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[Thomas Pogge]

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The following civil society letter about the Scaling Up for Better Health Plan
is being circulated for signature. If you wish to sign, please send your
endorsement to Ed and Greg at  attapon@apnplus.org[1]   and  itpc@apnplus.org[2]
by Monday, December 3rd.
Thomas Pogge
OPEN LETTER TO THE LEADERS OF THE HEALTH 8 ABOUT THE SCALING UP FOR BETTER
HEALTH PLAN
The Gates Foundation
Ms. Patty Stonesifer
The GAVI Alliance
Dr. Julian Lob-Levyt
Global Fund to Fight AIDS, Tuberculosis and Malaria
Dr. Michel Kazatchkine
UNAIDS
Dr. Peter Piot
UN Population Fund
Ms. Thoraya Ahmed Obaid
UNICEF
Ms. Ann Veneman
The World Health Organization
Dr. Margaret Chan
The World Bank
Mr. Robert B. Zoellick
Dear Colleagues:
As civil society organisations fighting for improved health care in developing
countries including universal access to AIDS treatment, care and prevention
services; the implementation of the Declaration of  Commitment on AIDS;  and
the other health Millennium Development Goals we welcome every new and bold
attempt to realise the right to health.
At face value, the Scaling Up for Better Health plan, which is in fact a
cluster of recent global health initiatives encompassing Germanys Providing
for Health, Canadas Catalytic Initiative to Save a Million Lives, the United
Kingdoms International Health Partnership, and Norways Deliver Now for Women
and Children; and which has recently been endorsed by all of you, could only
make us happy.
However, when reading the final draft note of 1 November 2007, combined with
our experience in developing countries, we fear that this new initiative might
undermine some existing efforts to realise the right to health. In particular
we fear that this new initiative might be inspired by recent public comments,
according to which the world is spending too much on the fight against AIDS.
If this were the intention, we could certainly not support this initiative.
The world is not spending enough on the fight against AIDS and the world is
not spending enough fighting against other health crises and problems. Only if
this is explicitly acknowledged as the foundation of the Scaling Up for Better
Health plan, would we be willing to support this plan.
The following conditions would have to be met for us to support the Scaling Up
for Better Health Initiative.
1. The Scaling Up for Better Health plan should explicitly aim for the
realisation of the right to health, and adopt a foreign assistance for health
target that matches this aim.
Health is a human right, and its realisation requires that all human beings
have access to health care and the essential medicines they need, delivered
professionally and to recognised effective standards. This includes, but is
obviously not limited to, relatively expensive medicines to treat AIDS.
Furthermore, the realisation of the right to health requires access to clean
water and sufficient and appropriate nutrition.
We realise that this is not a modest claim. Estimates for foreign assistance
needed to achieve the health-related Millennium Development Goals range from
US$ 30 billion and US$ 60 billion per year. However, the combined Gross
Domestic Product of the countries in Organisation for Economic Co-operation
and Development in 2006 was US$ 36,316.6 billion. These countries promised to
allocate 0.7% of their Gross Domestic Product to foreign assistance, which
would be US$ 254.2 billion. If 15% of that would be allocated to health which
corresponds with the allocation promised by African leaders in the so-called
Abuja Declaration there would be over US$ 38 billion available each year for
foreign health assistance, in an entirely predictable and sustained manner.
Any lesser target, or the absence of an explicit target, would mean that
governments of developing countries would be left to make impossible choices.
They would be forced to choose among tackling child mortality, maternal
mortality, mortality due to AIDS, tuberculosis or malaria. In our
understanding, this is exactly what the Scaling Up for Better Health plan
seeks to avoid. If it does not want to force countries to make those choices
to reduce ambitions in one area for the sake of another it should be explicit
about it.
2. The Scaling Up for Better Health plan should explicitly adopt the novel
approach to sustainability
We worry when the Scaling Up for Better Health plan states it will be
Supporting countries in creating sustainable financing structures and systems
so as to mobilize and sustain additional internal resources.
Of course, we agree that states retain the primary responsibility to their
citizens in realising the right to health.  We agree that most governments of
developing countries are not doing enough: they promised to allocate 15% of
their budgets to health, and they are not doing it.
However, some countries are simply too poor; even if their governments would
allocate 15% of their budgets to health, that would not be sufficient.
Too often, in our experience, sustainable internal resources is simply
translated as payments from patients. If that is what the Scaling Up for
Better Health plan wants to promote, we disagree. User fees or health
insurance schemes should be handled with care, and make little sense when the
majority of the population will need an exemption or waiver anyhow, to realise
universal access to essential health care. The fulfilment of the right to
health and the achievement universal access, as we see it, are
responsibilities of the State.
