Communication from the Commission to the Council and the European Parliament - Health and Poverty Reduction in Developing Countries
Date: 2002-03-22
Institutions: European Commission
Subjects: AIDS, EU aid, democracy, development aid, health policy, poverty, social policy

COMMISSION OF THE EUROPEAN COMMUNITIES

Brussels, 22.03.2002
COM(2002) 129 final

COMMUNICATION FROM THE COMMISSION
TO THE COUNCIL AND THE EUROPEAN PARLIAMENT

Health and Poverty Reduction in Developing Countries

EXECUTIVE SUMMARY

This Communication is  formulated in the context of the affirmation of poverty reduction as
the central  goal of the Community’s  overall  development  effort  and evolving  approaches to
development  assistance.  It  details  the  relationship  between  health  and  poverty;  it  outlines
critical elements of a coherent development approach to improve health and well-being; and it
establishes, for the first  time,  a single Community policy  framework to  guide investment in
health, AIDS, and population within the context of overall European assistance to developing
countries.

Health  targets  feature  prominently  in  the  Millennium  Development  Goals  to  which  the
Community, the Member States and the global community are committed. There is increasing
consensus  on  the  key  principles  that  promise  more  effective  development  assistance,
sustainable development and better health outcomes for the poor with new approaches being
undertaken  at  the  country  and  global  level  to  this  end.  Key  principles  include:  greater
ownership  and  participation  of  developing  countries  in  framing  aid  policies;  reducing  the
administrative  burden  on  political  and  administrative  systems  through  increasing  donor  co-
ordination; use of common pooled funding approaches with partner countries responsible for
designing  their  own  development  policy  in  consultation  with  all  stakeholders  (Poverty
Reduction  Strategy  processes);  the  further  untying  of  aid;  decentralisation  and  the  need  for
donor  countries  to  move  towards  0.7%  GNP  target.  This  health  and  poverty  policy  is  built
around these key  principles and  as  such  attempts  to  contribute  to  achieving  the  Millennium
Development Goals.

This  Communication  proposes  four  objectives  of  future  Community  support:  1)  to  improve
health, AIDS and population outcomes at country level, especially  among  the poorest; 2) to
maximise  health  benefits  and  minimise  potential  negative  health  effects  of  EC  support  for
other sectors; 3) to protect the most vulnerable from poverty through support for equitable and
fair  health  financing  mechanisms;  and  4)  to  invest  in  the  development  of  specific  global
public goods.

Past EC investment to improve health outcomes has been substantial and the present portfolio
exceeds  Euro  1.4  billion.  The  clear  link  between  improved  health  and  poverty  reduction
warrants further investment building on this extensive experience.

The country level will remain the focus of future health investment while the EC will engage
at  the  regional  and  global  level  where  it  can  add  particular  value.  At  the  country  level  the
Community will employ a range of  complementary interventions including: macroeconomic
support linked to improved health outcomes; support to sectors that have a wider impact on
health outcomes,  and  direct  support  to  the  health  sector.  The  Community  will  aim  to  speak
with  one  voice  at  all  levels  and  will  identify  more  effective  ways  of  working  with  all
development partners including the private sector.

Particular  challenges  include  the  implementation  of  pro-poor  health  policies,  making  health
systems more  equitable, assuring an environment that  is  compatible  with a  high standard of
human  health,  expanding  social  protection,  the  operationalisation  of  new  public/private
partnerships for health, the need for greater investment in specific global public goods and the
monitoring of performance, results and outcomes.

2

The Council and the  European  Parliament  are  invited to  work  with  the Commission  to take
forward  the  directions  set  out  in  this  Communication  to  contribute  to  sustained  support  for
health and poverty in developing countries.

3

TABLE OF CONTENTS

1.

2.

3.

4.

5.

6.

7.

INTRODUCTION ....................................................................................................... 4

HEALTH AND POVERTY-THE CASE FOR INVESTING IN HEALTH ............... 4

THE GLOBAL HEALTH ENVIRONMENT ............................................................. 5

TOWARDS MORE EFFECTIVE DEVELOPMENT ASSISTANCE IN HEALTH . 7

THE CONTRIBUTION OF THE EC TO BETTER HEALTH................................. 10

MONITORING INVESTMENT AND IMPACT OF EC DEVELOPMENT
ASSISTANCE IN HEALTH ..................................................................................... 18

CONCLUSIONS AND RECOMMENDATIONS .................................................... 20

Annex 1: The Millennium Development Goals ....................................................................... 21

Annex 2: The Evolution of the EC's Health, AIDS and Population Policy (1990-2000) ........ 23

Annex 3: Major Causes of Morbidity and Mortality in Developing Countries ....................... 24

Annex 4: Development approaches.......................................................................................... 25

Annex 5: Major Financing Instruments for EC Support of Health, AIDS and Population...... 26

Annex 6: Summary of Community Development Policy Framework, EU Member State
investments and development policies in health ...................................................................... 30

4

1.

INTRODUCTION

Health is a key  determinant of economic  growth and development  while  ill  health  is  both a
cause and effect of poverty. At the beginning of the 21st century global health is much worse
than it could be. The world’s developing countries suffer a huge burden of disease, much of
which is preventable or manageable using  available  interventions.  This  toll  of ill health and
premature  death  affects  the  poor  disproportionately.  In  many  countries  the  situation  is
deteriorating  with,  in  the  most  affected  countries,  reversal  of  the  health  and  development
gains  of  recent  decades.  This  decline  constitutes  a  public  health  crisis  and  a  major
development  challenge  to  the  international  community.  Improving  the  health  of  the  poor  is
both a vital contribution to efforts to reduce poverty and a moral imperative.

Current policy guidance for investment in health, AIDS and population activity is set out in a
series  of  Community  Communications  and  Resolutions  dating  from  1994.  The  evolution  of
development assistance approaches in the European and global contexts and increasing clarity
of  the  relationship  between  health  and  poverty  warrants  a  revision  of  guidance.  The  EC
Development  Policy  of  2000  established  poverty  reduction  as  the  overarching  aim  of  the
Community’s  development  assistance.  The  Community’s  approach 
to  sustainable
development clearly puts an emphasis on health as an indicator of improved socio-economic
outcomes  and  as  a  prerequisite  for  the  necessary  socio-economic  balance  that  underlies
sustainable  development.  The  increasing  convergence  of  development  objectives  across  the
EU  around  the  Millennium  Development  Goals  offers  an  opportunity  for  a  stepped-up  co-
ordination of Community and Member States’ policies and approaches in health.

EC  investment  in  knowledge  and  support  for  health,  AIDS  and  population  policies  and
programmes  in  developing  countries  has  been  substantial  with  a  current  EC  health  and
development  portfolio  of  Euro  1.4  billion  (section  6).  This  extensive  experience  warrants
continued  and  increased  investment  to  improve  health  outcomes  through  a  multi-sectoral
approach at the country level and through additional efforts at the regional and global level.

This Communication details  the  relationship  between  health  and  poverty.  It  outlines  critical
elements  of  a  coherent  development  approach  to  improve  health  and  well-being;  and  it
establishes, for the first time, a single Community policy framework to guide future support
for  health,  AIDS,  population  and  poverty  within  the  context  of  overall  EC  assistance  to
developing countries1.

2.

HEALTH AND POVERTY-THE CASE FOR INVESTING IN HEALTH

The  poor  are  deprived  of  resources,  opportunities  and  from  realising  their  potential.
They live in insecure and marginal conditions and have a limited ability to withstand shocks.
Almost  half  the  world’s  population  lives  on  less  than  USD  two  per  day.  Limited  access  to
education restricts options for employment and access to information that could improve their
well being. Geographical and social exclusion further limits access to jobs and markets. Poor
health and premature death due to malnutrition, poor hygiene, lack of clean water, unhealthy
lifestyles and inadequate health care represents a significant loss of human capital. All social
indicators are worse for the poor with women and girls often the most disadvantaged.

1

DAC List of Developing Countries and Territories. ODA recipients as of January 2001

5

                                                
The  health  of  individuals  and populations  is  a  major  determinant  of  economic  growth
and social development. There is a strong correlation between investments in public health,
better  health  outcomes  and  economic  growth.  Better  health  improves  the  quality  of  life,
expands opportunities and safeguards livelihoods. There is a similar link between the state of
the environment and the health of the people exposed to that environment. As health improves
parents invest more in education. Improved intellectual development and physical well-being
leads to higher labour productivity, increased per capita income and extends the economically
productive  life  of  individuals.  Health  improvements  lead  to  lower  rates  of  fertility  and
reduced  dependency  ratios.  Infant  and  child  mortality  rates  are  particularly  sensitive  to
economic  security  with  low  levels  of  infant  mortality  correlating  well  with  higher  levels  of
economic growth and reduced rates of population increase. A healthy population can improve
social wellbeing  and macroeconomic  stability through  increasing tax  revenues  and  reducing
the burden of health related expenditure.

Poor health drives poverty, acting through a variety of direct and indirect mechanisms.  Ill
health, malnutrition and high fertility cause households to become or remain poor. The poor
have  the  highest  burden  of  communicable  diseases,  the  highest  levels  of  fertility,  often  to
compensate  for  high  childhood  death  rates,  and  the  highest  rates  of  child  and  maternal
mortality. They have the least access to formal health care and tend to under-utilise available
health services, particularly preventive services, which may not be seen as responsive to their
immediate needs.  The  poor have little capacity to  cope  financially  with  catastrophic  illness,
which can precipitate debt and deep poverty from which it is difficult to escape. In East Asia,
50%  of  household  financial  crises  are  triggered  by  such  events.  The  poor  are  also  most
vulnerable  to  natural  and  man-made  environmental  shocks.  Often  they  live  in  ecologically
fragile areas and such shocks can push them into deeper poverty.

A  heavy  disease  burden  reduces  economic  growth  and  further  limits  the  resources
available  to  governments  to  invest  in  public  health,  or  poverty  reduction  efforts.  The
World  Bank  estimates  that  many  African  countries  may  lose  0.5-1.2  %  per  capita  growth
annually  due  to  HIV/AIDS  alone  yet  the  total  impact  may  not  have  been  fully  calculated.
Malaria  in  sub-Saharan  Africa  is  the  direct  cause  for  a  7.4%  loss  of  total  GNP.  There  is  a
growing awareness, further documented through the detailed work recently carried out by the
Commission  on  Macroeconomics  and  Health  of  the  WHO  (CMH)2,  that  the  extent  and
duration  of  these  effects  are  significantly  more  profound  than  previously  realised.  The  total
return  on  health  investments  in  developing  countries  is  estimated  by  the  CMH  at  18%  per
annum.  The  CMH  further  calculates  conservatively  that  a  major  global  effort  to  tackle
avoidable diseases would generate at the very least USD 168 billion per year in extra revenue.
More  specific  estimates  demonstrate  for  example  annual  global  savings  of  USD  1.5  billion
per  year  once  poliomyelitis  has  been  eradicated  and  all  control  measures  stopped3.  These
estimates do not include the additional benefits of improved prospects for economic growth.

