Ethiopia Aid effectiveness in the health sector - Action for Global ...

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Ethiopia – Aid Effectiveness in the health sector support. But it still does not withstand comparison with the money going into HIV/AIDS, TB and malaria. It has been mentioned before that this uneven distribution of resources has created problems with harmonisation and duplication of structures. In addition, both PEPFAR and the Global Fund have been criticised for focusing too much on urban areas and not supporting health efforts in rural Ethiopia. 27 It is true that HIV/AIDS has a much higher incidence in big population centres (incidence in urban areas is 5.5%, versus 0.7% in rural areas). 28 However, with 83% of the population living in rural areas, the total amount of infected people living in rural and urban areas is approximately the same. Furthermore, it has been argued that PEPFAR has very high transaction costs, makes heavy use of technical assistance and delivers very little value for money. As one of the interviewees put it, “It spends a lot, but reaches a few”. 29 The Global Fund has traditionally been seen as a more versatile player. The Fund, for instance, has contributed to developing a stronger civil society. When it started working in Ethiopia one of its conditions was that CSOs should be involved, and two networks of service delivery NGOs and CSOs were created. The approach of both PEPFAR and the Global Fund has recently started to change in Ethiopia. The Government has been putting a lot of pressure on both DPs, even though it is difficult to tell who has been responsible for this change, given other contributing factors such as the views of other DPs and mounting criticism at international level. The Fund is now supporting the Health Extension Programme (HEP) by helping with the construction of the basic health posts in villages and it is also investing in laboratories and other infrastructures, which will have spillover effects in the health sector. Similarly, PEPFAR has shown signs of making a similar turn. It has started to implement its first Partnership Framework in Malawi, which should increase alignment and coordination. Other countries will soon follow. Internal regulations still mean that PEPFAR will remain independent to a certain extent, but the framework could help reduce the number of management bodies set up by PEPFAR as well as improve alignment with instruments such as the IHP+ (even though they are not signing on to it). Though only a first, it is an important step forward. Many more will need to follow if PEPFAR wants to contribute to the advancement of the AE agenda in developing countries. 14
Ethiopia – Aid Effectiveness in the health sector PEPFAR’s new Partnership Frameworks In July 2008, US legislation (Public Law 110-293) reauthorised US Government (USG) global efforts to combat HIV/AIDS, tuberculosis and malaria for 2009- 2013. The law authorised the USG to establish compacts or framework documents with partner countries to promote a more sustainable approach, characterised by strengthened country capacity, ownership and leadership. This approach represents a substantially new focus for PEPFAR. The purpose of a Partnership Framework is to provide a five-year joint strategic framework for cooperation between the USG, the partner or “host” Government and, in some cases, other partners to combat HIV/AIDS in the host country through service delivery, policy reform and coordinated financial commitments. PEPFAR 30 Key challenges Major vertical donors in Ethiopia are showing positive signs of change. The Global Fund is making efforts to increase the impact of its activities on the health sector in general. PEPFAR has announced a move towards better alignment and harmonisation. But is still has to start implementing it. However, one should not expect to see a radical transformation of these donors. Internal regulations limit their movements and changing them will take time. Country ownership Ethiopia is a complex arena for aid processes. More than 20 donor countries and 20 multilateral agencies are active in the country. Reportedly, during the High-Level Forum between the Government of Ethiopia and the Development Assistance Group (the High-Level Forum is Ethiopia’s highest level annual meeting on development assistance), it is common to see three representatives from the Government sitting among over 35 DP representatives. 31 The Government is similarly represented all throughout the coordination chain described in the preceding section. This situation disempowers government representatives and places them in a weaker position when it comes to defending and sustaining their views. However, this seemingly weakened position is elsewhere contested. On the one hand, given the country’s characteristics, it is difficult for individual DPs to embark on large-scale projects; guarantee their continuity, and make them successful without coordination with other DPs and the Government. 15
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