EN    EN EN
 
EN    EN  EUROPEAN COMMISSION 
Brussels, 31.3.2010 
SEC(2010) 382 final 
  
COMMISSION STAFF WORKING DOCUMENT 
Contributing to universal coverage of he alth services through development policy 
  
Accompanying document to the  
 
COMMUNICATION FROM THE COMMISSI ON TO THE COUNCIL, THE 
EUROPEAN PARLIAMENT, THE EU ROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMI TTEE OF THE REGIONS 
 
The EU Role in Global Health 
{COM(2010) 128} 
{SEC(2010) 380} {SEC(2010) 381} 
 
EN 2   EN COMMISSION STAFF WORKING DOCUMENT 
Contributing to universal coverage of he alth services through development policy 
TABLE OF CONTENTS 
1. Latest trends ............................................................................................................... .. 3 
1.1. Health inequities......................................................................................................... .. 4 
1.2. Insufficient and uneven progre ss towards the health MDGs ....................................... 5 
1.3. Weak health systems.................................................................................................... 6 1.3.1. The main features of health systems ............................................................................ 6 1.3.2. Health financing........................................................................................................ ... 7 
2. The global response...................................................................................................... 8 2.1. Complex global health governance.............................................................................. 8 2.2. Fragmented health aid architecture .............................................................................. 8 2.3. Growing attention to stre ngthening health systems ..................................................... 9 
3. Making better use of global aid for health ................................................................... 9 3.1.1. Distributing health aid better acro ss countries and health services.............................. 9 
3.1.2. Increasing country ownership .................................................................................... 10 3.1.3. Addressing the link between poverty and health ....................................................... 10 4. The EU strategy for moving towards unive rsal coverage by health services in 
developing countries .................................................................................................. 11 
a. Where? ...................................................................................................................... . 11 
b. What? ....................................................................................................................... .. 12 
c. How? ........................................................................................................................ .. 13 
 
EN 3   EN COMMISSION STAFF WORKING DOCUMENT 
 
Contributing to universal coverage of he alth services throug h development policy 
This staff working document complements the Communication ‘The EU Role in Global 
Health’ . It elaborates on specific objectives, within  the present legal, regulatory and financial 
framework. 
Health is central to poverty reduction  and sustainable development and ill-health is a barrier 
to social and economic progress. The EU is committed to protecting and promoting health as a human right for all
1. The European social model  includes certain common features aimed at 
guaranteeing healthcare for a ll EU citizens. The EU has agreed common values of solidarity  
with a view to equitable and universal coverage by quality care2 in health systems . 
1. LATEST TRENDS  
During the last decade millions of children’s deaths per year have been averted. The 
under-five mortality rate declined 28  % between 1990 and 2008. The decade has seen 
unprecedented mobilisation to combat HIV/AIDS, malaria and tuberculosis. HIV/AIDS treatment reached over 4 million people (over 40
 % of those in need) in 
developing countries, compared  with virtually none  at the beginning of the decade, 
pushing back AIDS mortality.   
Three of the eight millennium developmen t goals (MDGs) are directly related to 
health: reducing child mortality (MDG 4), reducing maternal mortality (MDG 5) and 
the fight against AIDS, malaria and other poverty-related dis eases (MDG 6). They 
are closely interconnected with all the ot her MDGs, as nutrition (MDG 1), education 
(MDG 2), gender equality (MDG 3) and water/sanitation (MDG 7) tie in with the main risk factors behind ill -health. Unfortunately, these h ealth-related goals are the 
MDGs least likely to be achieved in many parts of the developing world – especially 
in Africa.  
However positive these particular outcomes are, overall progress towards the health 
MDGs has been slow, with over 50 developi ng countries off-track , especially in sub-
Saharan Africa. Progress towards MDG 5
3 has been particularly disappointing. This 
                                                 
1 In 2000 the United Nations Committee on Economic, Social and Cultural Rights published General 
Comment 14, which defines in detail states’ obligations, patients’ health entitlements, and their ethical 
implementation using human rights principles. Child health is specifically protected by the Convention on the Rights of the Child, reproductive and maternal health by the Cairo Action Plan and the 
Resolution on Preventable Maternal Mortality and Morbidity at the United Nations’ Human Rights 
Council; and rights of persons with disabilities as ou tlined in the Convention of the Rights of People 
with Disabilities.. 
2 Council Conclusions on Common values and principles in European Union Health Systems (2006/C 
146/01). 
3 ‘The Millennium Development Goals Report 2009’:  
http://www.undp.org/mdg/ basics_ontrack.shtmlhttp://www.undp .org/mdg/basics_on track.shtml. 
 