3.

THE GLOBAL HEALTH ENVIRONMENT

Improvements in global health but uneven benefits and new threats

2

3

Commission on Macroeconomics and Health, Interim Report, October 2001, Final report December 2001.
Economic analyses of disease eradication remain problematic and somewhat controversial. This figure stems from
the most comprehensive analysis available even though focused primarily on the costs and benefits in industrialised
countries. From: Theme Papers, Disease eradication as a public health strategy: WHO 2000, 78(3)

6

                                                
The past 40 years have seen unprecedented improvements in global health. Life expectancy,
particularly in the developing countries, has risen,  fertility  has fallen, infant and  child  death
rates  have  halved,  malnutrition  rates  have  declined  by  one  third,  and  the  percentage  of  the
population  with  access  to  safe  water  has  doubled  to  70%.  There  have  been  notable  public
health successes; smallpox has been eradicated and polio may soon follow. Yet the benefits
have  not  been  equally  shared.  In  much  of  the  developing  world,  infant  mortality  still
remains 20 times that of developed countries, malnutrition and disease are rife and half of the
population has no access to safe water and sanitation.

Globalisation  offers  enormous  potential  but  also  introduces  considerable  challenges  to  all
societies, developed  and developing.  Health  may  be  further  improved  through  the  increased
sharing  of  knowledge,  wider  access  for  developing  countries  to  world  markets,  increased
investment  in  health,  education  and  food  security,  and  the  development  of  new  life-saving
technologies.  However,  there  are  also  social,  environmental  and  health  threats  such  as  the
HIV/AIDS  pandemic,  the  rapid  increases  in  microbial  resistance  and  the  emergence  or  re-
emergence of infectious diseases, the migration of skilled labour, environmental degradation,
the  undermining  of  traditional  practices  and  access  to  affordable  drugs.  The  sustainable
development challenge is the most acute in developing countries. Insufficient determination
to tackle stark inequalities between countries and within them is not just a failure in itself, it
could also undermine progress achieved thus far.

Conditions influencing health and well-being of the poor

The most substantial proportion  of  the  disease  burden  of  the  poor  is  represented  by  a
continuing high toll of illness and premature death from a small number of preventable
or manageable conditions:

1)  communicable  diseases  including  HIV/AIDS,  malaria,  tuberculosis,  acute  respiratory
infections, diarrhoeal diseases, parasitic diseases and vaccine preventable diseases, which all
affect  the  poor  disproportionally;  2)  reproductive  health  including  sexually  transmitted
infections,  abortion  and  maternal  health  affecting  poor  women  most;  3)  nutritional
deficiencies  affecting  poor  children  most;  4)  lifestyle  related  illness,  particularly  those
caused by the increasing use of tobacco in developing countries. The characteristics and scale
of these conditions are elaborated in annex 3.

Additional  concerns  contributing  to  the  burden  of  diseases  and  well-being  of  the  poor
are the following:

High  levels  of  population  growth  place  enormous  stress  on  societies  including  many  of
those bearing the heaviest disease burden. World population has tripled from 2 billion to 6.1
billion over the past 70 years4 and will reach 9.3 billion by 2050 with 95% of the growth in
developing  countries.  Rapid  population  growth  leads  to  reduced  family  investment  in  each
child, affecting health and education prospects, lower levels of food production and damage
to  the  environment.  There  will  be  increased  numbers  of  the  elderly,  the  poor  and  large
numbers  of  youth  under  18  years,  who  constitute  50%  of  the  population  of  developing
countries.

The health and gender divide. Some 70% of the world’s poor are women and girls5. They
experience more ill health, are less likely to benefit from health services and endure a cycle of

4

5

UNFPA, The State of the World Population, 2001
UNDP, Human Development Report: Gender and Human Development, 1995

7

                                                
ill  health,  child  bearing  with  high  morbidity  and  mortality,  and  hard  labour.  Maternal
outcomes in pregnancy represent the starkest example of continuing gender and health status
inequity. For every maternal death there is additional disability, continuing ill health and long
lasting impact on the family. There is a strong correlation between female education and use
of (reproductive)  health services, health status  and  child mortality of  future generations,  yet
girls  remain  less  likely  to  be  educated  than  boys.  Education  positively  influences  gender
relations and the ability to make informed choices.

Environmental factors are responsible for 20% of the total disease burden in the developing
world  and  for  30%  in  sub-Saharan  Africa.  Lack  of  access  to  affordable  safe  water  and
sanitation is a major cause of ill  health and  life  threatening  disease in developing  countries.
Water related diseases kill an estimated three million people annually, mostly young children
and improving access to safe water is the most important health priority for the poor. Without
targeted action to encourage improved supply and use of energy, rising population will lead to
higher levels of greenhouse gas emissions, as energy consumption increases; this will further
contribute  to  climate  change.  A  consequence  will  be  the  increased  spread  of  vector  born
diseases,  including  perhaps  the  return  of  malaria  to  areas  where  it  has  previously  been
eradicated, increased risks of flooding, land degradation and conflict.

The  increasing  use  of  fertilisers  and  pesticides,  needed  to  produce  greater  crop  yields,  will
further  disturb  the  ecological  balance.  The  global  loss  of  bio-diversity  is  also  undermining
health  and  productive  capacity.  The  burning  of  traditional  biomass  for  cooking  and  heating
accounts for over half of the energy consumed in many developing countries and presents a
major health hazard, particularly for women and children, due to poor indoor air quality from
the  resulting  smoke.  The  absence  or  lack  of  control  over  the  environmental  impact  of
industrialisation can lead directly or indirectly to additional threats to people’s health. All of
these  negative  trends  have  a  disproportionate  impact  on  current  and  future  livelihood
opportunities  of  the  poor  who  are  over-reliant  on  income  from  primary  environmental
resources.

Current investment in health in developing  countries  influencing  interventions  including
public  health,  personal  health  services  and  education  is  insufficient  and  often  ineffective.
Developing  countries  face  difficult  choices  where  budgets  fall  far  short  of  the  minimum
required  to  deliver  a  minimal  health  system  to  the  population.  Policies  and  plans  are  often
over-ambitious,  under-resourced  and  fail  to  prioritise  interventions  for  the  best  returns  to
health  outcomes  and  poverty  reduction.  A  clearer  view  is  emerging  of  the  costs  needed  to
provide  health  services.  The  CMH  estimated  that  USD  30-40  per  capita  per  year  in  public
investments  would  be  needed  to  deliver  a  very  minimal  health  system  able  to  significantly
reduce avoidable deaths in low-income countries6. The WHO arrived at a figure of USD 607
for a more comprehensive health system. This compares with an average level of expenditures
among the 49 least developed countries (LDCs) of USD  11  per  year8. While there are wide
variations,  resources  clearly  fall  far  short.  The  commitment  of  African  leaders  at  the  Abuja
Summit9 to allocate 15% of  national budgets to  health is widely  commended. However,  the
process  of  increasing  domestic  revenues  and  using  these  for  social  sectors  will  need  to  be

6

7

8

9

Commission on Macroeconomics and Health, 2001. Note: this does not include important elements such as family
planning,  tertiary  hospitals  and  emergencies,  which  would  also  need  to  be  part  of  any  fully  functional  health
system. Low income countries – per capita GNP less than USD 760 in 1998
World Health Report, 2000
Commission  on  Macroeconomics  and  Health,  2001.  Note:  this  includes  total  investments  from  the  public  and
private sectors and from donors
African Summit on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, Abuja, April 2001

8

                                                
supported  by  far  greater  efforts  of  the  international  community,  until  a  sustainable  level  of
development has been reached.

4.

TOWARDS  MORE  EFFECTIVE  DEVELOPMENT  ASSISTANCE  IN
HEALTH

Poverty reduction as a central goal and clear international targets

Health,  and  the  need  to  dramatically  improve  health  outcomes  for  the  poor,  is  high  on  the
international  development  agenda  and  has  featured  prominently  in  major  international
development fora of recent years, including UN conferences and Special Sessions of Cairo,
Beijing  and  Copenhagen,  New  York  and  the  G8  summits.  The  Johannesburg  Summit  is
another  opportunity  to  reinforce  the  links  between  health  and  sustainable  development  at  a
global  level,  and  in  particular  to  demonstrate  the  EU’s  experience  with  sustainable
development. More recently the members of the World Trade Organisation have affirmed that
the  TRIPS10  agreement  does  not  and  should  not  prevent  Members  from  taking  measures  to
protect public health.

Most governments  and  international organisations  are  committed to achieving  a  set  of  eight
ambitious  and interrelated  Millennium  Development  Goals  (MDGs  –  annex  1).  Central  to
these goals is the reduction in the proportion of people living in extreme poverty by one-half
by  2015.  Health  targets  feature  prominently  highlighting  the  link  between  overall  poverty
reduction and health investments. Current trends suggest that the goals can only be met with
more effective use of existing interventions, alongside major increases in investment and the
application  of  more  effective  public  health  approaches  and  incentives.  Further  work  on
meeting  the  goals  and  targets,  and  translating  the  international  commitment  into  a  strategy
with  intermediate  and  national  health  indicators  is  an  ongoing  process,  which  requires
constant monitoring and regular evaluation. This is further elaborated in section 6 below.

Improving development effectiveness in health

Development approaches

A variety of approaches now being put into practice both at the country level and at the global
level, offer the potential for delivering more  effective development assistance  and improved
health  outcomes  for  the  poor.  More  explanatory  details  on  the  development  approaches  are
included in annex 4.11

At  the country level,  increased ownership, good  governance  and  stewardship are critical
pre-requisites for  development  effectiveness and  efficiency.  The  potential  for  greater  policy
coherence  across  sectors  is  provided  by  the  increasing  adoption  of  Poverty  Reduction
Strategies  (reflected  in  national  development  frameworks  or,  where  applicable,  in  Poverty
Reduction Strategy Papers (PRSPs)) as the framework to guide development assistance by
all donors. The PRS provide an opportunity to ensure that relevant policies and investments in
sectors that have an impact on health, e.g. education; food security and safety; safe water
and sanitation; clean household energy sources; taxes, trade and investment policy and micro-

10

11

|Agreement  on  Trade  Related  Aspects  of  Intellectual  Property  Rights  and  WTO  Ministerial  Declaration  on  the
TRIPs Agreement and Public Health adopted at Doha on 14 November 2001, paragraph 4
For more background on key principles to fulfil the poverty and development commitments enshrined in the United
Nations Millennium Declaration, see the report of the High-Level Panel on Financing for Development, prepared
by E. Zedillo, UNGA 55th Session, 26.7.2001

9

                                                
credit,  are  coherent  and  work  towards  better  health.  At  the  global  level  there  is  a  need  to
promote  policy  coherence  in  international  development  policies  and  institutions  and
within  multilateral  rules  and  treaties  in  trade  and  investment,  economic  development,
environment, intellectual property protection and labour policies.

