Commission staff working document - Contributing to universal coverage of health services through development policy - Accompanying document to the Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions - The EU Role in Global Health {COM(2010) 128} {SEC(2010) 380} {SEC(2010) 381}
Date: 2010-03-31
Institutions: European Commission
Subjects: EU policy, developing countries, development policy, equal treatment, health policy, international affairs, medical research, public health, right to health

EN

EN 

   EN 

 
 
EUROPEAN COMMISSION 

Brussels, 31.3.2010 
SEC(2010) 382 final 

COMMISSION STAFF WORKING DOCUMENT 

Contributing to universal coverage of health services through development policy 

Accompanying document to the  

COMMUNICATION FROM THE COMMISSION TO THE COUNCIL, THE 
EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 

The EU Role in Global Health 

{COM(2010) 128} 
{SEC(2010) 380} 
{SEC(2010) 381} 

EN 

   EN 

 
 
 
  
 
 
 
 
COMMISSION STAFF WORKING DOCUMENT 

Contributing to universal coverage of health services through development policy 

TABLE OF CONTENTS 

1. 

1.1. 

1.2. 

Latest trends ................................................................................................................. 3 

Health inequities........................................................................................................... 4 

Insufficient and uneven progress towards the health MDGs ....................................... 5 

1.3.  Weak health systems .................................................................................................... 6 

1.3.1.  The main features of health systems ............................................................................ 6 

1.3.2.  Health financing ........................................................................................................... 7 

2. 

2.1. 

2.2. 

2.3. 

3. 

The global response...................................................................................................... 8 

Complex global health governance.............................................................................. 8 

Fragmented health aid architecture .............................................................................. 8 

Growing attention to strengthening health systems ..................................................... 9 

Making better use of global aid for health ................................................................... 9 

3.1.1.  Distributing health aid better across countries and health services.............................. 9 

3.1.2. 

Increasing country ownership .................................................................................... 10 

3.1.3.  Addressing the link between poverty and health ....................................................... 10 

4. 

a. 

b. 

c. 

The EU strategy for moving towards universal coverage by health services in 
developing countries .................................................................................................. 11 

Where? ....................................................................................................................... 11 

What? ......................................................................................................................... 12 

How? .......................................................................................................................... 13 

EN 

2 

   EN 

 
COMMISSION STAFF WORKING DOCUMENT 

Contributing to universal coverage of health services through development policy 

This  staff  working  document  complements  the  Communication  ‘The  EU  Role  in  Global 
Health’. It elaborates on specific objectives, within the present legal, regulatory and financial 
framework. 

Health is central to poverty reduction and sustainable development and ill-health is a barrier 
to social and economic progress. The EU is committed to protecting and promoting health as 
a human right for all1. The European social model includes certain common features aimed at 
guaranteeing healthcare for all EU citizens. The EU has agreed common values of solidarity 
with a view to equitable and universal coverage by quality care2 in health systems. 

1. 

LATEST TRENDS 

During the last decade millions of children’s deaths per year have been averted. The 
under-five mortality rate declined 28 % between 1990 and 2008. The decade has seen 
unprecedented  mobilisation  to  combat  HIV/AIDS,  malaria  and  tuberculosis. 
HIV/AIDS treatment reached over 4 million people (over 40 % of those in need) in 
developing countries, compared with virtually none at the beginning of the decade, 
pushing back AIDS mortality.   

Three  of  the  eight  millennium  development  goals  (MDGs)  are  directly  related  to 
health: reducing child mortality (MDG 4), reducing maternal mortality (MDG 5) and 
the  fight  against  AIDS,  malaria  and  other  poverty-related  diseases  (MDG  6).  They 
are closely interconnected with all the other MDGs, as nutrition (MDG 1), education 
(MDG  2),  gender  equality  (MDG  3)  and  water/sanitation  (MDG  7)  tie  in  with  the 
main  risk  factors behind  ill-health. Unfortunately, these health-related goals are  the 
MDGs least likely to be achieved in many parts of the developing world – especially 
in Africa.  