Sustainability concerns often act as an inhibiting factor for governments who
want to reduce dependency on foreign assistance. They make estimations about
their future capacity to finance health care without foreign assistance, and
are reluctant to aim for an expenditure level that exceeds their own future
capacity. As a result, some governments will not try to realise the right to
health, as it seems too expensive.
There is a different way to approach sustainability concerns. A sustainable
health service must therefore be intended as an activity guaranteed on an
uninterrupted basis, even if financed by external resources. This quote comes
from the website of the World Health Organization and we do agree with it.  (http://www.who.int/hac/techguidance/tools/disrupted_sectors/module_06/en/index6.html[3])
The Global Fund to fight AIDS, Tuberculosis and Malaria has already adopted
this novel approach to sustainability, as it was essential to make AIDS
treatment possible. As explained above, if the member states of the
Organisation for Economic Co-operation and Development would allocate 0.7% of
their Gross Domestic Product to foreign assistance, as they promised, and if
15% of that amount would be allocated to health, there would be over US$ 38
billion available for foreign assistance for health, per year, in an entirely
predictable and sustained manner. This should be included in the
sustainability equation.
3. The Scaling Up for Better Health plan should confirm the primacy of the
right to health, above macroeconomic concerns.
The International Monetary Fund imposes an extremely conservative policy on
health and other social expenditures. The main reasons for this policy are:
    Fears about the macroeconomic impact of increased foreign assistance (the
so-called Dutch disease);
    Fears about the volatility of foreign assistance.
To avoid these problems, the International Monetary Fund applies its fiscal
space concept: it defines maximum envelopes for health expenditure; it limits
health expenditure to some level that will not cause any macroeconomic
disturbance; it limits health expenditure to a level that can be sustained by
domestic resources. If foreign assistance for the health sector exceeds fiscal
space, the International Monetary Fund programmes foreign assistance to be
used for increasing international reserves or for domestic debt reduction,
rather than for an increase of expenditure. A recent report of the Independent
Evaluation Office of the International Monetary Fund revealed that 70% to 80%
of additional foreign assistance to Sub-Saharan countries since 1999 was
diverted from expenditure to savings.
The Global Fund to fight AIDS, Tuberculosis and Malaria has developed an
ability to avoid this loss of 70% to 80% of foreign assistance. First of all,
the Global Fund includes civil society in the participation of proposals.
Civil society representatives do not worry about theoretical fiscal space
constraints and false Dutch disease myths; civil society representatives worry
about real needs and real financing gaps. Second, the Global Fund took a very
strong stance on additionality: if a Global Fund grant would displace domestic
or other foreign resources, it is denied. Global Fund grants cannot be used
for increasing international reserves or for domestic debt reduction; they
must be spent.
Did this cause any macroeconomic disturbance? If it has, the first report
about it remains to be written. Furthermore, the International Monetary Fund
itself admits that macroeconomic problems due to increased foreign assistance
can be avoided, as long as additional foreign assistance is predictable and
reliable in the long run. This should not be a problem if the Scaling Up for
Better Health plan is based on an explicit ambition to mobilize US$ 38 billion
or 0.1% of the Gross Domestic Product of the members of the Organisation for
Economic Co-operation and Development in a sustained manner.
The Scaling Up for Better Health plan must be more explicit about supposed
macroeconomic problems. Identifying and addressing the fiscal and
macroeconomic implications of the scaled-up health plan sounds like a
willingness to scale down health expenditure to fit within a questioned notion
of fiscal space, while a Scaling Up for Better Health plan aiming for
sufficient and sustained foreign assistance could simply overrule such
imagined macroeconomic constraints.

4. The Scaling Up for Better Health plan should allow appropriate responses to
health crises
One of the lessons learnt from the fight against AIDS is that fragile and
poorly resourced health systems are unable to react swiftly to new challenges.
Recent history shows that new health crises are looming on the horizon: Severe
Acute Respiratory Syndrome (SARS), avian flu, extensively drug resistant
tuberculosis (XDR-TB).
We fear that the stated objective of binding development partners to
implementing the national health plan and agreeing modifications through joint
reviews will turn fragile and poorly resourced health systems into even more
static systems than they already are. We have not forgotten the lessons from
recent history; we know that the introduction of AIDS treatment became a
life-saving reality for hundreds of thousands of people because some
non-governmental organisations, working closely with courageous health
ministries, supported mainly by private donors, dared to challenge the
international consensus. The Global Fund to fight AIDS, Tuberculosis and
Malaria came as a deus ex machina and allowed the replication of pilot
projects at a larger scale, because medical experts judged proposals on their
technical merits, not by the prevailing health development consensus of the
time. Once approved on their technical merits, development partners could not
reject them.