EN 4   EN lack of progress on the hea lth MDGs reflects the hea vy burden of disease globally4, 
especially in developing countries. Over 60 million die prematurely every year, most 
due to social and environmental fact ors and lack of adequate healthcare5. Nine 
million of them are children under the age of five6.  
The difference in life expectancy  across the world has been widening, with the richer 
top billion enjoying an average life expectancy close to 80 years, twice that of the 
poorer bottom billion7. Worldwide, exposure to health risks and inadequate access to 
healthcare are to blame for a loss of 20  % of potential healthy life . The average loss is 
10 % in the EU but close to 50  % for the world’s poorest billion.  
This staff working document is a co ntribution to the communication on the EU role 
in global health . It elaborates on the policy commitments in relation to the specific 
objective of ‘ Progress towards universal coverage by basic quality healthcare’ . 
Consistent with the attention already give n to health equity within the EU, this 
document focuses on how the EU’s external action can contribute to reducing health 
inequalities worldwide  and to progress towards universal coverage by  health services 
in partner countries.  
1.1. Health inequities 
In the poorest parts of the world human su ffering from ill-health remains extremely 
high. There are also very large differences in state of health  between and within 
countries and regions. According to th e report by the Commission on Social 
Determinants of Health8, differences in health indicator s within countries are closely 
linked to degrees of social disadvantage, the circumstances  in which people live and 
work and the systems put in place to protect health and deal with illness. The report 
concludes that ‘ The development of a society, rich  or poor, can be judged by the 
quality of its population’s health, how fairly health is distributed across the social 
spectrum, and the degree of protection provid ed from disadvantage as a result of ill-
health’ .  
Amongst the countries of the EU itself, ther e is a five-fold difference in deaths of 
babies under one year of age and an 11-year gap in life expectancy at birth. Mortality 
rates are much higher in the least develope d countries than in the EU: more than 100 
times higher for maternal mortality and 15 times for infant mortality, with close to a 40-year difference in life expectancy. In sub-Saharan Africa, the region with the 
lowest health indicators, the lifetime risk  of dying during pregnancy is one in 20, the 
risk of dying during childhood is one in  six and the risk of dying during 
economically active life (betw een the ages of 15 and 60)  is almost one in two. 
                                                
 
4 Burden of disease is measured by Disability Life Adju sted  years, i.e. the healthy years lost to premature 
deaths and to various degrees of disability during disease. 
5 ‘The global burden of disease: 2004 update’, WHO. 
6 ‘The State of the World’s Children 2009’, UNICEF. 
7 WHO statistical information syst em: http://www.who.int/whosis/en/. 
8 CSDH (2008): ‘Closing the gap in a generation: health equity through action on the social determinants 
of health’, Final report by the Commission on Soci al Determinants of Hea lth, Geneva, World Health 
Organisation. 
 