The  increasing  support  for  sector-wide  approaches  (SWAp)  offers  further  potential  to
increase the effectiveness and efficiency of aid although experience of such approaches is still
limited  and  they  are  not  inherently  pro-poor.  Harmonising  donor  operational  policies  and
procedures, better targeting of aid, donor concentration where each can add the greatest value,
further untying of development aid and deeper debt relief12 are also needed to increase aid
effectiveness.  Information  and  communication  technologies  could  be  used  as  a  tool  to
improve  the  efficiency  in  the  management  of  resources  and  establishment  of  appropriate
information  systems  as  well  as  in  health  care  delivery  services,  notably  through  distance
applications.

Pro-poor health policies

Governments must ensure that health policies are co-ordinated and pro-poor. The supply
of  accessible  personal  and  non-personal  health  services,  the  promotion  of  policies  in  other
sectors that have an impact on health with particular benefits for the poor, and fair financing
mechanisms  that  reduce  the  burden  of  health  service  utilisation  are  all  part  of  a  pro-poor
health policy.

Pro-poor  strategies  include  targeting  services  on  the  poor,  combating  diseases  of  poverty
and/or  reallocating  resources  in  favour  of  poorer  geographic  areas.  Classic  public  health
interventions  are  inherently  pro-poor.  Examples  are  environmental  control,  provision  of
public  information  on  health  risks,  regulation  of  health  service  providers,  food  fortification
programmes, and ensuring safe water and workplace safety.

The  expansion  of  social  protection,  including  fair  and  equitable  financing  mechanisms
should remove barriers, encourage use of services by the poor and protect them from the risks
of  impoverishment  due  to  health  expenditure.  In  most  poor  countries  health  care  is
insufficiently  financed  through  taxation.  The  limited  resources  available  have  led  many
countries to introduce an element of cost sharing with safety nets to ensure that basic services
remain affordable. Out of pocket payments by the poor should gradually be reduced and risk
pooling  expanded  through  community,  private,  social,  and  national  insurance  schemes.  It  is
important  to  ensure  that  public  spending  is  focused  on  those  activities  most  likely  to
contribute  to  improved  health  outcomes  for  the  poor  and  that  budget  allocations  reflect
population distribution, the burden of disease, the cost of service delivery and poverty levels.

A healthy environment

Ill health can be improved through a better control of the environment, especially the quality
of  water  and  air,  and  through  increased  aid  aimed  at  managing  pollution  caused  by
industrialisation, which is often poorly controlled.

Encouraging corporate responsibility

12

The  continuing  debt  burden  impedes  development  efforts  and  the  Heavily  Indebted  Poor  Countries  Initiative
(HIPC), launched in 1996, aims to provide debt relief to the worlds poorest and  most  heavily  indebted  countries
with debt savings allocated to investments in the social sectors

10

                                                
Recent  years  have  seen  substantial  growth  in  the  movement  of  capital  around  the  globe,
bringing  Foreign  Direct  Investment  to  more  than  three  times  the  level  of  development  aid.
Transnational corporations  can  make  a  significant  contribution  to  economic  development  in
developing  countries.  The  positive  impact  of  these  investments  on  sustainable  development
overall, and on social standards in particular, can be optimised through appropriate regulation,
which  encourages  corporations 
to  higher  standards  of  corporate  social
responsibility.  One  way  in  which  good  practice  could  be  stimulated  is  though  encouraging
European companies to work with the OECD guidelines for foreign investors13.

to  adhere 

Reversing the decline in overall development aid

There  is  a  new  and  concerted  effort  by  the  Community  and  its  Member  States  to  meet  the
long-standing  commitment  to  allocate  0.7%  of  GNP  for  development  (Council  Declaration
November  2001).  Aid  levels  have  declined  for  much  of  the  1990s  so  that  by  2000,  donors
directed  only  0.22%  of  GNP  (USD  53.06  billion)14  to  development  efforts.  The  EU
contributes 0.33% of GNP (USD 25.4 billion). Not enough of this development  support has
been  allocated  to  the  countries  that  need  it  most  –  aid  to  the  poorest  countries  in  1999
accounted  for  only  0.06%  of  donors  GNP.  Realising  the  0.7%  target  could  release  an
additional USD 125 billion annually. World  Bank estimates  suggest  that  the  central  goal  of
halving poverty by 2015, would require a rapid doubling of ODA flows.15

Investments in global public goods

There  is  growing  recognition  of  the  importance  of  specific  global  public  goods  (GPGs),
particularly in relation to the need to boost research and development in new products. This
will  require  incentives  to  industry,  new  innovative  approaches  and  partnerships  and  new
financial instruments. At present less than 10% of health research budgets by both the public
and private sectors is devoted to health problems in developing countries. Only 2% of global
research and development funding is devoted to research on major communicable diseases.16
However,  investments  in  the  development  of,  for  instance,  an  AIDS  vaccine  or  in  polio-
eradication demonstrate how resources can benefit all societies and therefore should not only
come from existing development assistance or public funding. Urgent needs include vaccines
and  new  drugs  and  diagnostics  for  HIV/AIDS,  malaria  and  TB.  The  EC  Programme  for
Action on Communicable Diseases advocates a strong focus on GPGs alongside other actions
in the area of improving impact of existing interventions, and the affordability of medicines.
EC financing for clinical development of AIDS and malaria vaccines in the last Framework
Programme is a good example of EC investment in GPGs as well.

Public-private partnerships

A growing number of global public-private partnerships have emerged to address the major
public health challenges and respond to specific concerns. Examples include the recent STOP
TB partnership, Roll Back Malaria, the International AIDS Vaccine Initiative (IAVI) and the
Medicines for Malaria Venture. Many of the European Vaccine R&D clusters funded under
the Fifth Framework Programme are effective public-private partnerships with one or several
private industry partners. The philanthropic  Gates Foundation has largely funded the Global
Alliance  for  Vaccines  and  Immunisation  (GAVI),  which  is  revitalising  international

13

14

15

16

OECD Guidelines for Multinational Enterprises: Revision 2000
Development Assistance Committee (DAC) of the OECD, April 2000
Financing for Development, Report prepared by World Bank and IMF, August 2001.
Global Forum for Health Research, 1999

11

                                                
vaccination  efforts.  The  recently  established  Global  Fund  to  fight  HIV/AIDS,  Tuberculosis
and  Malaria  is  the  latest  such  international  partnership.  Some  of  these  partnerships  have
begun  to  produce  results,  however  there  remains  the  danger  that  a  multitude  of  different
systems, each focusing on a different issue or disease will pose problems of coherence.

Public-private  partnerships  in  general  are  playing  an  increasing  role  at  the  country  level,
reinforcing country processes and building up equitable health systems.

THE CONTRIBUTION OF THE EC TO BETTER HEALTH

5.
The  objective  of  the  European  Community  Development  policy17  as  set  out  in  the  Joint
Declaration of November 2000 (annex 6) is to contribute to the reduction of poverty through
support for sustainable economic, social and environmental development and the integration
of developing countries into  the world economy. The  key  principles  of  assistance  and  pro-
poor policies to establish the right environment for growth and poverty reduction are outlined
in section 4. This section highlights a set of Community priorities to achieve better health at
country,  regional  and  global level and new ways of  working  with  Member  States  and  other
partners including multilateral agencies, the UN, civil society and the private sector.

EC  health  and  poverty  policy  framework  -  increased  investment  for  better  health
outcomes

The current EC policy guidance for support for health, AIDS and population activities is
set out in a series of Communications and Resolutions dating from 1994 (annex 2). Support
has evolved over the  years from  an initial focus on  health  infrastructure development to the
provision  of  basic  health  services, 
institutional  strengthening  and  human  resource
development.  Specific  support  for  HIV/AIDS  policy  and  programmes  has  been  a  constant
feature while broad-based support included essential drug procurement, rehabilitation, health
financing and health systems strengthening.

More  recently,  the  EC  has  gained  experience  in-country  with  sector  wide  approaches  and
pooled  or  basket  funding  with  other  donors,  and  globally  with  policy  and  strategy
formulation, actively contributing to influencing international policy and external coherence.
The  Commission  has  increasingly  played  a  co-ordination  role  at  EU  level  for  health  and
development  issues,  and  has  developed  close  co-operation  with  civil  society  and  dialogue
with  the  private  sector.  The  EC  Programme  for  Action  on  Communicable  Diseases  in  the
Context of Poverty Reduction published in February 2001 reflects this effort.

The overall objectives of EC health and poverty policy are to:

(cid:1)  improve  health,  AIDS  and  population  outcomes  at  country  level,  especially  among  the

poorest;

(cid:1)  maximise health benefits and minimise any potential negative health effects of EC support

for other sectors;

(cid:1)  protect  the  most  vulnerable  from  poverty  through  support  for  equitable  and  fair  health

financing mechanisms;

(cid:1)  invest in the development of specific global public goods.

17

The European Community’s Development Policy, Com (2000) 212

12

                                                
To  achieve  the  above,  the  EC  has  identified  a  set  of  inter-linked  and  mutually  reinforcing
priorities  where  EC  interventions  add  particular  value.  The  country  level  will  remain  the
major focus of EC investment in health, and support for activities at at the regional and global
level,  will  reinforce  and  complement  the  health  related  objectives  of  the  countries  and
communities. Overall, EC interventions are expected to increase. Moreover, the Community
will increase efforts to speak with one voice (Community and its Member States) at country
and regional level and within international fora.

Country level focus

The  Community  has  strong  and  long-term  partnerships  with,  and  presence  in,  most
developing  countries.  The  Community  will  provide  long-term  support  to  policies  and
practices that promise the best health outcomes for the poor and will prioritise actions against
the following health concerns that disproportionately impact upon the poor:

(cid:1)  promotion  of  public  health  -  in  particular  prevention  efforts,  including  education  and

information about the spread of diseases, and tobacco control;

(cid:1)  strengthening of health systems to improve the access to quality services;

(cid:1)  ensuring pro-poor systems of health financing and social protection.

(cid:1)  communicable diseases - in particular HIV/AIDS mainstreaming, malaria and TB;

(cid:1)  reproductive and sexual health and rights - in particular maternal health.