However positive these particular outcomes are, overall progress towards the health 
MDGs has been slow, with over 50 developing countries off-track, especially in sub-
Saharan Africa. Progress towards MDG 53 has been particularly disappointing. This 

1 

2 

3 

In 2000 the United Nations Committee on Economic, Social and Cultural Rights published General 
Comment 14, which defines in detail states’ obligations, patients’ health entitlements, and their ethical 
implementation using human rights principles. Child health is specifically protected by the Convention 
on the Rights of the Child, reproductive and maternal health by the Cairo Action Plan and the 
Resolution on Preventable Maternal Mortality and Morbidity at the United Nations’ Human Rights 
Council; and rights of persons with disabilities as outlined in the Convention of the Rights of People 
with Disabilities.. 
Council Conclusions on Common values and principles in European Union Health Systems (2006/C 
146/01). 
‘The Millennium Development Goals Report 2009’:  
http://www.undp.org/mdg/basics_ontrack.shtmlhttp://www.undp.org/mdg/basics_ontrack.shtml. 

EN 

3 

   EN 

 
 
                                                 
lack of progress on the health MDGs reflects the heavy burden of disease globally4, 
especially in developing countries. Over 60 million die prematurely every year, most 
due  to  social  and  environmental  factors  and  lack  of  adequate  healthcare5.  Nine 
million of them are children under the age of five6.  

The difference in life expectancy across the world has been widening, with the richer 
top  billion  enjoying  an  average  life  expectancy  close  to  80  years,  twice  that  of  the 
poorer bottom billion7. Worldwide, exposure to health risks and inadequate access to 
healthcare are to blame for a loss of 20 % of potential healthy life. The average loss is 
10 % in the EU but close to 50 % for the world’s poorest billion.  

This staff working document is a contribution to the communication on the EU role 
in global health. It elaborates on the policy commitments in relation to the specific 
objective  of  ‘Progress  towards  universal  coverage  by  basic  quality  healthcare’. 
Consistent  with  the  attention  already  given  to  health  equity  within  the  EU,  this 
document focuses on how the EU’s external action can contribute to reducing health 
inequalities worldwide and to progress towards universal coverage by health services 
in partner countries.  

1.1. 

Health inequities 

In the poorest parts of the world human suffering from ill-health remains extremely 
high.  There  are  also  very  large  differences  in  state  of  health  between  and  within 
countries  and  regions.  According  to  the  report  by  the  Commission  on  Social 
Determinants of Health8, differences in health indicators within countries are closely 
linked to degrees of social disadvantage, the circumstances in which people live and 
work and the systems put in place to protect health and deal with illness. The report 
concludes  that  ‘The  development  of  a  society,  rich  or  poor,  can  be  judged  by  the 
quality  of  its  population’s  health,  how  fairly  health  is  distributed  across  the  social 
spectrum, and the degree of protection provided from disadvantage as a result of ill-
health’.  

Amongst  the  countries  of  the  EU  itself,  there  is  a  five-fold  difference  in  deaths  of 
babies under one year of age and an 11-year gap in life expectancy at birth. Mortality 
rates are much higher in the least developed countries than in the EU: more than 100 
times higher for maternal mortality and 15 times for infant mortality, with close to a 
40-year  difference  in  life  expectancy.  In  sub-Saharan  Africa,  the  region  with  the 
lowest health indicators, the lifetime risk of dying during pregnancy is one in 20, the 
risk  of  dying  during  childhood  is  one  in  six  and  the  risk  of  dying  during 
economically active life (between the ages of 15 and 60) is almost one in two. 

4 

5 
6 
7 
8 

Burden of disease is measured by Disability Life Adjusted  years, i.e. the healthy years lost to premature 
deaths and to various degrees of disability during disease. 
‘The global burden of disease: 2004 update’, WHO. 
‘The State of the World’s Children 2009’, UNICEF. 
WHO statistical information system: http://www.who.int/whosis/en/. 
CSDH (2008): ‘Closing the gap in a generation: health equity through action on the social determinants 
of health’, Final report by the Commission on Social Determinants of Health, Geneva, World Health 
Organisation. 

EN 

4 

   EN 

 
                                                 
1.2. 