EN 5   EN 1.2. Insufficient and uneven progress towards the health MDGs 
As mentioned in section 1, progress towards the health MDGs  has been slow and 
uneven. However, there are good examples where a combination of political stability, adequate domestic funding for h ealth, strong international support and a 
genuine policy dialogue has le d to sustained progress on reducing child and maternal 
mortality
9.  
Over the last decade progress was made towards MDG 4  (child mortality). The 
under-five mortality rate declined by 28  % between 1990 and 2008 (down to 65 per 
1000 live births). Most of this  reduction was attributable to  progress in Asia, mainly 
India and China. Almost 30 countries  made no progress on reducing childhood 
deaths10. Sub-Saharan Africa, with only 10  % of the world’s po pulation, accounts for 
about half the deaths of children under five in the developing world. Although 
coverage by measles vaccina tion has improved, many other risks to child health 
(mainly unsafe water, sanitation and inadequa te nutrition) remain high and access for 
children to basic health services remains low11. 
As regards MDG 5 , maternal mortality remains extremely high across much of the 
developing world. Over 500  000 women die every year  during pregnancy or 
childbirth, 99  % of them in developing countr ies with sub-Saharan Africa and 
Southern Asia accounting for 86  %. This reflects the low rate  of safe deliveries, but 
also gender inequities, lack of access to sexual and reproductive health and rights and 
high fertility rates, com pounded by the burden of HIV/ AIDS and malaria in sub-
Saharan Africa. 
In the case of MDG 6 , the decade has seen broad mob ilisation to combat HIV/AIDS, 
malaria and tuberculosis. HIV/AIDS treat ment reached over 4 million people (over 
40 % of those in need) in developing countri es, compared with virtually none at the 
beginning of the decade, pushing back AI DS mortality. The number of new 
infections decreased only slightly ─ by just 10  % ─ largely because prevention is still 
weak in many countries. As regards malaria,  rapid increases in the availability of 
insecticide-treated bed nets  (from close to nil in 2000  to one in three of the 
population at risk today) and effec tive treatment have resulted in a 50  % reduction of 
under-five mortality due to malaria in Asia and in Africa. Progres s on tuberculosis 
has been slower and during the decade the number of emerging diseases has 
increased. 
MDG 7 , in particular access to basic sanitation wh ich is directly related to health as it 
offers a means of preventing waterborne di seases, is also off-track globally and, 
                                                 
9 One good example could be Zambia where, despite  many weaknesses, there are acceptable levels of 
compliance with the Abuja targets (15  % national budget allocation to health), international aligned and 
predictable support (mainly basket fund and budget support, with the exception of PEPFAR and the Global Fund) leading to overall public on-budget funding above €
 20 per capita, SWAP set up with 
participation of CSOs, reforms in human resources fo r health and in abolition of user fees for basic 
services in rural areas, increased uptake and completion rates for basic education with progress on 
gender equity, sustained economic growth and improved household economies during one decade and 
demographic health surveys with ample statistical significance showing progress on MDGs and lower infant and maternal mortality. 
10 See UNDP MDG Monitor: http://www.mdgmonitor.org/map.cfm . 
11 ‘State of the World’s Children’, UNICEF, 2009. 
 
EN 6   EN especially, in Sub-Saharan Africa, where, at  the current rate, the sanitation target will 
be missed by more than two generations. 
1.3. Weak health systems 
In the 50 developing countries which are off-track to meet the health MDGs, access 
to comprehensive healthcare remains low. Coverage by many of the essential health services is low and has not expanded fo r the last decade in the least developed 
countries: one third of all pregnant wome n have no access to antenatal care and half 
of them lack safe care during delivery; only  half of the women who wish to avoid a 
pregnancy have access to contraceptives and fewer than half of children are adequately treated against diarrhoea, respiratory inf ections or malaria. Although 
coverage by vaccination and basic se rvices against HIV/AIDS, malaria and 
tuberculosis have been increased by targ eted programmes, prevention and treatment 
of other diseases are lagging behind: for example, under a third of hypertensive or 
diabetic patients are diagnosed in deve loping countries and only a minority have 
access to adequate treatment.  
1.3.1.  The main features of health systems 
The 1978 Alma-Ata
12 declaration put forward a set of values, principles and 
approaches with the aim of raising the leve l of health in deprived populations. Alma-
Ata’s holistic view of hea lth, looking beyond a narrow  medical model, and its 
participatory approach has become the basis for modern health systems.  
Thirty years later the Alma-Ata principles have been adapted to the global context 
today. Effective health systems should be based on the principles  set out in WHA 
Resolution 62.1213 on Primary Health Care, includi ng Health System Strengthening. 
The first principle ─ a rights approach with inclusive leadership  ─ requires active 
community participation together with cl ear institutional leadership. Few health 
systems allow meaningful community part icipation, although this  is difficult to 
measure. A second principle is that  health systems must include the health-in-all  
approach relating health services to the sources of the main risks (nutrition, water 
and basic sanitation, educati on, transport, governance and gender equity). The health 
system must also deliver people-centred services  which respond to needs at the level 
of care required for the final principle of universal coverage .  
Identifying the priority services with the ai m of universal coverage  requires access to 
and analysis of a comprehensive range of data gleaned from regular monitoring and 
population health surveys. This information is essential in order to define the package of priority health services  and to deliver it rationally across the different 
levels of care. At present, less than a third of all count ries have timely demographic 
and health surveys (DHS/MIPS) and only a third of national health systems in 
developing countries have up-to-date data on national health accounts. Very few of 
them conduct performance analysis and monitoring.  
                                                
 
12 Alma-Ata Declaration, International Conferen ce on Primary Healthcare,  Alma-Ata, USSR, 6-12 
September 1978 . 
13 WHA 2009, Resolution 62.12 on Primary Healthcare, including Health System Strengthening. 
 