The above concerns will be addressed through:

(cid:1)  following  a  comprehensive  approach  in  country  level  programming,  linking  as  far  as
possible  all  resources  and  instruments  in  support  of  a  nationally  owned  health  policy
framework;

(cid:1)  reinforcing  macro-economic  policy  dialogue  in-country,  addressing  social  sectors,  in
particular  health  and  education,  to  protect  and  where  possible  increase  social  sector
budgets and to work to make their distribution made more equitable;

(cid:1)  ensuring that Country Strategy Papers (CSPs) reflect the basic principles of EC support for

health, AIDS and population in developing countries18;

(cid:1)  ensuring coherence in policy planning, programme and project design and implementation,

between health and other sectors that particularly influence health outcomes;

(cid:1)  maintaining and where possible increasing support for health in developing countries;

(cid:1)  reinforcing support for human resource development and institutional capacity building;

(cid:1)  enhancing  support  for  monitoring  national  social  sector  budget  allocations  and

improvements in health outcomes as part of the PRSP process;

18

See programming guidelines: EC Support for Health, AIDS and Population, October 2001

13

                                                
(cid:1)  support for knowledge generation and management, capacity building and dissemination of

best practice built on evidence-based approaches in developing countries.

Community assistance will target low-income countries19 though prioritisation will be flexible
and also take into account non income-based criteria. In middle-income countries20, emphasis
will be to reform health systems to become more equitable and efficient, alongside support for
populations with poor health outcomes.

The  Community  will  work  closely  with  development  partners  including  government,  civil
society  and  the  private  sector  and,  where  appropriate,  will  encourage  regular  fora  for
stakeholder consultation. It will maximise opportunities for joint working with Member States
and other donors.

The country specific approach, level of support and instruments used (annex 5) will be further
defined  by  the  quality  of  macroeconomic  and  budget  management,  the  degree  of  aid
dependence, the quality of sector level policies and management within the country. Budget
support, social sector support, programme- and project support can be complementary as long
as  they  support  a  nationally  defined  policy  framework.  Where  budget  support  is  not
appropriate, Community funding will support programmes and projects within the context of
a national framework and will focus on capacity building. Where a national framework is not
in place, the Community will facilitate the evolution towards a sector wide approach. In most
developing  countries,  the  Community  will,  during  an  interim  period  of  capacity  and
confidence  building,  maintain  a  mixed  portfolio  (project,  pooled  sector  funds,  earmarked
budget support).

In  the  light  of  the  ongoing  reform  of  the  Commission’s  External  service,  including  the
deconcentration of the management of external assistance, it is expected that EC Delegations
will be reinforced to meet the requirements in the area of social development.

Regional added value

The  European  Community  embodies  the  EU’s  collective  experience  of  regional  integration.
The  Community  has  a  particular  role  to  play  in  supporting  regional  integration  to  address
cross-border  challenges.  Past  and  current  regional  EC  support  includes  HIV/AIDS  in
Southern  Africa,  malaria  prevention  in  South  East  Asia,  reproductive  health  in  Asia  and
vaccination  and  pharmaceutical  policy  and  practice  in  West  Africa.  The  following  areas
where a regional approach may particularly add value are prioritised for EC support:

(cid:1)  experiences in health sector reform and health care delivery approaches and tools linked to
public  health  priorities;  decentralisation,  human  resources  development,  monitoring  and
assessment of performance in social development;

(cid:1)  demographic surveys, integrated disease surveillance and epidemic preparedness;

(cid:1)  issues  related  to  pharmaceutical  policy  including  drug  regulation,  regional  procurement

and capacity building for implementation of the TRIPS agreement;

19

20

Low income countries – per capita GNP less than USD 760 in 1998
Middle income countries-per capita GNP USD 761-3030 in 1998 (lower middle income) and USD 3031-9360 in
1998 (upper middle income)

14

                                                
(cid:1)  support for research, development, provision and protection of public goods, in particular
AIDS  and  malaria  vaccines,  but  also  knowledge  and  education,  food  security,
environment, peace and security, financial stability.

The above areas will be addressed through:

(cid:1)  providing  input  into  Regional  Economic  Partnership  Agreements  to  ensure  that  health

issues are adequately addressed;

(cid:1)  support for critical analyses of the capacity of regional institutions;

(cid:1)  developing partnerships  with  governments,  regional institutions,  multilateral  and bilateral

agencies, the UN, civil society groups, development banks and the private sector;

(cid:1)  support for knowledge generation and management, capacity building and dissemination of

best practice built on evidence-based approaches.

Existing  Community  financing  instruments  provide  adequate  support  for  regional  activities.
The  EC  will  explore  the  provision  of  regional  technical  support  through  collaborative
arrangements  with  Member  States.  Past  and  current  experience  whereby  interested  Member
States second regional health experts to an EC Delegation, has proven to be highly effective
and  further  arrangements  will  be  explored.  Other  accompanying  measures  towards  a  sector
wide approach in line with strategies for poverty reduction will be explored as well.

Co-ordination, complementarity and synergy with Member States

The  Member  States  have  drawn  from  their  differing  histories  and  experiences  in  framing
development  policy.  This  has  led  them  to  adopt  a  range  of  approaches  to  improving  health
outcomes  in  developing  countries  (annex  6).  Areas  of  relative  strength  and  expertise  vary
correspondingly, but there is a strong degree of complementarity and synergy between them
and  taken  together  with  the  Community  they  represent  a  rich  pool  of  knowledge,  resources
and experience to draw from.

While  differences  in  approaches  and  instruments  remain,  there  is  increasing  convergence
around  the  Millennium  Development  Goals.  As  EU-wide  collaboration  in  health  deepens,
greater  consensus  and  increased  levels  of  co-ordination  and  complementarity  will  provide
opportunities  for  building  on  best  practice  and  maximising  the  impact  of  European
development assistance in health.

At  the  country  level,  policy  and  programming  co-ordination  should  be  assured  through  the
country strategy process. The Country Strategy Paper is the main multi-annual instrument
for  guiding,  managing  and  reviewing  EC  development  assistance.  It  builds  on  the  existing
national development framework, including the PRSP where applicable. It is developed with
governments  and  in  consultation  with  Member  States,  other  donors  and  civil  society.
Partnership,  co-ordination  and  co-financing  opportunities  between  EU  Member  States  are
increasing  as  policy  shifts  towards  sectoral  support  mechanisms  and  in  some  countries  to
budget support. Strengthened EC partnership in-country will aim to facilitate operational co-
ordination,  the  harmonisation  of  procedures,  joint  monitoring,  and  -  eventually  -  unified
financial support.

At headquarters and delegations level, the co-ordination experience of recent years through
expert  groups  and  partnerships  with  multi-laterals  has  had  tangible  results.  The  established

15

EC  Health,  AIDS  and  Population  Experts  Group,  which  allows  informal  discussion  on
priority  issues  and  consultation  on  policy  and  strategy  development,  should  be  further
developed.  The  concerted  efforts  in  international  policy  dialogue  should  be  further
maximised. Recent joint achievements include progress on untying aid and the establishment
of the common EU research platform  for  communicable diseases.  The  initiative to establish
the EC Programme for Action against major Communicable Diseases is a further example of
strong EC co-ordination.

The EC will prioritise the following areas of work on complementarity and co-ordination with
the Member States:

(cid:1)  identifying  practical  steps  for  improved  coherence  between  EC  sector  policies  and

activities;

(cid:1)  increasing EC participation in public/private partnerships and in other donor partnerships;

(cid:1)  strengthening  operational  co-ordination  between  EC  and  Member  States  in  developing

countries.

The above areas could be addressed through:

(cid:1)  identifying  the  respective  comparative  advantage  of  the  European  Community  and  its
Member  States  in  health  and  poverty  and  preparing  a  proposal  on  how  best  to  share
responsibilities  and  work  programmes  in  order  to  maximise  EC  complementarity  at
country and global level;

(cid:1)  strengthening  the  Commission's  role  in  EU  policy  co-ordination  in  health  and  social

sectors and in ensuring the complementarity of Community aid;

(cid:1)  sharing  information  and  know-how  through  systematic  networking  in  close  partnership
with  developing  countries.  The  establishment  and  maintenance  of  an  EC  health  and
poverty  web-site  and  a  public  access  database  providing  information  on  health
interventions of the EC and Member States is one example of possible activities to explore;

(cid:1)  strengthening  the  work  of  the  EC  and  the  Member  States  Health  Experts  Group  at

headquarters level;

(cid:1)  establishing  in-country  regular fora  and joint  missions for EC co-operation  in health.  EC
and  Member  States'  aid  institutions  de-concentration  should  facilitate  in-country  co-
operation with increased number of skilled and directly responsible staff in place;

(cid:1)  maximising  the  use  of  skilled  Member  States  staff  with  a  range  of  expertise  on  health
issues, by improving their allocation and, where appropriate, by pooling them to obtain a
critical mass of European health and poverty expertise at country and regional level;

(cid:1)  awareness  building  and  guidance  for  staff  working  in  non-health  sectors  in  order  to

increase accountability towards health and poverty.

A stronger emphasis on ensuring a full and active Community/Member States partnership in
health,  population  and  poverty  requires  flexible  financing  instruments  and  matching  human
resources.

16

Global level input – working with international partners

As  highlighted  in  section  4,  the  European  Community  and  its  Member  States  share  a
responsibility to uphold the  principles of  international agreements such as the Cairo (1994),
Copenhagen  and  Beijing  (1995)  Programmes  of  Action, 
the  UNGASS  HIV/AIDS
Declaration,  and  to  contribute  towards  achieving  the  Millennium  Development  Goals.
Community initiated or funded work has influenced international policy in the area of health.
EC investments have also supported global knowledge generation and capacity building, such
as the HIV/AIDS policy research partnerships established with the World Bank and UNAIDS.

The  Community  is  a  substantial  donor  to  the  United  Nations  agencies21  and  participates
actively in the work of the G8. Strong transnational relationships with particular partners such
as the US, Canada and Japan have enhanced the impact of EC health and poverty principles in
international  debates,  and  have  advocated  the  scaling  up  of  resources  needed  for  health  in
developing  countries.  The  Commission  is  playing  an  active  role  in  co-ordinating  a  EU
approach in the  negotiations  around the  Global Convention  on  Tobacco,  initiated  by  WHO.
The impact of the Convention on developing countries is of utmost importance.