Insufficient and uneven progress towards the health MDGs 

As  mentioned  in  section  1,  progress  towards  the  health  MDGs  has  been  slow  and 
uneven.  However,  there  are  good  examples  where  a  combination  of  political 
stability,  adequate  domestic  funding  for  health,  strong  international  support  and  a 
genuine policy dialogue has led to sustained progress on reducing child and maternal 
mortality9.  

Over  the  last  decade  progress  was  made  towards  MDG  4  (child  mortality).  The 
under-five mortality rate declined by 28 % between 1990 and 2008 (down to 65 per 
1000 live births). Most of this reduction was attributable to progress in Asia, mainly 
India  and  China.  Almost  30  countries  made  no  progress  on  reducing  childhood 
deaths10. Sub-Saharan Africa, with only 10 % of the world’s population, accounts for 
about  half  the  deaths  of  children  under  five  in  the  developing  world.  Although 
coverage  by  measles  vaccination  has  improved,  many  other  risks  to  child  health 
(mainly unsafe water, sanitation and inadequate nutrition) remain high and access for 
children to basic health services remains low11. 

As  regards  MDG  5,  maternal  mortality  remains  extremely  high  across  much  of  the 
developing  world.  Over  500 000  women  die  every  year  during  pregnancy  or 
childbirth,  99 %  of  them  in  developing  countries  with  sub-Saharan  Africa  and 
Southern Asia accounting for 86 %. This reflects the low rate of safe deliveries, but 
also gender inequities, lack of access to sexual and reproductive health and rights and 
high  fertility  rates,  compounded  by  the  burden  of  HIV/AIDS  and  malaria  in  sub-
Saharan Africa. 

In the case of MDG 6, the decade has seen broad mobilisation to combat HIV/AIDS, 
malaria and tuberculosis.  HIV/AIDS  treatment  reached  over  4  million  people  (over 
40 % of those in need) in developing countries, compared with virtually none at the 
beginning  of  the  decade,  pushing  back  AIDS  mortality.  The  number  of  new 
infections decreased only slightly ─ by just 10 % ─ largely because prevention is still 
weak  in  many  countries.  As  regards  malaria,  rapid  increases  in  the  availability  of 
insecticide-treated  bed  nets  (from  close  to  nil  in  2000  to  one  in  three  of  the 
population at risk today) and effective treatment have resulted in a 50 % reduction of 
under-five  mortality  due  to  malaria  in  Asia  and  in  Africa.  Progress  on  tuberculosis 
has  been  slower  and  during  the  decade  the  number  of  emerging  diseases  has 
increased. 

MDG 7, in particular access to basic sanitation which is directly related to health as it 
offers  a  means  of  preventing  waterborne  diseases,  is  also  off-track  globally  and, 

9 

10 
11 

One  good  example  could  be  Zambia  where,  despite  many  weaknesses,  there  are  acceptable  levels  of 
compliance with the Abuja targets (15 % national budget allocation to health), international aligned and 
predictable  support  (mainly  basket  fund  and  budget  support,  with  the  exception  of  PEPFAR  and  the 
Global  Fund)  leading  to  overall  public  on-budget  funding  above  € 20  per  capita,  SWAP  set  up  with 
participation  of  CSOs,  reforms  in  human  resources  for  health  and  in  abolition  of  user  fees  for  basic 
services  in  rural  areas,  increased  uptake  and  completion  rates  for  basic  education  with  progress  on 
gender equity, sustained economic growth and improved household economies during one decade and 
demographic health surveys with ample statistical significance showing progress on MDGs and lower 
infant and maternal mortality. 
See UNDP MDG Monitor: http://www.mdgmonitor.org/map.cfm. 
‘State of the World’s Children’, UNICEF, 2009. 

EN 

5 

   EN 

 
                                                 
especially, in Sub-Saharan Africa, where, at the current rate, the sanitation target will 
be missed by more than two generations. 

