architecture actively prepared for change instead of passively reactive to it. The data collected by donors and aid recipients on the global burden of disease and on financing requirements must be standardized to enable monitoring and comparisons across health programmes and systems. Common data gathering mechanisms for all diseases and global health programmes, as well as improved monitoring of the data furnished by both funders and recipients, will ensure better tracking of finances, resources and, ultimately, outcomes. This will in turn heighten accountability and responsibility on all sides. Country-level ownership of NCD programmes will make governments and local players more inclined to "buy into" policy-making and planning and will put financial and outcome data within the public's reach.
Despite a call for "a quantitative, scientific framework to guide health-care scale-up in developing countries",9 the scale-up of NCD prevention and treatment programmes is hampered by lack of measurable targets and disagreement on the policies and interventions required. Evidence-based global health interventions relevant to low- and low-middle income settings sometimes conflicts with quick, pragmatic policy-making.10 New research is necessary to design the best evidence-based policies for the control of NCDs, but a thorough understanding of the policies' sociopolitical and cultural ramifications should underlie their design and implementation.10 Importantly, inadequate tracking and non-transparency of NCD programme finances, funding and outcomes detract from programme acceptability in social and political spheres.
In summary, reliable monitoring of funding is required, since without it, the empirical research and data to shape NCD policy-making and scale up NCD programmes will be shaky from the outset. The importance of studying the lessons learnt from yesterday's and today's global health programmes cannot be over-stressed. Finally, intra- and inter-national cooperation is fundamental when designing and implementing NCD-related policies, and although both donors and recipients are responsible for tracking funding, neutral parties such as the World Health Organization have a key role to play.
Available at: http://www.who.int/bulletin/volumes/90/7/12-108795
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