The  new  global  health  and  poverty  agenda  requires  strengthened  international  partnerships
with key agencies. To this end the following areas are prioritised for EC support:

(cid:1)  continued  EC  focus  on  global  initiatives  related  to  specific  global  public  goods,
communicable diseases, reproductive health, tobacco, fair financing and social protection;

(cid:1)  a  coherent  response  across  other  policy  areas  where  the  EC  has  competence,  including
trade, research and development, education, food security, agriculture and environment;

(cid:1)  active  involvement  in  the  development  and  operationalisation  of  public/private  global

initiatives such as the Global Fund to fight HIV/AIDS, TB and Malaria;

(cid:1)  maintain a high health and poverty profile within the G8 and other international fora;

(cid:1)  explore  and  further  develop  partnerships  with  International  Development  Banks  and

specialised UN agencies and engage with other international organisations;

(cid:1)  continue to work closely with the WHO on health policy, pharmaceutical policy, normative

issues and with UNAIDS on the specifics of HIV/AIDS policy and operations;

(cid:1)  continue  to  work,  through  country  and  regional  partnerships  for  service  delivery  and

commodity supply, with UNFPA and UNICEF;

(cid:1)  strengthen  Commission  input  in  the  Development  Assistance  Committee  (DAC)  of  the

OECD;

(cid:1)  work  closely  with  the  World  Bank  within  the  framework  of  support  for  PRSPs,  and  on
health and poverty policy, programming, research and operations in developing countries;

21

Improving  co-ordination  with  the  UN  is  a  Community  priority  with  development  assistance  the  initial  focus  for
closer  working.  See  for  more  detail:  Communication  from  the  Commission  to  the  Council  and  the  European
Parliament  on  Building  an  effective  partnership  with  the  United  Nations  in  the  fields  of  Development  and
Humanitarian Affairs (April 2000)

17

                                                
(cid:1)  Enchanced  co-operation  with,  and  support  for,  global  public/private  partnerships  such  as

GAVI, IAVI and others will be further explored.

The above areas will be addressed through:

(cid:1)  increasing efforts to speak with one voice (Community and Member States) at international

fora22;

(cid:1)  strengthening  efforts  to  present,  explain  and  project  Community  policy  priorities  in  the

global context;

(cid:1)  increasing  Community  presence  and  input  into  different  governing  bodies  of  the  UN

entities and other international fora;

(cid:1)  exploring opportunities to work with the private non-for-profit and for-profit sectors.

In order to use the  possibility  to  create  innovative  partnerships  with  different  actors,  and  to
contribute,  where  appropriate  and  duly  justified,  to  global  initiatives,  Community  financing
instruments  may  need  to  be  revisited.  A  first  attempt  has  been  made  through  the  ongoing
proposal for revision of the regulation of a special budget line for poverty diseases (B7-6211),
which  is  expected  to  be  adopted  in  2002  and  incorporates  financial  support  for  full
Community involvement at the global level.

Civil Society and Non Governmental Organisations

The NGO community has been a powerful advocate, influencing recent action on debt relief,
drug  affordability  and  patent  issues  and  has  acted  as  a  barometer  on  the  effectiveness  and
failures  of  development  assistance.  The  Commission  will  further  strengthen  work  with
NGOs/CSOs  to  advocate  and  influence  policy  dialogue  and  strategy  on  major  development
and health issues.

At  the  country  level,  the  EC  will  continue  to  include  NGOs/CSOs  in  programmes  as
important  service  delivery  and  outcome  or  performance  monitoring  partners.  A  substantial
part of EU investment flows through programmes and projects with the non-for-profit private
sector (annex 5). The Commission will continue to work on ensuring coherence between the
work of NGOs/CSOs and governments, donors and other partners. It will establish an EC and
Civil  Society  Working  Group  on  Health  and  Poverty.  The  intention  is  to  strengthen  and
maintain  a  confident  working  relationship  between  the  Commission  and  civil  society
representatives.  This  constitutes  a  recognition  that  there  are  ways  and  means  for  the
Commission to further improve transparency and openness, particularly in the area of policy.
Meetings may be organised on a bi-annual basis, including all stakeholders, i.e. NGOs/CSOs,
business and trade union representatives, MEPs and representatives of Member States and are
not to overlap with other existing regular fora for Community/civil society consultation.

Private sector

The  HIV/AIDS  epidemic  has  led  many  transnationals,  private  companies  and  investors  in
developing countries to review and extend their involvement in health and social protection.
The  private  sector  could  still  make  a  far  greater  input  to  health  in  developing  countries

22

A higher degree of consistency in EC and Member State positions in international fora is foreseen by the EC treaty
article 180.

18

                                                
through,  for  example,  the  Global  Fund  to  fight  HIV/AIDS,  TB  and  Malaria,  increased
commitments to work on corporate responsibility and the promotion of the wide application
of tiered pricing.

Community work with the private for profit sector has been limited to date and started to take
a more active approach under  the  EC Programme  for Action on  Communicable  Diseases in
the  Context  of  Poverty  Reduction  (February  2001).  Greater  attention  will  be  given  to
developing mechanisms for collaborating with this group, in particular in the following areas:

(cid:1)  New incentives are being discussed to engage transnationals and other private companies

in the development of global public goods;

(cid:1)  Enhanced co-operation with private investors to improve their responsibility for health in

developing countries;

(cid:1)  Exploring  options  to  increase  capacity  in  developing  countries  for  local  production  of
pharmaceuticals.  Viable  projects  will  be  supported  through  existing  private  sector
investment facilities facilitated by the EIB.

European  companies  will  be  encouraged  to  work  with  the  OECD  guidelines  for  foreign
investors and monitor performance to this end.

6.

MONITORING  INVESTMENT  AND  IMPACT  OF  EC  DEVELOPMENT
ASSISTANCE IN HEALTH

Community  development  assistance  for  health,  AIDS  and  population  has  evolved  from  an
initial focus on investment in discrete projects to sector support and  general budget support.
Monitoring  is  similarly  shifting  from  a  focus  on  specific  Community  inputs  and  outputs  to
assessments  of  performance  against  a  sector  or  national  development  framework.  These
assessments  are undertaken  jointly  with all development  partners. There  is  a  further shift in
focus  to  monitor  higher  global  level  outcome  measures  rather  than  inputs  and  outputs,
although the latter remain important intermediary measures.

Monitoring  performance  against  the  national  development  framework  allows  development
partners  to  best  understand  and  address  the  underlying  constraints  that  limit  effective
implementation of poverty reduction and pro-poor health policies and strategies.

The  Commission  will  work  with  development  partners  to  define  effective  approaches  to
monitor sector and thematic objectives at the country and global level.

Country level: linking inputs to performance and outcomes in health

Health  systems  in  many  developing  countries  are  resource  starved.  Developing  countries
themselves will need to mobilise much of the increased investment for better health outcomes.
Initiatives  such  as  that  of  African  Governments  (Abuja  2001)  to  commit  15%  of  national
budgets  to  health  are  to  be  commended,  yet  in  most  low-income  countries  the  international
community will need to complement country level public and private investments with long-
term  financial  support.  Many  countries  will  require  technical  support  and  capacity  building
rather than major financial transfers.

Countries  and  their  development  partners  will  need  to  monitor  all  inputs  including  public,
private (a significant proportion in many countries) and donor resources. Country monitoring

19

frameworks need to  assess  total investments  in  health  including  direct  support  to  the  health
sector and support to other sectors influencing health and macroeconomic support.

(cid:1)  Through  policy  dialogue  at  country  level  the  EC  will  contribute  to  attaining  appropriate
levels of investment to improve health outcomes. The EC will thereby draw on a number
of  instruments  including  macro-economic  support,  debt  relief  linked  to  social  sector
budgets, and finance for specific initiatives and clearly identified funding gaps.

Country  strategies  seldom  present  a  coherent  analysis  of  how  programme,  sector  or
macroeconomic  support  will  translate  into  improved  health  outcomes  for  the  poor.  The
response  is  often  direct  investment  in  the  health  sector  without  consideration  of  whether
alternative interventions in other sectors could have a greater impact on diseases of the poor
or on global health.

To build a basis for budget and sector review processes many countries are in the process of
establishing benchmark indicator sets to measure health system performance and progress in
meeting  defined  health  outcomes  in  the  context  of  poverty  reduction  and  the  Millennium
Development  Goals.  Such  indicators  typically  reflect  a  mix  of  input,  output,  outcome,  and
process,  and  to  a  lesser  extent  impact  data.  While  sometimes  imperfect,  country  specific
indicators are being improved as experience is gained and capacities developed.

Indicators  will  need  to  be  evaluated  for  their  value  in  assessing  improvements  in  health
outcomes  for  the  poor.  The  Community  intends  to  link  future  disbursement  to  performance
against targets agreed with countries and their partners. Defining a limited number of outcome
indicators  poses  formidable  challenges  of  measurement  where  statistical  systems  are  poorly
developed and also may present perverse incentives to focus only on the key areas by which
performance will be measured.

(cid:1)  The EC will test the utility of intermediate indicators in a number of countries where future

support will be provided as macroeconomic and /or sector support.

(cid:1)  The  Commission  will  take  forward  work  on  intermediate  indicators  with  Member  States

and within the context of the DAC/OECD.

Routine statistical  systems  are  commonly  flawed  and  limited  to  public  sector  providers  and
the non-for-profit sector. Aggregate data can conceal wide variations and deep inequities and
are  often  not  linked  to  policy  making  or  financial  allocations.  However  some  countries  are
improving  the  management  of  information  and  performance  monitoring  through  the
disaggregation of data (by gender, income level, geographic area, service provider), through
detailed analysis and feedback to providers and through interaction with policy makers.

(cid:1)  The Community will further facilitate work to strengthen monitoring systems and capacity

in co-operation with countries and other key partners.

Investments at the regional and global levels

New  global  level  partnerships  offer  increased  potential  for  additional  and  more  efficient
resource flows linked to better health outcomes. There is no effective system to monitor total
health related investment. The Millennium Development Goals are high level indicators and
represent an agreed international point of reference. Multiple efforts are underway within the
development community to establish a limited set of core intermediate-level indicators for use
by development partners. Global health outcomes are monitored by WHO.

20

(cid:1)  The EC will play an increasing role in strategic areas where the EU can make a difference

in reaching the Millennium Development Goals.

(cid:1)  The EC will contribute to work on high level indicators with Member States and within the

context of the DAC/OECD.

Monitoring Community aid management

Community assistance to health, AIDS and population activity  reached  a  peak of  over  Euro
700  million  in  1998  amounting  to  8%  of  the  Community  budget.  The  total  1995-2000
portfolio amounts to over Euro 1.4 billion (annex 5). An evaluation of the current portfolio is
ongoing. Early recommendations include: the need  for differentiated approaches; the crucial
role of deconcentration of EC aid; the need to continue institutional support to countries for
the development of appropriate health strategies; the need for greater coherence, co-ordination
and  complementarity;  and  the  need  to  develop  an  appropriate  set  of  indicators  to  measure
progress. This Communication incorporates these and other recommendations from previous
evaluations of the EC  AIDS/HIV  Programme,  and  the use of special budget lines for AIDS
and population.23

EC health and poverty aid management will be further monitored through an ongoing process
related  to  the  budgetary  process,  portfolio  reviews,  sector  and  thematic  evaluations  and
through the production of an annual performance report, presented in the annual report on the
EC Development Policy. The mechanisms put in place and the guiding principles assuring the
effective  use  of  the  results  of  reviews  and  evaluations  will  be  further  detailed  in  a  specific
work programme, following this Communication.

