Expanding progress, or expanding market access?
The failure of DfID to expand healthcare to the world’s poorest
Under the tenureship of Justine Greening we have seen a fundamental change in the way DfID operates. Despite the claim from her much-maligned predecessor, Andrew Mitchell, that “there is not a Conservative, Liberal-Democratic or Labour development policy but a British one”, there has been a fundamental pole shift in DfID’s ideology. Whereas policy-makers once led with more independence in setting British aid strategies, there has been a change to economic development as a means of poverty reduction or, put simply, “aid for trade”. This has practically meant a shift away from government-to-government advisory partnerships, to business-government advisory, even in social sectors such as health.
DfID’s existing welfare-oriented approach remains important but was not seen by Greening as enough. DfID, she said, was adopting a “frontier economy strategy”. Growth, she argued, was the best long-term solution to poverty, and helping to develop the next generation of rapidly-growing economies would be good for British trade and finance. This alone is not a contentious fact — it goes without saying that economic growth helps take millions out of poverty, improves health indicators for rural, marginalised communities in the Global South. What must be questioned of this the ambition of the approach, and whether it is being coordinated in the most effective ways.
Despite Mitchell’s claims during his time at Whitehall, DfID’s present strategies are inherently Conservative, for aid can never truly be neutral. This approach favours the advancement of the private sector in many areas of public services, without recourse to expanding the provision of these services to populations at large. To this effect, DfID talks about strengthening healthcare systems in the Global South, but then undermines this by quite explicitly investing £35 million in HANSHEP (or Harnessing Non State Actors for Better Health for the Poor), a global network of partners that seeks to improve the functioning of health markets in developing countries.
It is almost taken as consensus among donor-giving governments that market-based healthcare systems in the developing world are here to say. This consensus has become so established that in South Africa, private health insurance firms have been accused of lobbying against a new National Health Insurance Scheme that promises to provide essential health care for all. This story is all too familiar in countries not protected by rigorous legislation that prevent domestic and international corporations from promoting business interests over civic health interests. It is therefore clear that for-profit healthcare providers are most interested in expanding access based on profit-making incentives and should not be prioritised in the SDG framework.
With private sector actors providing piecemeal, market-based approaches to expanding access to healthcare in the developing world, is the ambition to truly create stronger economies where citizens can pay higher lump sums to access quality healthcare? If so, this is a dangerous approach, and presupposes that neoliberal, pro-market economies will be able to overcome significant barriers to access that not only include socio-economic indicators. It seems short-sighted, since a better universal healthcare system improves socio-economic indicators in of itself, allowing better investment opportunities in the long-run. Also assumed is long-term, continued investment from investors to build job markets, businesses and livelihoods to raise the average income to afford such investments that prop-up private sector health providers. Even if this is achieved, this would be both unsustainable and most definitely create larger inequalities in access to health.
The Independent Commission for Aid Impact (ICAI), a neutral aid monitoring and evaluation body set up by previous Secretary of State for International Development, Andrew Mitchell, has been critical of elements of DfID’s involvement with private sector actors, A report by the ICAI reviews how DFID currently works with the private sector in achieving poverty reduction strategies around the world. Most worrying is that it states that:
‘DFID should reassess how it appraises, monitors and evaluates its engagements with business to ensure fitness for purpose and a sharper focus on the poor’ and that ‘In some cases… we are not confident that DFID’s support is additional to what businesses would have done anyway’.
A report from Global Justice Now even goes as far to suggest that DfID often seems to behave more like a hedge fund [than an aid agency], investing capital alongside banking partners like JP Morgan.” If DfID is committed to investing only in healthcare projects with capital that is most likely to offer the greatest returns to investment, what does this mean for countries in conflict, or countries lowest on the Human Development Index (HDI), which have seen virtually no improvements in health indicators over the MDG framework? What message does this send to countries that have seen economic growth, but a slow-down in improvements to health indicators, such as Kenya?
Kenya has been a leading light for economic development in Africa, recently crossing the threshold into becoming a lower-middle income country. Under Greening’s theories it would follow that health indicators have drastically improved. But this simply is not the case. Kenya only spends 4.5% of its GDP on healthcare, whereas its neighbour Tanzania spends around 7%. The Global Nutrition Report claimed, around 35% of children are currently stunted. This is a risky strategy to be adopting, when much criticism was labelled at the international community, and the British aid strategy for not building healthcare systems in Ebola affected areas. Sierra Leone, most blighted by Ebola, simply did not have the resources, infrastructure or specialist doctors to deal with the crisis.
Therefore it is clear that DfID, along with the international community must do more to ensure that financing for healthcare is a priority, and that universal healthcare is championed in the SDG framework. This is mentioned most clearly in a number of the targets under the third proposed SDG goal to “ ensure healthy lives and promote well-being for all at all ages”, but most particularly:
“achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”
Britain quite rightly should hold its head high for its commitment to international aid and development. Indeed we are among the most generous of aid donating countries, as seen in our commitment to spending 0.7% of our GDP on ODA. By the same token we should be ever more critical of where our own taxes are being spent, and whether they truly project our own understanding as a nation about the importance of universal access to healthcare. A YouGov poll in 2013 revealed that 84% of the public believe that the NHS should be run by the public sector. Therefore it is only right that DfID should support, and provide technical assistance to the establishment of universal healthcare systems like our NHS in Kenya and right across the developing world.
Charlie is a development practitioner with field research experience in Somaliland on a UCL child and maternal global health project. My email is charlieensor1990@googlemail.com