EN 7   EN Once the services to be delivered have been defined and the components of the 
system (see below) identified, the health strategy would ideally provide input for a 
national health  budget  and a mid-term expenditure framework. A health information 
and management system  would monitor inputs, processes and outcomes, provide 
input for policy decisions and steer re search towards health priorities.  
Effective health systems need  to respond in a balanced wa y to the four main health 
challenges: sexual and reproductive health, child health, communicable diseases and 
non-communicable diseases . Each of these areas will require an integrated approach 
combining specific training, protocols by le vels of services, i ndicators and applied 
research. At present, many na tional strategies in developi ng countries are able to 
cover only some of the diseases or se rvices essential to their population. 
There are a number of essential components or ‘health pillars’ which health systems 
require in order to provide universal  coverage of the services agreed: human 
resources , access to essential medicines,  infrastructure and logistics  allowing access 
and timely referrals between levels of care and fair financing schemes ensuring 
equitable access for all . Each of these pillars requires a strategy and a budget. 
Together, they should provide an integr ated response to th e goal of universal 
coverage. In some developing countries thes e pillars suffer from serious structural 
weaknesses: a shortage of human resources, low availabi lity and unaffordability of 
essential medicines, inadequate infrastructure and referral capacity (one clear example is in obstetric emergencies) and financing schemes which, in most countries, still require direct paym ents at the point of delivery. 
1.3.2.  Health financing 
Global health expenditure totals €
 4 trillion. Sixty percent of it is collected via taxes 
or social insurance schemes. Low GDP per capita, limited fiscal revenue and weak macroeconomic frameworks  leave many of the poorest countries with levels of public 
per capita financing of health  100 times lower than in the richest. Low public 
expenditure places significant constraints on the availability of health professionals 
and their capacity to deliver quality serv ices. In some countries inefficiency 
compounds the problem.   
Under resolutions adopted  in 2005 (WHA 58.33) and 2009 (62.12), all countries are 
committed to fair financing of essential health services, ensuring universal coverage. However, little progress has been made in th is direction, except on specific diseases 
in the global spotlight, such  as HIV/AIDS. In most deve loping countries, user fees 
are a barrier to access to basic services for the poor. Direct payments for health 
services drive some 100 million under the pove rty line every year. Extending the EU 
principles of solidarity to global level w ith a view to universal coverage would 
require a major shift in the distribution of  health financing worldwide. Ill-health 
should be mitigated by a wide r set of policies, includi ng protection during sickness 
(paid sick leave), occupational health a nd safety and adequate working conditions. 
Basic social protection schemes can be set up, even in poor countries, with some 
financial support. Social protection for he alth should therefor e be part of each 
country’s wider social protect ion net covering basic needs. 
 
EN 8   EN 2. THE GLOBAL RESPONSE  
2.1. Complex global health governance 
In theory, global health gove rnance stems from the deba tes and resolutions at the 
World Health Assembly and the guidance from the WHO. In practice, however, 
many of the resulting resolutions re main non-binding. Many decisions which 
influence health strategies originate in the G8 context. International financial 
institutions also influence the health polic y choices of national governments. On the 
other hand, private and philanthropic entities provide a significant share of health 
services, reflecting their own sensitivities or  interests. This complex set-up generates 
strong and dynamic interactions and draws on multiple sources of funding, but it also 
calls for clearer global leadership. 
2.2. Fragmented health aid architecture 
The aid architecture for h ealth is complex and has gone through numerous changes 
over the last decade, in terms of leve ls of aid, donor profile and focus. 
Because health is critical to achievi ng the millennium development goals, it has 
attracted a high level of political attenti on and increased international funding. In 
2007, DAC countries’ bilateral aid to health amounted to € 8,1 billion (53% from the 
EU) and multilateral agencies ’ aid to € 3,45 billion. Average annual growth over the 
period 1980-2007 was 10% but this accelerat ed over the most recent years (17% 
annually from 2000 to 2007)14. 
The patterns of aid funding for health have  also changed. The sh are contributed by 
the UN and the World Bank has decreased from one third to one sixth and has gradually been targeted on specific activities. For example, less than 20
 % of WHO 
funding is un-earmarked. In parallel, gl obal health initiativ es and NGOs have 
gradually stepped up their shares of public health aid, and the contributions by private philanthropy and corporations  have also increased. This ‘privatisation of 
health aid’  has sharpened the focus of aid on proj ects and disease-targeted activities, 
leading to ‘fragmentation of health financing.’  
Aid is not being used to support comprehens ive national health plans. Instead, it is 
becoming increasingly fragmented, with the bulk of health aid now outside 
government accounts and, for the most part, neither recorded by countries’ planning 
authorities nor connected to national health plans. At Accra, signatories reasserted 
the Paris Declaration commitment to dis burse 66% of aid by means of Programme 
Based Approaches (PBAs) by 2010. Howe ver, overall progress with making a 
greater use of PBAs is slow and remains at around 40%
15. 
 