EC funding provided under this Community policy framework shall be subject to supervision
and  financial  control  of  the  Commission,  in  accordance  with  the  usual  arrangements  laid
down  by  the  Commission  under  the  provisions  in  force,  particularly  those  in  the  Financial
Regulation  applicable  to  the  general  budget  of  the  European  Communities  and  the  EDF
Financial Regulation.

7.

CONCLUSIONS AND RECOMMENDATIONS

This  policy  framework  is  the  Community's  overall  response  to  commitments  made  by  the
international community to contribute to the Millennium Development Goals related to health
and poverty. The Johannesburg Summit provides an opportunity to move forward this work,
reinforcing  the  common  goal  of  improving  sustainable  development.  An  effective  EC
response  will  require  coherent  efforts  of  the  Community  and  its  Member  States  in
collaboration with partner countries, international and civil society partners, the private sector,
the UN, other multilateral organisations and stakeholders.

The choice for the proposed policy poses different challenges to the Community. New ways
of  working  and  reinforced  investment  need  to  receive  full  attention.  The  search  for  greater
coherence between policies, the choice to target health through other sectors, the commitment
to  link  inputs  to  performance  and  outcomes  in  health,  and  to  scale  up  investment  and

23

'Evaluation  de  l'aide  de  la  coopération  Nord-Sud  en  matière  de  lutte  contre  l'expansion  de  'l'épidémie  du
HIV/SIDA et aide aux politiques et programmes démographiques dans les pays en développement 1997 - 1999', by
Jean-Claude  Deheneffe,  et  al.,  November  2000;  'Evaluation  of  the  EC  AIDS/HIV  Programme  in  developing
countries', by Health Research for Action (HERA), December 1996.

21

                                                
resources where possible, the need to make Community instruments respond effectively and
efficiently to the increasing demand can all not be addressed at once. The main challenge may
well be the area of EU complementarity and division of work among the Community and its
Member States, and increased Community co-operation with the Member States to act as one
voice in development fora and partnerships.

This Communication will be supplemented with a comprehensive work programme, detailing
the priorities for action and the required human and financial resources, compatible with the
existing  financial  programming  and  instruments.  The  need  for  human  and  administrative
resources shall be covered within the allocation granted to the managing DG in the framework
of the annual allocation procedure.

22

Annex 1: The Millennium Development Goals

23

24

Annex 2: The Evolution of the EC's Health, AIDS and Population Policy (1990-2000)

Health
(Commission Communication – COM (94) 77)
Strategic priorities:
(1) 

(2) 
(3) 
(4) 

(2) 
(3) 
(4) 

to  ensure  that  the  health  dimension  is  taken  more  fully  into  account  in  development  policies,
particularly in structural adjustment programmes;
to help correct structural imbalances in health systems, by directing action to basic services;
to facilitate institutional reform by building capacity at central level and suppor4ing decentralisation;
to help countries develop systems to measure and mobilise resources more efficiently.

HIV/AIDS
(Commission Communication – COM (94) 79)
Strategic priorities:
(1) 

to reduce the spread of the epidemic while preventing discrimination and exclusion of people at risk of
infection or living with HIV and AIDS;
to enable the health sector to cope with additional burden of HIV/AIDS;
to lessen the impact of the epidemic on economic and social development;
to increase scientific understanding and know-how.

(Council  Regulation  -  550/97  –  currently  under  revision  as  a  basis  for  EC  support  for  ‘poverty  diseases’
HIV/AIDS, malaria and TB)
Strategic priorities:
(1) 

to reduce the transmission of HIV/AIDS and the spread of other diseases capable of being transmitted
sexually or perinatally;
to reinforce health and social services so they can cope with the growing demands of the epidemic;
to help governments and communities to assess the epidemic's impact on different economic and social
sectors and to define and implement strategies to cope with it;
to  develop  scientific  understanding  of  the  epidemic  and  the  impact  of  measures,  with  a  view  to
improving their quality (while excluding basic research).

(2) 
(3) 

(4) 

Population
(Council Regulation - 1484/97 – currently under revision as a basis for EC support for ‘reproductive and sexual
health and rights’)
Strategic priorities:
(1) 

to  enable  women,  men  and  adolescents  to  make  a  free  and  informed  choice  about  the  number  and
spacing of their children;
to contribute to the creation of a socio-cultural, economic and educational environment conducive to the
full exercise of that choice;
to help develop or reform systems in order to improve accessibility and quality of reproductive health
care.

(2) 

(3) 

Communicable Diseases
(Commission Communication - COM(2000) 585 and COM (2001) 96)
Core areas for accelerated action:
(1) 

(2) 

(3) 

Reaching  optimal  impact  of  existing  interventions,  services  and  commodities  targeted  at  the  major
communicable diseases affecting the poorest populations;
Increasing  affordability  of  key  pharmaceuticals  through  a  comprehensive  and  synergistic  global
approach;
Increasing  investment  in  research  and  development  of  global  goods  targeted  at  the  three  major
communicable diseases.

25

Annex 3: Major Causes of Morbidity and Mortality in Developing Countries

HIV/AIDS threatens to be the worst pandemic in world history. 40 million people live with HIV and AIDS has
caused more than 22 million deaths. An additional five million people are infected each year. Almost one third
of  those  with  HIV  are  also  infected  with  TB.  HIV/AIDS  affects  individuals,  households,  communities  and
societies.  It  strains  health  and  education  systems,  and  retards  economic  growth.  Most  countries  have  failed  to
deal with the problem effectively and infection rates continue to rise. There are now 14 million AIDS orphans in
Africa with estimates of 40 million by 2010. The advent of effective treatment regimes has widened disparities
in  HIV  outcomes  between  rich  and  poor  societies  and  between  individuals.  HIV  threatens  all  countries  and
societies.  The  fastest  growing  epidemic  is  in  Eastern  Europe  and  the  Caribbean  is  the  second  most  affected
region after Africa.

Fifty  years  after  the  introduction  of  effective  treatment,  tuberculosis  (TB)  still  causes  two  million  deaths
annually and remains, allied to HIV/AIDS, the leading cause of death in adults. A course of effective treatment
costs as little as USD 10 yet only one quarter of patients world-wide receive appropriate care. The TB problem is
not confined to the poorest countries. In countries of the former Soviet Union, 10% of the prison population has
active TB and infection rates are a hundred times those of the general population. Multi-drug resistant forms of
TB (MDRTB) are common and have now been reported in 100 countries.

Malaria  causes  500  million  episodes  of  infection  and  over  one  million  deaths  annually,  with  most  in  Africa
where malaria control efforts in many countries have all but collapsed. Transmission has returned to previously
controlled areas and resistance to standard treatments is increasing.

Acute  respiratory  infections  and  diarrhoeal  diseases  remain  major  causes  of  ill  health  and  mortality,
particularly in children. Both cause and result  from  malnutrition.  Diarrhoeal  diseases  reflect  poor  hygiene  and
limited access to clean water. Vaccine preventable diseases cause three million deaths each year.

Nearly  half  of  child  mortality  in  low-income  countries  can  be  linked  to  malnutrition,  which  contributes  to
infant,  child  and  maternal  morbidity,  decreased  learning  capacity,  lower  productivity  and  mortality.  Reducing
malnutrition and addressing specific micronutrient deficiencies are key elements of poverty reduction.

Reproductive and sexual health and rights remain a key public health concern. Maternal and perinatal causes
alone lead to the loss of 600,000 women and several million new-borns each year. Maternal deaths are a stark
reminder of the inequalities between, and within, countries. Most are caused by birth-related complications and
most are avoidable using existing inexpensive technologies. In 2000, WHO estimated that maternal conditions
were second only to HIV/AIDS in their contribution to the global burden of disease. Despite major achievements
in  increasing  access  to  contraceptive  information  and  commodities  there  remains  a  massive  gap  in  ensuring
access to wider reproductive rights.

Lifestyle related causes of ill-health are becoming much more prevalent in developing countries. Populations
with  a  major  communicable  disease  problem,  often  face  an  added  burden  due  to  the  rising  impact  of  non-
communicable  diseases  such  as  heart  disease  and  diabetes.  Particularly  important  are  tobacco  related  illnesses
(cancer, cardio- and cerebro-vascular diseases, and lung disease) which caused over four million deaths in 1998,
two thirds of which were in developing countries. Tobacco related deaths are projected to double over the next
20 years. Many countries also face a rising toll from the negative  health effects of high-risk sexual behaviour,
drug  abuse  including  alcohol,  violence,  conflict  and  road  accidents.  Mental  illness  is  in  many  developing
countries a neglected and very common cause of ill health.

26

Annex 4: Development approaches

Good  governance  is  first  and  foremost  an  issue  at  the  national  level.  Democracy  and  the  rule  of  law  are
necessary prerequisites for sustainable development. Up to now the political response to governance challenges
has  proved  insufficient  on  any  level  –  national,  European  and  international,  public  or  private.  Inadequate
domestic  policies  in  many  countries,  including  developing  countries,  have  contributed  to  the  widening  of  the
gap between the poor and the rich. Likewise, the lack of balance between global market forces on the one hand
and global governance institutions on the other, has resulted in what one could call a ‘global governance gap’.
Both factors breed discontent and conflict and undermine sustainable development. One particularly significant
aspect  of  poor  governance  is  corruption,  which  not  only  has  damaging  effects  on  a  country’s  own  political
system and economy, but also deters foreign investment and has negative spill-over effects into other countries,
through money laundering and international crime.

Ownership,  political  commitment  and  leadership  and  effective  planning  are  needed  to  drive  forward  a
process of sector reform, to ensure adequate finance, from both government and donors to prioritise investments
and  fair  resource  allocation  within  the  health  sector.  At  the  same  time,  efforts  are  needed  to  ensure
accountability,  encourage  the  broad  participation  of  stakeholders  including  civil  society  in  policy  dialogue,  in
service delivery and in monitoring performance. The failings of past health systems have lead to a re-appraisal of
the traditional role of government as the main provider of services. It is increasingly acknowledged that a more
effective  role  for  government  is  that  of  ‘stewardship’  whereby  the  state  assumes  responsibility  for  oversight,
regulation  and  quality  control  of  the  whole  sector  with  multiple  providers  sharing  responsibility  for  service
delivery.

Policy coherence within the EU. Domestic EU policies may have negative spill-over effects on other countries,
notably in the developing world. In several important areas existing EU policies conflict with health and poverty
objectives.  Policy  coherence  has  several  dimensions:  coherence  of  policies  pursued  in  different  international
organisations, coherence between external policies; coherence between external policies and the external effects
of domestic policies; coherence between community policies and Member State policies; coherence within one
single policy area. This makes it a politically challenging concept, and therefore difficult to operationalise.