1.3.  Weak health systems 

In the 50 developing countries which are off-track to meet the health MDGs, access 
to comprehensive healthcare remains low. Coverage by many of the essential health 
services  is  low  and  has  not  expanded  for  the  last  decade  in  the  least  developed 
countries: one third of all pregnant women have no access to antenatal care and half 
of them lack safe care during delivery; only half of the women who wish to avoid a 
pregnancy  have  access  to  contraceptives  and  fewer  than  half  of  children  are 
adequately  treated  against  diarrhoea,  respiratory  infections  or  malaria.  Although 
coverage  by  vaccination  and  basic  services  against  HIV/AIDS,  malaria  and 
tuberculosis have been increased by targeted programmes, prevention and treatment 
of  other  diseases  are  lagging  behind:  for  example,  under  a  third  of  hypertensive  or 
diabetic  patients  are  diagnosed  in  developing  countries  and  only  a  minority  have 
access to adequate treatment.  

1.3.1.  The main features of health systems 

The  1978  Alma-Ata12  declaration  put  forward  a  set  of  values,  principles  and 
approaches with the aim of raising the level of health in deprived populations. Alma-
Ata’s  holistic  view  of  health,  looking  beyond  a  narrow  medical  model,  and  its 
participatory approach has become the basis for modern health systems.  

Thirty  years  later  the  Alma-Ata  principles  have  been  adapted  to  the  global  context 
today.  Effective  health  systems  should  be  based  on  the  principles  set  out  in  WHA 
Resolution 62.1213 on Primary Health Care, including Health System Strengthening. 
The  first  principle  ─  a  rights  approach  with  inclusive  leadership  ─  requires  active 
community  participation  together  with  clear  institutional  leadership.  Few  health 
systems  allow  meaningful  community  participation,  although  this  is  difficult  to 
measure.  A  second  principle  is  that  health  systems  must  include  the  health-in-all 
approach  relating  health  services  to  the  sources  of  the  main  risks  (nutrition,  water 
and basic sanitation, education, transport, governance and gender equity). The health 
system must also deliver people-centred services which respond to needs at the level 
of care required for the final principle of universal coverage.  

Identifying the priority services with the aim of universal coverage requires access to 
and analysis of a comprehensive range of data gleaned from regular monitoring and 
population  health  surveys.  This  information  is  essential  in  order  to  define  the 
package  of  priority  health  services  and  to  deliver  it  rationally  across  the  different 
levels of care. At present, less than a third of all countries have timely demographic 
and  health  surveys  (DHS/MIPS)  and  only  a  third  of  national  health  systems  in 
developing countries have up-to-date data on national health accounts. Very few of 
them conduct performance analysis and monitoring.  

12 

13 

Alma-Ata  Declaration,  International  Conference  on  Primary  Healthcare,  Alma-Ata,  USSR,  6-12 
September 1978. 
WHA 2009, Resolution 62.12 on Primary Healthcare, including Health System Strengthening. 

EN 

6 

   EN 

 
                                                 
Once  the  services  to  be  delivered  have  been  defined  and  the  components  of  the 
system  (see  below)  identified, the  health  strategy  would  ideally  provide  input  for  a 
national health budget and a mid-term expenditure framework. A health information 
and  management  system  would  monitor  inputs,  processes  and  outcomes,  provide 
input for policy decisions and steer research towards health priorities.  

Effective health systems need to respond in a balanced way to the four main health 
challenges: sexual and reproductive health, child health, communicable diseases and 
non-communicable diseases. Each of these areas will require an integrated approach 
combining  specific  training,  protocols  by  levels  of  services,  indicators  and  applied 
research.  At  present,  many  national  strategies  in  developing  countries  are  able  to 
cover only some of the diseases or services essential to their population. 

There are a number of essential components or ‘health pillars’ which health systems 
require  in  order  to  provide  universal  coverage  of  the  services  agreed:  human 
resources, access to essential medicines, infrastructure and logistics allowing access 
and  timely  referrals  between  levels  of  care  and  fair  financing  schemes  ensuring 
equitable  access  for  all.  Each  of  these  pillars  requires  a  strategy  and  a  budget. 
Together,  they  should  provide  an  integrated  response  to  the  goal  of  universal 
coverage.  In  some  developing  countries  these  pillars  suffer  from  serious  structural 
weaknesses:  a  shortage  of  human  resources,  low  availability  and  unaffordability  of 
essential  medicines,  inadequate  infrastructure  and  referral  capacity  (one  clear 
example  is  in  obstetric  emergencies)  and  financing  schemes  which,  in  most 
countries, still require direct payments at the point of delivery. 