                                                 
14 November 2009, OECD-DAC, www.oecd.org/dac/stats/health  
15 2008 Monitoring Survey Appendix table A9. Note: 
 
EN 9   EN 2.3. Growing attention to strengthening health systems 
Aware of the central role of health syst ems in improving health and making effective 
and sustainable progress towards the health MDGs, the international community has been paying growing attention to strengthe ning health systems. One essential for 
robust health systems is the availability of adequate national funding, supplemented 
by aligned and predictable external support. 
In September 2007, the International Health Partnership  (IHP) was established to 
apply aid effectiveness principles to the he alth sector. In 2009 the global debate on 
health development aid (HDA) has focused on ‘health systems’. Whether in Accra, 
in Doha, in New York (UNGA) or at the World Health Assembly,  the international 
community has reiterated the need to suppor t health systems to enable countries to 
make progress towards the MDGs and to st rengthen the synergie s between vertical 
programmes and country systems. 
The High-Level Task Force on financing for health  concluded a cycle of studies and 
consultations with an analysis of the publ ic funding gap to be bridged to support 
health systems, plus a menu of innova tive financing initiatives to top up ODA 
commitments. At the same time, the IHP has been developing a tool for ‘joint 
assessment of national strategies’  whereby donors and global health initiatives can 
join in country compacts and fund comp rehensive national h ealth strategies. 
Likewise, the main global health initiatives ─ the Global Fund for Aids, TB and 
Malaria (GFATM) and the Global Allian ce for Vaccines and Immunisation (GAVI) 
─ have expanded their scope to include support for health system components in 
disease-specific programmes or to fund ‘hor izontal’ health system components. In 
this context, the Washington seminar ( 2008) agreed on the id ea of a joint World 
Bank-GFATM-GAVI platform to strengthen health systems . – The provision of 
supporting national policies through single joint mech anisms of performance 
assessment and dialogue ("Sector-wide approaches" – SWAps) have been 
implemented in a number of countries, for some already a decade (e.g. Ghana, 
Mozambique, Tanzania, Zambia), and stocktak ing and assessment of these processes 
can provide valuable insights for future wo rk and become a basi s for partnerships 
and Division of Labour in health sector monitoring and policy dialogue at country 
level. 
3. M
AKING BETTER USE OF GLOBAL AID FOR HEALTH  
Given the landscape described above, it is e ssential to make better use of global aid 
for health, in order to boost progress toward s health MDGs. The main challenges are 
to improve the distribution of  health aid and country ow nership and to sharpen the 
focus of health strategies on poverty. 
3.1.1.  Distributing health aid better acro ss countries and health services  
a) The distribution of health aid per capita across countri es varies greatly. A recent 
analysis confirmed a positive correlation between health aid per capita and the burden of disease. This correlation has increased during the last decade, influenced by higher 
levels of aid to countries with high HI V prevalence and where malaria is endemic 
(mainly by the US President's Emergency Plan for AIDS Relief  PEPFAR and the 
 