National development strategies to reduce poverty are increasingly elaborated in a Poverty Reduction Strategy
Paper  (PRSP).  This  comprehensive  country-led  framework  is  to  ensure  that  all  investments,  government  and
donor,  in  relevant  sectors  including  health  are  complementary  and  work  towards  the  same  overall  goal  of
reducing  poverty.  Donors,  including  the  EC,  are  progressively  linking  their  assistance  to  such  country  driven
strategies that are increasingly developed with the engagement of civil society and the private sector. The PRSP
provides the opportunity for interventions to be prioritised in such a way as to reduce poverty with an increasing
proportion of external assistance channelled through the national budget.

Sector  wide  approaches  (SWAP)  characterise  a  potentially  more  effective  and  efficient  method  of  working
between  government  and  donors.  All  significant  funding  for  the  sector  supports  a  single  sector  policy  and
expenditure  programme,  under  government  leadersh7ip,  adopting  common  approaches  across  the  sector,  and
progressing towards relying on government procedures to disburse and account for all funds. This approach has
evolved  from  two  directions:  interest  to  improve  the  allocation  of  the  national  budget  and  of  donor  flows
between, and within sectors, and from concern that the traditional project approach has not produced sustainable
improvements  in  services.  Whilst  there  are  positive  early  experiences  most  SWAPs  are  at  an  early  stage  of
implementation. One of the main challenges is to ensure pro-poor targeting within SWAPs.

The untying of aid. Following the recommendations of the OECD/DAC, there is general agreement within the
EU  to  explore  options  for  the  further  untying  of  development  aid  as  a  means  of  improving  its  efficiency  and
effectiveness.  The  EU  has  initiated  this  process  in  relation  to  services  and  commodities  essential  to  the  fight
against HIV/AIDS, tuberculosis and malaria.

27

Annex 5: Major Financing Instruments for EC Support of Health, AIDS and Population

European Development Fund (EDF)

The mainstay of EC Co-operation to the 77 ACP countries is provided through the European Development Fund
(EDF). . The Cotonou Agreement (2000) lays the foundation for the five-yearly financing protocols for 9th EDF
(2002-2006).

Economic and Technical Co-operation with Asia and Latin America

Economic and technical co-operation with Asia and Latin  America is embedded  within an framework  Council
Regulation, adopted in 1992. In addition, co-operation agreements were signed on a sub-regional or country-by-
country basis and cover co-operation as well as trade. Aid disbursed on an annual basis comes directly out of the
Community’s  own  budget.  Overall,  some  18  countries  in  Latin  America  and  17  in  Asia  benefit  from  EC  aid
under the co-operation programme, which is mainly  financed through budget headings B7-300 (Asia) and B7-
310 (Latin America). The regulation is currently under revision. An agreement with Mexico has been expanded
into  a  more  complex  partnership  and  others  with  Mercosur  and  Chile  are  under  a  new  negotiation  process.
Overall regional and per country strategies are being re-designed in order to better focus on priority interventions
differing from country to country.

Co-operation with the Mediterranean under the MEDA programme

The  Euro-Mediterranean  Partnership  was  inaugurated  by  the  November  1995  EU  ministerial  conference  in
Barcelona.. This Partnership stresses the importance of the human aspect of relations between the two regions.
Health plays a prominent role in efforts to promote sustainable development and overall well-being, backed by
considerably increased financial aid. The MEDA Programme is the principal financial instrument of the EC for
the implementation of the Euro-Mediterranean Partnership.

HIV/AIDS and Population Special Budget Lines

To  complement  the  principal  financial  and  technical  co-operation  instruments,  special  Community  thematic
budget lines have been used to support key policy and strategy development work in HIV/AIDS and population.
These  funds  are  designed  to  support  the  testing  out  of  innovative  methodologies  and  strategies  as  well  as  the
generation  of  knowledge  in  gaps  of  understanding.  The  regulations  for  these  budget  lines  are  currently  under
revision  and  represent  a  focus  on  the  implementation  of  the  EC  Programme  for  Action  on  Communicable
Diseases, including a contribution to the Global Fund to fight HIV/AIDS, malaria and tuberculosis, and on EC
support for reproductive and sexual health and rights.

NGO Co-Financing

Established in 1976, the NGO Co-financing line has come to play an increasingly important role in supporting
health, AIDS and population work over recent years. It has been a flexible mode of funding for European NGOs
who, in collaboration with their developing country partners, are seen by the EC as a particularly effective means
of reaching the poorest and most marginalised communities. Around 25% of all NGO Co-financed projects are
currently health targeted.

Humanitarian Aid

EC  humanitarian  aid  covers  a  broad  range  of  interventions,  including  the  provision  of  emergency  relief  to
victims  of  wars  and  natural  disasters,  assisting  with  refugees  and  carrying  out  short-term  rehabilitation  and
construction work. In 1993 ECHO (the European Community Humanitarian Office) assumed responsibility for
the  management  of  non-food  humanitarian  aid  and  funding  to  this  area  increased  strongly  from  that  year
onwards. Health and medical assistance has always taken up a very important proportion of all humanitarian aid.

Research

The  EC  supports  research  geared  towards  the  health  problems  of  developing  countries  within  its  Framework
Programme budget.. In the past, during the fourth Framework Programme, funding was provided through the EC
International  Collaboration  Programme  (INCO-DEV),  which  emphasised  active  collaboration  in  research
between  scientists  from  both  developing  country  and  European  institutions  on  the  basis  of  equal  partnerships.
Under  the  INCO  more  than  300  health  related  partnership  projects  have  been  funded,  including  HIV  vaccine
work in China and Tanzania, and Tuberculosis vaccine R&D in Zambia and Ethiopia.

28

As part of the Fifth Framework Programme, activities continued in the following programmes: 'Confirming the
International Role of Community Research' and 'Improving Human Potential'. A specific initiative has been set
up to increase malaria vaccine testing: the European malaria Vaccine Testing Network. The share of EC funded
malaria  drugs  projects  is  also  increasing.  In  addition,  funding  is  available  to  support  the  participation  of
researchers from developing countries in EC financed research projects.

Portfolio

Community assistance to health, AIDS and population activity reached a peak of over Euro 700 million in 1998
amounting  to  8%  of  the  Community  budget.  The  total  1995-2000  portfolio  amounts  to  over  Euro  1.4  billion.
This figure represents EDF, South Africa, and ALAMEDA financing, including targeted budget support for the
period  1995  -  2000.  It  does  not  include  NGO  co-financing,  other  special  budget  lines,  research,  non-targeted
budget  aid,  humanitarian  aid  management  by  ECHO.  The  Euro  1.4  billion  includes  36%  committed  to
interventions in the ACP region, 8% to South Africa, 30% to Asia, 20% to the Southern Mediterranean (MEDA)
and 6% to Latin America. A further breakdown by instruments and themes shows: 22% was allocated for health
systems support, 21% for humanitarian aid (outside ECHO), 14% for reproductive health, 5% for AIDS, 2% for
other diseases. An estimated 35% of the total portfolio was committed under the 'Structural Adjustment' heading.
From: 'Evaluation de l'aide de la CE dans les pays ACP/ALA/MED dans le domaine de la sante': by Dr Paud De
Caluwe, Jean-Claude Deheneffe, Marlene Abrial, Helene Ryckmans, Delphine Huybrecht, Jean-Pierre d'Altillia;
Participating institutions: COTA, AEDES, GRET, IIED. Draft report released on 17.1.2002.

29

Type of commitments and geographical distribution in Health, HIV/AIDS and
Population investments
Total portfolio: Euro 1.4 billion (1995-2000)24

Support Focus 1995 - 2000

HIV/AIDS
5%

Health Systems 
Support
22%

Structural 
Adjustment 35%

Humanitarian Aid 
21%

Other Diseases 2%

Reproductive 
Health 14%

Geographical distribution of commitments 1995 - 2000

Latin America 
6%

Mediterranean 
Development 
Area 
20%

Africa, 
Carribean & 
Pacific region 
36%

Asia
30%

South Africa 
8%

24

This  does  not  include  NGO  co-financing,  other  special  budget  lines,  research,  non-targeted
budget aid or humanitarian aid managed by ECHO.

30

                                                
OVERALL COMMITMENTS RELATED TO HAP PROJECTS/PROGRAMMES
FOR 1995-2000 FUNDED THROUGH EDF & ALAMED FINANCIAL &
TECHNICAL COOPERATION INSTRUMENTS25

Region

Commitments Total

Disbursement Total

Disbursement versus
Commitment Total

Euro Million

Euro Million

Asia

Latin America

Mediterranean

ACP (incl. South
Africa)

408,620

111,127

285,160

584,970

36,657

28,128

126,813

126,449

31.03%

25.31%

12.86%

21.62%

Overall Total

Euro 1,389,877
million

Euro 318,047
million

22.88%

25

Inventory  EuropeAid  Office,  7.3.2001.  This  list does  not  include  interventions  funded  through  other  instruments
such as budget aid (including structural adjustment), NGO co-financing, research, refugee budget lines or ECHO
nor does it include funding of health programming under PHARE or TACIS.

31

                                                
Annex 6: Summary of Community Development Policy Framework, EU Member State investments and development policies in health

Community development policy

EC  development  policy  identifies  a  limited  number  of  areas  selected  for  their  potential  contribution  towards  poverty  reduction  and  for  which  Community  action  provides  added
value.  The  six  EC  development  priority  areas  are:  transport;  support  for  regional  integration;  links  between  trade  and  development;  support  for  macroeconomic  policies  and
promotion  of  equitable  access  to  social  services;  food  security  and  sustainable  rural  development;  institutional  capacity  building.  Health  and  education  are  included  within  the
priority area: support for macroeconomic policies and promotion of equitable access to social services. The Joint Statement of the Council and the Commission of November
2000 highlights an  emphasis on the social sectors: ‘In line with the macroeconomic framework, the Community must also continue its support to the social sectors (health and
education), particularly with a view to ensuring equitable access to the social services…. In view of the global dimension of the communicable disease situation and its impact on
poverty  accelerated  action  by  the  Community  and  its  Member  States,  targeting  its  various  dimensions,  must  be  considered  an  absolute  necessity.’  The  Statement  gives  a  clear
mandate  to  the  Commission  for  coherence  and  sustainable  development:  'There  must  be  greater  coherence  between  the  various  Community  policies  focused  on  sustainable
development. The way to achieve this is to make a systematic and thorough analysis of any indirect effects of measure in especially sensitive areas and to take development problems
into  account  in  the  Commission  decision  making  process'.  In  most  countries  EC  development  assistance  is  to  be  limited  to  one  or  two  sectors,  and  possible  macroeconomic
support. Given this limitation, direct social sector support, in particular for health, may not always feature prominently within the EC assistance package for developing countries.
However the total Community contribution to health in developing countries, through macroeconomic support and through support for other sectors will remain substantial.