1.3.2.  Health financing 

Global health expenditure totals € 4 trillion. Sixty percent of it is collected via taxes 
or social insurance schemes. Low GDP per capita, limited fiscal revenue and weak 
macroeconomic frameworks leave many of the poorest countries with levels of public 
per  capita  financing  of  health  100  times  lower  than  in  the  richest.  Low  public 
expenditure  places  significant  constraints  on  the  availability  of  health  professionals 
and  their  capacity  to  deliver  quality  services.  In  some  countries  inefficiency 
compounds the problem.   

Under resolutions adopted in 2005 (WHA 58.33) and 2009 (62.12), all countries are 
committed to fair financing of essential health services, ensuring universal coverage. 
However, little progress has been made in this direction, except on specific diseases 
in  the  global  spotlight,  such  as  HIV/AIDS.  In  most  developing  countries,  user  fees 
are  a  barrier  to  access  to  basic  services  for  the  poor.  Direct  payments  for  health 
services drive some 100 million under the poverty line every year. Extending the EU 
principles  of  solidarity  to  global  level  with  a  view  to  universal  coverage  would 
require  a  major  shift  in  the  distribution  of  health  financing  worldwide.  Ill-health 
should be mitigated by a wider set of policies, including protection during sickness 
(paid  sick  leave),  occupational  health  and  safety  and  adequate  working  conditions. 
Basic  social  protection  schemes  can  be  set  up,  even  in  poor  countries,  with  some 
financial  support.  Social  protection  for  health  should  therefore  be  part  of  each 
country’s wider social protection net covering basic needs. 

EN 

7 

   EN 

 
2. 

THE GLOBAL RESPONSE  

2.1. 

Complex global health governance 

In  theory,  global  health  governance  stems  from  the  debates  and  resolutions  at  the 
World  Health  Assembly  and  the  guidance  from  the  WHO.  In  practice,  however, 
many  of  the  resulting  resolutions  remain  non-binding.  Many  decisions  which 
influence  health  strategies  originate  in  the  G8  context.  International  financial 
institutions also influence the health policy choices of national governments. On the 
other  hand,  private  and  philanthropic  entities  provide  a  significant  share  of  health 
services, reflecting their own sensitivities or interests. This complex set-up generates 
strong and dynamic interactions and draws on multiple sources of funding, but it also 
calls for clearer global leadership. 

2.2. 

Fragmented health aid architecture 

The aid architecture for health is complex and has gone through numerous changes 
over the last decade, in terms of levels of aid, donor profile and focus. 

Because  health  is  critical  to  achieving  the  millennium  development  goals,  it  has 
attracted  a  high  level  of  political  attention  and  increased  international  funding.  In 
2007, DAC countries’ bilateral aid to health amounted to € 8,1 billion (53% from the 
EU) and multilateral agencies’ aid to € 3,45 billion. Average annual growth over the 
period  1980-2007  was  10%  but  this  accelerated  over  the  most  recent  years  (17% 
annually from 2000 to 2007)14. 

The patterns of aid funding for health have also changed. The share contributed by 
the  UN  and  the  World  Bank  has  decreased  from  one  third  to  one  sixth  and  has 
gradually been targeted on specific activities. For example, less than 20 % of WHO 
funding  is  un-earmarked.  In  parallel,  global  health  initiatives  and  NGOs  have 
gradually  stepped  up  their  shares  of  public  health  aid,  and  the  contributions  by 
private  philanthropy  and  corporations  have  also  increased.  This  ‘privatisation  of 
health aid’ has sharpened the focus of aid on projects and disease-targeted activities, 
leading to ‘fragmentation of health financing.’ 