EN 10   EN Global Fund). By contrast, the correlation between health aid and GDP is weak. In 
2008, the Commission introduced the concept of  ‘potential public financing gap for 
health.’ This contrasts the public finance th at would be available for health if the 
country complied with the Abuja target (15  % of national budget) with the minimum 
threshold of spending per capita (as estimated by the Commission on Macroeconomics and Health in 2001 and maintained at €
 20 by the IHP). The distribution of health aid 
between countries does not appear to correl ate with these potential financing gaps, 
with some countries in critic al need receiving far less heal th aid per capita than others 
whose public financing capacity is  above the minimum threshold. 
b) The distribution of health aid by diseases al so reveals wide disparities. Despite its 
limitations, the sub-sectoral breakdown of health aid by of OECD Development 
Assistance Committee (DAC)  sub-codes indicates that 40  % of health aid targets 
HIV/AIDS, close to 20  % malaria and tuberculosis, 16  % ‘basic health care’ (with a 
large proportion for vaccinat ion programmes by GAVI), 13  % reproductive health and 
the remaining 14  % going to ‘health in general’ wher e investment in health facilities, 
training, research and untargeted support fo r health would be included. HIV/AIDS, 
which causes 10  % of the burden of disease in  developing countries (and 20  % in 
Southern Africa), receives 40  % of health aid. By contrast , other diseases which also 
cause a heavy burden, such as acute respiratory infections, diarrhoea or malnutrition, receive little direct support and depend on the limited aid for ‘health in general’.  
3.1.2.  Increasing country ownership 
At country level, health ai d is excessively fragmented  between partners, each of 
whom has its own reporting requirements and preferred areas of activity. This 
fragmentation undermines the leadership of  national governments. Poorly resourced 
and ill-equipped health ministries in deve loping countries find it difficult to negotiate 
the contributions from so many partners a nd to coordinate them under an agreed 
plan. Health support for count ries should gradually shift to on-budget and predictable 
funding. This shift requires greater trus t in the capacity of national governments 
sustained by policy dialogue and mutual accountability mechanisms. In this area, the EU could benefit from making more systema tic use of its experi ences with single 
joint monitoring and dialogue mechanisms in the health sector, and build partnerships for health sector monitori ng and dialogue on established country level 
mechanisms.  
Beyond government ownership, democratic governance in health requires the 
involvement of national parliaments in  policy-making and budget scrutiny. Active 
participation by civil society can improve  equity, pertinence and accountability. 
However, in many countries civil society is not able to contribut e effectively to the 
national planning, implementation and monitori ng and, in some cases, is not entirely 
representative.  
3.1.3.  Addressing the link between poverty and health 
Within each country, health indicators are correlated with social determinants of 
health. Poverty decreases access to safe wa ter and sanitation and increases the risks 
of malnutrition, low-quality living conditions , unhealthy working environments and 
lower levels of education. The poor have lower access to health services and, when 
they do use them, are exposed to longer de lays, lower quality and higher case-fatality 
 
EN 11   EN rates. Poverty has a similar adverse effect on under-five mortality, maternal mortality 
and adult survival rates.  
The poor have lower access to health servi ces and spend a higher proportion of their 
income on paying for them, mainly in the form of direct payments at the point of delivery. If health systems are to reach  out to the poor, the arrangements for 
financing them should therefore also be re formed, by greater pooli ng of contributions 
based on the ability to pay in advance and moving towards gradual abolition of user fees. This should be part of  wider social protection nets  that protect the poor from 
disease and other risks.
 
Health is central to poverty reduction  and sustainable development and ill-health is a 
barrier to social and economic progress.  The EU is committed to protecting and 
promoting health as a human right for all16. The European social model  includes 
certain common features aimed at guaranteei ng healthcare for all EU citizens. The 
EU has agreed common values of solidarity  with a view to equitable and universal 
coverage by quality care in health systems17. 
 
4. THE EU STRATEGY FOR MOVING TOWARDS UNIVERSAL COVERAGE BY HEALTH 
SERVICES IN DEVELOPING COUNTRIES  
(1) This section gives fuller details of the proposals made in the Communication. 
a. Where?   
- To ensure that health ODA goes to c ountries in critical need, Commission 
services will organise colle ctive EU analysis and a list of priority countries will 
be defined on the basis of health financi ng gaps identified in country compacts of 
the International Health Pa rtnership.  The Commission will seek support of the 
WHO in this exercise.  
- Commission services will monitor programmed and forecast direct EU health 
aid by recipient country  and by global channels, in order to facilitate compliance 
with the EU Code of Conduct on Division of Labour18 and improve the 
distribution of aid across partner countries. This will require regular updates and annual meetings to identif y opportunities to increase support for countries in 
greater need. 
 