We remember how major institutional donors, including the United Kingdom
Department for International Development (DFID), tried to block this evolution
and tried to stop the Global Fund from funding AIDS treatment. We can only try
to imagine what would have happened if, at the turn of the millennium, the
Scaling Up for Better Health plan and its compacts binding all development
partners would have existed. We are quite sure that the fight against AIDS
would still be restricted to prevention campaigns.
For obvious reasons, we do not want that to happen for new health crises.
5. Vertical, or disease-specific interventions
We are concerned that the Scaling up for Better Health plan renders a negative
judgment on vertical or disease-specific interventions.
We are aware of the fact that too much verticalism can be harmful; however we
reject the increasingly popular idea that AIDS, tuberculosis and malaria
interventions are by definition disturbing health systems.
History and medical science show that disease-specific interventions can and
have been effective in combating many diseases. There is no evidence-based
reason to exclude them from future comprehensive health programmes.
It may not be the intention of the Scaling Up for Better Health plan to
exclude vertical initiatives. If vertical initiatives can be viewed as part of
a comprehensive health programme, it would be very helpful to mention
explicitly that countries are encouraged to strive for the right balance
between vertical and horizontal interventions.
Furthermore, recent history has shown that health sector reforms applied
without regard to their effects on disease control initiatives can significant
disrupt these programmes. For instance, in the late 1990s, health sector
reforms in Zambia caused the national tuberculosis programme to collapse.  The
Scaling Up for Better Health plan needs to take a nuanced, incremental and
balanced approach to integration of vertical programming into the health
sector lest it hamper efforts already underway to control major public health
threats.
6. A transparent overview of contributions and grants
>From the start, the Global Fund to fight AIDS, Tuberculosis and Malaria
provided information about received donations, in an unusually transparent
manner. This allowed us to compare the efforts of different institutional
donors, and to create peer pressure. It also allowed us to compare the
ambitions of health ministries and to demand more efforts whenever and
wherever appropriate.
As far as we can see, the Scaling Up for Better Health plan will not provide
this kind of information. The foreign assistance flows supporting health
compacts will be a spider web of World Bank, Global Fund and bilateral grants;
nobody will be able to tell which country is giving how much, and which
country is trying how hard.
If you want us to do for the Scaling up for Better Health plan what we did for
the Global Fund to fight AIDS, Tuberculosis and Malaria, we will need a
transparent overview of contributions and grants.
7. Civil society participation
Last but not least, the Scaling Up for Better Health plan should seriously
work on its intentions to include civil society at all stages of the
decision-making process.
As far as we understand, the elaboration of health compacts for the first wave
countries has already started, or will take place during the last months of
2007 and the first months of 2008. Until now, we have not been invited to
participate.
This does not look like a serious endeavour to include civil society. Civil
society was a critical force in the realisation of the Global Fund and is now
integrated into the governance of the Fund at all levels, building an
unprecedented resource for health in the developing world.  Use us. We are not
single-issue chauvinists.  We are willing to fight for the right to health in
general, as we did and continue to do fight for the rights of people with
AIDS, tuberculosis and malaria.
If you are serious about the realisation of the right to health if your
intention is not to displace funds for the fight against AIDS to other
specific health interventions, but to increase predictable and sustained
foreign assistance for the fight against AIDS and for the realisation of the
right to health in general you should not fear us. You need us.  A top-down
approach relying solely on governments will fail.  Civil society offers a
vehicle to provide accountability, transparency and improved governance for
health in our countries.  We are the consumers of health care, we have a
vested interest in seeing programmes succeed in reaching their goals.  We are
able to provide an independent voice from our countries villages to our
nations capitals describing what we need in real terms and what is and isnt
working on the ground. We are willing to work together, but our conditions for
collaboration are clear.
We would like to meet with all of you at your earliest convenience to discuss
our concerns and how to move forward as partners in health.  Please contact
Greg Gray, the International Coordinator of the International Treatment
Preparedness Coalition at itpc@apnplus.org[4] with your replies.
Yours truly,
<endorsers>

===References:===
  1. mailto:attapon@apnplus.org
  2. mailto:itpc@apnplus.org
  3. http://www.who.int/hac/techguidance/tools/disrupted_sectors/module_06/en/index6.html
  4. mailto:itpc@apnplus.org