Aid is not being used to support comprehensive national health plans. Instead, it is 
becoming  increasingly  fragmented,  with  the  bulk  of  health  aid  now  outside 
government accounts and, for the most part, neither recorded by countries’ planning 
authorities  nor  connected  to  national  health  plans.  At  Accra,  signatories  reasserted 
the  Paris  Declaration  commitment  to  disburse  66%  of  aid  by  means  of  Programme 
Based  Approaches  (PBAs)  by  2010.  However,  overall  progress  with  making  a 
greater use of PBAs is slow and remains at around 40%15. 

14 
15 

November 2009, OECD-DAC, www.oecd.org/dac/stats/health 
2008 Monitoring Survey Appendix table A9. Note: 

EN 

8 

   EN 

 
 
                                                 
2.3. 

Growing attention to strengthening health systems 

Aware of the central role of health systems in improving health and making effective 
and sustainable progress towards the health MDGs, the international community has 
been  paying  growing  attention  to  strengthening  health  systems.  One  essential  for 
robust health systems is the availability of adequate national funding, supplemented 
by aligned and predictable external support. 

In  September  2007,  the  International  Health  Partnership  (IHP)  was  established  to 
apply aid effectiveness principles to the health sector. In 2009 the global debate on 
health development aid (HDA) has focused on ‘health systems’. Whether in Accra, 
in Doha, in New York (UNGA) or at the World Health Assembly, the international 
community  has  reiterated  the  need  to  support  health  systems  to  enable  countries  to 
make  progress  towards  the  MDGs  and  to  strengthen  the  synergies  between  vertical 
programmes and country systems. 

The High-Level Task Force on financing for health concluded a cycle of studies and 
consultations  with  an  analysis  of  the  public  funding  gap  to  be  bridged  to  support 
health  systems,  plus  a  menu  of  innovative  financing  initiatives  to  top  up  ODA 
commitments.  At  the  same  time,  the  IHP  has  been  developing  a  tool  for  ‘joint 
assessment  of  national  strategies’  whereby  donors  and  global  health  initiatives  can 
join  in  country  compacts  and  fund  comprehensive  national  health  strategies. 
Likewise,  the  main  global  health  initiatives  ─  the  Global  Fund  for  Aids,  TB  and 
Malaria (GFATM) and the Global Alliance for Vaccines and Immunisation (GAVI) 
─  have  expanded  their  scope  to  include  support  for  health  system  components  in 
disease-specific  programmes  or  to  fund  ‘horizontal’  health  system  components.  In 
this  context,  the  Washington  seminar  (2008)  agreed  on  the  idea  of  a  joint  World 
Bank-GFATM-GAVI  platform  to  strengthen  health  systems.  –  The  provision  of 
supporting  national  policies  through  single  joint  mechanisms  of  performance 
assessment  and  dialogue  ("Sector-wide  approaches"  –  SWAps)  have  been 
implemented  in  a  number  of  countries,  for  some  already  a  decade  (e.g.  Ghana, 
Mozambique, Tanzania, Zambia), and stocktaking and assessment of these processes 
can  provide  valuable  insights  for  future  work  and  become  a  basis  for  partnerships 
and  Division  of  Labour  in  health  sector  monitoring  and  policy  dialogue  at  country 
level. 

3. 

MAKING BETTER USE OF GLOBAL AID FOR HEALTH 

Given the landscape described above, it is essential to make better use of global aid 
for health, in order to boost progress towards health MDGs. The main challenges are 
to  improve  the  distribution  of  health  aid  and  country  ownership  and  to  sharpen  the 
focus of health strategies on poverty. 

3.1.1.  Distributing health aid better across countries and health services 

a)  The  distribution  of  health  aid  per  capita  across  countries  varies  greatly.  A  recent 
analysis confirmed a positive correlation between health aid per capita and the burden 
of disease. This correlation has increased during the last decade, influenced by higher 
levels  of  aid  to  countries  with  high  HIV  prevalence  and  where  malaria  is  endemic 
(mainly  by  the  US  President's  Emergency  Plan  for  AIDS  Relief  PEPFAR  and  the 