                                                
 
16 The Treaty of the European Union stipulates that a high-level of health protection shall be ensured in 
the definition and implementation of all Union policies and activities. The Charter of Fundamental 
Rights of the EU further stipulat es that everyone has the right of access to preventive healthcare 
17 Council Conclusions on Common values  and principles in European Union Health Systems (2006/C 
146/01). 
18 See, for example, the ‘EU Code of Conduct on Division of Labour in Development Policy’, 
Communication from the Commission to the Council and the European Parliament, COM(2007) 72, 
Brussels, 28 February 2007. 
 
EN 12   EN b. What?  
- Where health is a focal sector a nd/or there is general budget support, 
Commission services will ensure that its financial support is linked with adequate 
dialogue on strengthening health syst ems, taking into account the main 
components described in section 2.3. 
- The Commission services will contribute to joint assessment of national 
strategies (JANS) under the International H ealth Partnership and using the results 
of the JANS to align its f unding behind national strategies. 
- In order to increase the collective EU cap acity in the health sector dialogue and 
global health issues, the following activiti es will be carried out by Commission's 
services: 
a) Organise a stocktaking exercise of es tablished single joint mechanisms of 
performance monitoring and policy  dialogue in the health sector, 
particularly in countries with expe rience over longer periods (e.g. SWAps 
in Ghana, Mali, Mozambique, Tanzania, Zambia and other countries). These processes will be assessed and lessons learnt will be used for a 
common EU concept for performance monitoring and policy dialogue in 
the health sector at country level; opportunities for partnerships and 
division of labour will be explored. 
b) Mapping every two years the health expe rtise capacity available at country 
level and match it against the needs fo r health sector assessment and policy 
dialogue in partner countrie s, especially where health  is a focal sector and 
where the Commission provides general budget support and MDG contracts. The resulting analysis of needs will provide input for the 
Commission, the Member States concer ned for allocating human resources 
in the relevant EU delegati ons. It will also facilita te practical arrangements 
for in-country division of la bour in the health sector. 
c) Development with Member States of join t health sector gu idelines covering 
assessment of the health situation and tr ends, analysis of the health sector, 
choice of forms of aid, monitoring of system performance and of the 
impact of aid and the relation to glob al commitments and aid architecture. 
d) Explore with the WHO, other releva nt UN agencies and the World Bank, 
opportunities for closer collaboration on health assessments and policy 
dialogue in the context of  the IHP and JANS technical assistance in the 
field of health. In collaborati on with the UN agencies, Commission 
services will comply with the Accra commitments and maximise use and development of local expertise. 
e) Contribute, in collaboration with EU Member States, to quality assessment 
and dialogue in global health fora su ch as the WHO Executive Board, the 
World Health Assembly and the relevant UN summits. Commission services will also engage in a dial ogue on health and development matters 
with other major partners such as USAID, the African Union Commission 
and the health policy agencies of Brazil, China and India.  
 
EN 13   EN f) Commission services will contribute, from the resources of the thematic 
programme ‘Investing in People’, to development of a workforce of 
excellence in global health analysis and policy dialogue based on the 
existing EU public health networks.  
g) In health emergencies, opportunities to build national capacity from the 
start of EU humanitarian actions will be analysed for linking humanitarian 
aid to longer-term reconstruction and de velopment of the health sector. The 
Linking Relief Rehabilitation and Deve lopment (LRRD) analysis of health 
needs should provide input for the annual meetings on division of labour for health referred to above. 
 
c. How?  
 
1. To comply with aid effectiveness commitments
: 
 
a) In line with the Paris and Accra commitments in aid effectiveness and the 
proposed target in the Communication, th e Commission will allocate, by 2015, at 
least 80% of its health aid using country systems (public finance and 
procurement) and 66% through programme based assistance. 
b) In countries where the IHP JANS and count ry compacts are not in place or where 
there is insufficient assurance of the qua lity of health strategies and public 
financing and notably in fragile cont exts, opportunities for “shadow alignment 
processes” and enhanced capacity-building wi ll be explored so as to prepare the 
ground for aligned and predictable health aid. 
c) Commission services will or ganise information sessions with the IHP Secretariat 
for EU Member States to inform them and encourage them to consider joining the IHP principles and its country compact commitments. 
d) Commission services will call for join t EU positions on the boards of global 
health initiatives (the Global Fund to fi ght HIV/AIDS, Tuberc ulosis and Malaria 
and the Global Alliance for Vaccines a nd Immunisation) encouraging them to 
comply with IHP commitments. This will imply gradually expanding the scope 
of their activities and the predictability  of their grants to adapt to national 
expenditure frameworks and to country st rategies and using the JANS process as 
a basis for their funding. 
 