Total EU Member States investments in health in developing countries

Member State

Total
ODA/GNP
2000

Total health
commitments of
ODA - 199926

Member State

Total
ODA/GNP
2000 - %

Total health
commitments of
ODA - 1999

Member State

Total ODA/GNP
2000

Total health
commitments of
ODA - 2000

Austria

Belgium

Denmark

Finland

France

0.25

0.36

1.06

0.31

0.33

13.4

12.9

14.0

6.4

3.8

Members development policies in health

Germany

Greece

Ireland

Italy

Luxembourg

0.27

0.19

0.30

0.13

0.70

2.8

4.3

10.1

5.2

14.5

Netherlands

Portugal

Spain

Sweden

UK

0.82

0.26

0.24

0.81

0.31

5.0

3.0

6.0

4.2

5.8

26

OECD-Aid by Major Purposes, 1999: http://webnet1.oedc.org/xls/M00002000/M00002855.xls

32

                                                
Member State

Focus on priority diseases / burden of diseases of the poor Multi-sectoral approach

Fair financing

Global level

Data not available (N/A.)

N/A.

N/A.

N/A.

Strengthening of health systems (SWAP, Health Sector
Reform, Decentralisation)

Integration of activities for the Prevention and Control of
major infectious diseases within the Basic Health Services as
well as special emphasis on Reproductive, Maternal and
Child Health

AIDS/STI control and management

Prevention of HIV/AIDS, Respiratory Tract Infections,
Diarrhoeal diseases, TB, Malaria, maternal mortality;
prevention of malnutrition in children; Immunisation,
Sustainability of achievements; Poverty alleviation; Gender
equity; Disease control

Health system reform; Public-Private partnership; SWAP;
Drug Supply and Management

Respond to emerging threats such as chronic diseases

Health is mainstreamed in
the strategic papers on
education, social
economy and
infrastructure, and to a
limited extent also in
those on peace building
and international co-
operation; the
environment, agriculture
and food security

N/A.

Operational research and
support to micro-credit and
health care financing

Advocacy for increased donor and
national support for better access to
health care

Support to community
financing systems and mutual
healthcare insurance companies
adapted to local circumstances
and managed by the local
population

Advocacy for enhanced access to
medicines

Global research on drugs and
vaccines especially for the
neglected diseases

N/A.

Reorganisation of the public
financing to ensure that priority
areas are effectively financed
and subsidies properly targeted

Reduction of impoverishing
impact of health events;
development of modalities for
exemptions and for risk-sharing

N/A.

N/A.

N/A.

N/A.

Austria

Belgium

Reference: Ministry of Foreign Affairs,
International Trade and International Co-
operation

New sector policy paper on “International
Co-operation in the Health sector” in
preparation, 2002 -2006

Denmark

(DANIDA)

Ministry of Foreign Affairs, DANIDA,
DANIDA Sector Policies “Health”
November 2000

Finland

Ministry for Foreign Affairs, Development
Co-operation: “Women, men and
development: Gender equality in Finnish
Development Co-operation”(1999)
“Humanitarian Aid in Finnish
Development Co-operation”
July 1999 “Finland’s Development Co-
operation 2000” Annual report

France

Communicable diseases- HIV/AIDS, TB and malaria
Trypanosomiasis

N/A.

Development of sustainable
health-financing strategies

N/A.

33

“L’action de la France en matière de
Coopération, d’Aide au Développement, de
Traitement de la dette et de lutte contre la
pauvreté” (mars 2000)

Strengthening health systems through reform,
decentralisation, human resource development
pharmaceutical policy

Germany (GTZ)

Establish functional health systems, primary health care

Primary environmental
care

Development of sustainable
health-financing strategies

N/A.

“Investing in health for Poverty reduction,
Economic development and Social
Security” Proceedings of the Summer
Seminar on the GTZ Health and Population
Section, September 2001

“Promotion of initiatives to eradicate
Female Genital Mutilation”

“Responding to HIV/AIDS in the
Developing World, the GTZ contribution:
15 years of experience-an overview” June
2001

“HIV/AIDS Threat and Prevention in
marginalised ethnic groups” June 2001

Greece

“Statement on United Nations General
assembly on HIV/AIDS” June 2001

Provide quality preventive, curative and promotive services,
including MTCT and prevention among marginalised ethnic
groups

Decentralisation and community participation to improve
health of the poorest populations; Disease control;
Reproductive and sexual health, women

Integration of HIV/AIDS
activities into non-health
projects (workplace,
vocational schools, parent
associations, primary
school pupils)

Private-Public partnerships

Promotion of Social Health
Insurance

Promotion of initiatives to eradicate Female Genital
Mutilation

Private-Public
partnerships

Increased access to health services for the poor, including
primary care and drugs

Multi-sectoral approaches
involving health,
education and poverty

Development of sustainable
health-financing strategies

Support for the World Health
Organisation, UNICEF,
UNAIDS, UNPFA

Communicable diseases (HIV/AIDS, Malaria, TB),
especially for prevention and fight against HIV/AIDS

Improve child, women and reproductive health

Ireland

Health System strengthening at national and sub-national
level

Mainstreaming of
HIV/AIDS into all sectors

Ensuring Ireland Aid support is
within National Budgets

Ireland Aid Strategy and Guidelines for the
Health Sector 2000

A HIV/AIDS Strategy for the Ireland Aid
Programme 2000

Guidelines for Ireland Aid support to

Support for the prevention/control of communicable diseases,
reproductive health, human resource development;
information and surveillance

Consideration of health
impacts of Ireland Aid
support to other sectors

Facilitating the development of
MTEF and Health Financing
Strategies

Support for decentralised health service delivery and the

Support for piloting of cost

34

Access to medicines

Advocacy role within UN, EU
and other international
organisations

Support for International
Initiatives and some Public-
Private Partnerships

Support for multilateral agencies

Water and Sanitation 2000

strengthening of community based initiatives

recovery schemes

such as WHO, UNICEF,
UNAIDS

Promoting Ireland’s Interests: strategy
statement of the Department of Foreign
Affairs 1998 – 2000

Supporting the prevention of HIV/AIDS the mitigation of its
impact through institutional, mainstreaming and targeted
responses

Italy

N/A.

N/A.

N/A.

N/A.

Ministry of Foreign Affairs, Development
Co-operation Department “Linee guida
della cooperazione italiana sulla riduzione
della povertà” October 1999

Luxembourg

Ministère des Affaires Etrangères du
Grand-Duché de Luxembourg / Direction
de la Coopération au Développement :

Continue current investments in Human Resources,
particularly in Education and Primary Health Care

- Une stratégie pour la coopération
luxembourgeoise 1997

- La lutte contre la pauvreté dans la
coopération luxembourgeoise

- Rapport annuel 1999

Netherlands

Tackling poverty related health problems

Sector-wide approaches for health
development: Dutch field experiences in
international co-operation (1999)

Improving reproductive and sexual health

Strengthening health systems

Dutch policy and practice in reproductive
health (1999)

Reduce the spread of HIV/AIDS and mitigate the effects on
individuals and societies

Water supply and sanitation in developing
countries (1998)

Nutrition: interaction of food, health and

35

N/A.

« Integrated actions » for
fighting poverty at several
levels (health, transport,
agriculture, water, family
planning, women’s roles,
microcredits)

Mainstream health
concerns in other sectors

N/A.

Collaboration with other
departments to enhance
and support intersectoral
actions

Multisectoral issues (e.g.
reproductive health,
nutrition, water and
sanitation) in health
SWAPs

Partnership with UNFPA, WHO,
UNRWA, OECD (DAC
guidelines)

Support for multilateral
organisations, including WHO,
UNFPA, UNAIDS, UNICEF,
World Bank

Global health initiatives

Global public goods

Access to medicines,
WTO/TRIPs

care (1998)

Progress report on HIV/AIDS (1998, 2002
in prep)

Poverty and HIV/AIDS (2001)

Poverty and health (2001)

Portugal

Ministry of Health

“Health a compromise – a health strategy
at the turning of the century (1998-2002)”

“Guidelines Health – contribution for the
great plan options”, 2001

Mainstreaming
HIV/AIDS

Priority on reducing health differences among the population

Surveillance on water and
sanitation quality

Co-operation with the Ministry
of Labour and Solidarity

Supports for the World Bank,
WHO, UNAIDS, UN, UNICEF

Strategy to improve access to the National Health System by
the poorest populations and migrants

Health programs and projects on Family Planning,
Vaccinations, HIV/AIDS, Tuberculosis, Addictions

Surveillance on
environment pollution

Promoting Health Schools

Co-operation programs based on formation and co-operation
for development

N/A.

N/A.

Spain

N/A.

N/A.

N/A.

Development of sustainable
health-financing strategies

Strengthened role for
health sector in
influencing health-related
policies of other sectors

Initiation of multi-sectoral
approaches

Sweden (SIDA)

Health system development

“Handbook for Mainstreaming Gender in
the Health Sector”, June 1997

To ensure coverage for health services of acceptable, cost
effective, quality, equity and gender equity; public-private
financing

Improvement of sexual and reproductive health rights

Public health; Immunisation and child health; Drug policy
and rational use of drugs

"Investing for Future Generations.
Sweden’s International Response to
HIV/AIDS”, 1997

“Policy for development Co-operation,
Health Sector” June 1997

“Strategy for Development Co-operation,
Sexual and reproductive Health and
Rights” 1997

“Position Paper: Population, Development
and Co-operation” 1997

36

“Facts and Figures 2000: Health and
Development”

UK (DFID)

Addressing priority health problems of poor people

DFID “Better Health for Poor People-
Strategies for Achieving the International
development targets” November 2000

Investing in strong, efficient and effective health systems

Promoting a more effective global response to HIV/AIDS

Creating social, political and physical environments to
improve health

Improve reproductive and sexual health

Improve child health

Maternal health

Millennium Development Goals

Increase access to clean
water and sanitation

Budget support

SWAPS

Investment in new knowledge
generation through WHO and
directly funded programmes

Mainstreaming
HIV/AIDS

Education

Poverty and Health

Global Public Goods

Access to Medicines

Support for UNICEF, UNFPA,
UNAIDS, IPPF

An early assessment of the above leads to the following conclusion: Most Member States have well elaborated health policies for developing countries and some have re-formulated their policies in the
context of poverty reduction. Most Member States primarily focus on efforts at the country level in order to improve health outcomes for the poor and some play a key role at the global level. Less
attention  is  given  to  policy  coherence  at  the  country  and  global  level.  Few  Member  States  highlight  the  potential  for  a  multi-sectoral  approach  in  health,  beyond  HIV/AIDS.  Few  Member  States
concentrate on equitable and fair financing and the investment in global public goods.

37