EN 

9 

   EN 

 
Global  Fund).  By  contrast,  the  correlation  between  health  aid  and  GDP  is  weak.  In 
2008,  the  Commission  introduced  the  concept  of  ‘potential  public  financing  gap  for 
health.’  This  contrasts  the  public  finance  that  would  be  available  for  health  if  the 
country complied with the Abuja target (15 % of national budget) with the minimum 
threshold of spending per capita (as estimated by the Commission on Macroeconomics 
and Health in 2001 and maintained at € 20 by the IHP). The distribution of health aid 
between  countries  does  not  appear  to  correlate  with  these  potential  financing  gaps, 
with some countries in critical need receiving far less health aid per capita than others 
whose public financing capacity is above the minimum threshold. 

b)  The  distribution  of  health  aid  by  diseases  also  reveals  wide  disparities.  Despite  its 
limitations,  the  sub-sectoral  breakdown  of  health  aid  by  of  OECD  Development 
Assistance  Committee  (DAC)  sub-codes  indicates  that  40 %  of  health  aid  targets 
HIV/AIDS,  close  to  20 %  malaria  and  tuberculosis,  16 %  ‘basic  health  care’  (with  a 
large proportion for vaccination programmes by GAVI), 13 % reproductive health and 
the remaining 14 % going to ‘health in general’ where investment in health facilities, 
training,  research  and  untargeted  support  for  health  would  be  included.  HIV/AIDS, 
which  causes  10 %  of  the  burden  of  disease  in  developing  countries  (and  20 %  in 
Southern Africa), receives 40 % of health aid. By contrast, other diseases which also 
cause a heavy burden, such as acute respiratory infections, diarrhoea or malnutrition, 
receive little direct support and depend on the limited aid for ‘health in general’.  

3.1.2. 

Increasing country ownership 

At  country  level,  health  aid  is  excessively  fragmented  between  partners,  each  of 
whom  has  its  own  reporting  requirements  and  preferred  areas  of  activity.  This 
fragmentation undermines the leadership of national governments. Poorly resourced 
and ill-equipped health ministries in developing countries find it difficult to negotiate 
the  contributions  from  so  many  partners  and  to  coordinate  them  under  an  agreed 
plan. Health support for countries should gradually shift to on-budget and predictable 
funding.  This  shift  requires  greater  trust  in  the  capacity  of  national  governments 
sustained by policy dialogue and mutual accountability mechanisms. In this area, the 
EU  could  benefit  from  making  more  systematic  use  of  its  experiences  with  single 
joint  monitoring  and  dialogue  mechanisms  in  the  health  sector,  and  build 
partnerships  for  health  sector  monitoring  and  dialogue  on  established  country  level 
mechanisms.  

Beyond  government  ownership,  democratic  governance  in  health  requires  the 
involvement  of  national  parliaments  in  policy-making  and  budget  scrutiny.  Active 
participation  by  civil  society  can  improve  equity,  pertinence  and  accountability. 
However, in many countries civil society is not able to contribute effectively to the 
national planning, implementation and monitoring and, in some cases, is not entirely 
representative.  

3.1.3.  Addressing the link between poverty and health 

Within  each  country,  health  indicators  are  correlated  with  social  determinants  of 
health. Poverty decreases access to safe water and sanitation and increases the risks 
of malnutrition, low-quality living conditions, unhealthy working environments and 
lower levels of education. The poor have lower access to health services and, when 
they do use them, are exposed to longer delays, lower quality and higher case-fatality 

EN 

10 

   EN 

 
rates. Poverty has a similar adverse effect on under-five mortality, maternal mortality 
and adult survival rates.  

The poor have lower access to health services and spend a higher proportion of their 
income  on  paying  for  them,  mainly  in  the  form  of  direct  payments  at  the  point  of 
delivery.  If  health  systems  are  to  reach  out  to  the  poor,  the  arrangements  for 
financing them should therefore also be reformed, by greater pooling of contributions 
based on the ability to pay in advance and moving towards gradual abolition of user 
fees.  This  should  be  part  of  wider  social  protection  nets  that  protect  the  poor  from 
disease and other risks. 