2. To support developing countries’ efforts
: 
a) In relation with the Council conclusions of November 2008, Commission 
services will convene joint EU dialogues with partner countri es to facilitate 
progress towards their commitments on allocation of domestic revenue to 
 
EN 14   EN health19. This dialogue will be closely linked to public expenditure reviews and to 
regular monitoring of budget support and MDG contracts. 
b) In compliance with the Council conclusions of November 2008, Commission 
services will support development of so cial protection frameworks aimed at 
improving access to quality health services  and mitigating the economic impact 
of ill-health, giving priority to action in the most disadvantaged communities. 
• Commission services, in collaboration with the WHO, ILO and 
initiatives such as ‘Providing fo r Health’ or the International 
Centre of Progressive Financing, will develop specific guidelines on assessment and di alogue at country level on 
health financing schemes and strategies to improve their 
contribution to universal coverage. 
• Commission services will facilitate exchanges of experience 
between the EU and other regions on different models of health 
financing schemes based on th e common principles of 
solidarity, equity, universality and quality of care and adapted to 
local contexts. 
• Commission services will monitor, in collaboration with the 
WHO and WHO-Afro, the progress towards the target set in the EU-Africa Strategy on progressive abolition of user fees for 
basic healthcare, its impact and the lessons learned from those 
processes. Based on the experience gained from this, Commission services will adjust its sector policy guidelines.   
 
3. To address the multi-sectoral nature of health
: 
Commission services will stress, in EU coordination and in the dialogue with 
partner countries, the multi-sectoral dimens ion of health, particularly the links to 
gender equality and access to education (MDGs 2 and 3), nutrition (MDG 1) and water and sanitation (MDG 7). 
 
a) Commission services, in collabora tion with the WHO, UNFPA and 
UNIFEM, will assess progress and promote policy dialogue at country level on the gender dimensions of na tional health strategies, ensuring 
universal access to reproductive health  and a better gender balance in 
human resources for health. It will fo cus on the EU efforts in this area, 
such as the EU Action Plan on Gender Equality and Women’s Empowerment, and promote greater coll ection and use of data on health 
giving a breakdown by gender. 
b) Commission services will continue to explore, with the UN, diverse leads 
                                                
 
19 Africa Union in Abuja target, other ACP countries in Brussels declaration: both calling for 15  % 
national budget allocations to health. 
 
EN 15   EN on food security and nutri tion, ways to support st ronger UN leadership and 
a global multi-sectoral action plan on nutrition, as agreed by the WHO 
Executive Board in 2010. At country level, Commission services will 
continue to address nutr ition in the policy area s of food security, food 
assistance, social protection and h ealth and to support development of 
national nutrition plans which are multi-s ectoral with clear leads, mandates, 
services and targets. Commission services will ensure that health strategies include basic nutrition se rvices and links with the key sectors on food 
security and social protection. The wider relations between health and nutrition and access to adequate food will need to consider the important concept of the right to food,  making use of tools such  as the FAO Right to 
Food Methodological Toolbox. 
c) Commission services will continue to  collaborate with UN organisations 
and other partners to  speed up the contribution made by water and 
sanitation services to improving health. Commission services itself, and whenever calling for joint EU action, will promote aid effectiveness and the link between comprehensive and multi-sectoral national health 
strategies and availability, access and rational use of safe water and 
hygienic sanitation with the aid of links with the sectors and/or ministries 
responsible at country level. The link between health strategies and water 
includes considering the national legal definition of the human right to 
water  and sanitation and its relationship to other civil, cu ltural, economic, 
political and social rights. At operational level, attention will be paid to measuring water- and sanitation-related indicators in the health and other related sectors (mainly, the incidence of water-borne diseases and endemic 
parasitic infections which, together, ar e responsible for a large share of the 
burden of disease in developing countries).