Health is central to poverty reduction and sustainable development and ill-health is a 
barrier  to  social  and  economic  progress.  The  EU  is  committed  to  protecting  and 
promoting  health  as  a  human  right  for  all16.  The  European  social  model  includes 
certain  common  features  aimed  at  guaranteeing  healthcare  for  all  EU  citizens.  The 
EU has agreed common values of solidarity with a view to equitable and universal 
coverage by quality care in health systems17. 

4. 

THE  EU  STRATEGY  FOR  MOVING  TOWARDS  UNIVERSAL  COVERAGE  BY  HEALTH 
SERVICES IN DEVELOPING COUNTRIES 

(1)  This section gives fuller details of the proposals made in the Communication. 

a.  Where?   

-  To  ensure  that  health  ODA  goes  to  countries  in  critical  need,  Commission 
services will organise collective EU analysis and a list of priority countries will 
be defined on the basis of health financing gaps identified in country compacts of 
the  International  Health  Partnership.    The  Commission  will  seek  support  of  the 
WHO in this exercise.  

- Commission services will monitor programmed and forecast direct EU health 
aid by recipient country and by global channels, in order to facilitate compliance 
with  the  EU  Code  of  Conduct  on  Division  of  Labour18  and  improve  the 
distribution of aid across partner countries. This will require regular updates and 
annual  meetings  to  identify  opportunities  to  increase  support  for  countries  in 
greater need. 

16 

17 

18 

The Treaty of the European Union stipulates that a high-level of health protection shall be ensured in 
the  definition  and  implementation  of  all  Union  policies  and  activities.  The  Charter  of  Fundamental 
Rights of the EU further stipulates that everyone has the right of access to preventive healthcare 
Council Conclusions on Common values and principles in European Union Health Systems (2006/C 
146/01). 
See,  for  example,  the  ‘EU  Code  of  Conduct  on  Division  of  Labour  in  Development  Policy’, 
Communication  from  the  Commission  to  the  Council  and  the  European  Parliament,  COM(2007)  72, 
Brussels, 28 February 2007. 

EN 

11 

   EN 

 
 
 
                                                 
b.  What?  

-  Where  health  is  a  focal  sector  and/or  there  is  general  budget  support, 
Commission services will ensure that its financial support is linked with adequate 
dialogue  on  strengthening  health  systems,  taking  into  account  the  main 
components described in section 2.3. 

-  The  Commission  services  will  contribute  to  joint  assessment  of  national 
strategies (JANS) under the International Health Partnership and using the results 
of the JANS to align its funding behind national strategies. 

- In order to increase the collective EU capacity in the health sector dialogue and 
global health issues, the following activities will be carried out by Commission's 
services: 

a)  Organise a stocktaking exercise of established single joint mechanisms of 
performance  monitoring  and  policy  dialogue  in  the  health  sector, 
particularly in countries with experience over longer periods (e.g. SWAps 
in  Ghana,  Mali,  Mozambique,  Tanzania,  Zambia  and  other  countries). 
These  processes  will  be  assessed  and  lessons  learnt  will  be  used  for  a 
common  EU  concept  for  performance  monitoring  and  policy  dialogue  in 
the  health  sector  at  country  level;  opportunities  for  partnerships  and 
division of labour will be explored. 

b)  Mapping every two years the health expertise capacity available at country 
level and match it against the needs for health sector assessment and policy 
dialogue in partner countries, especially where health is a focal sector and 
where  the  Commission  provides  general  budget  support  and  MDG 
contracts.  The  resulting  analysis  of  needs  will  provide  input  for  the 
Commission, the Member States concerned for allocating human resources 
in the relevant EU delegations. It will also facilitate practical arrangements 
for in-country division of labour in the health sector. 

c)  Development with Member States of joint health sector guidelines covering 
assessment of the health situation and trends, analysis of the health sector, 
choice  of  forms  of  aid,  monitoring  of  system  performance  and  of  the 
impact of aid and the relation to global commitments and aid architecture. 

d)  Explore with the WHO, other relevant UN agencies and the World Bank, 
opportunities  for  closer  collaboration  on  health  assessments  and  policy 
dialogue  in  the  context  of  the  IHP  and  JANS  technical  assistance  in  the 
field  of  health.  In  collaboration  with  the  UN  agencies,  Commission 
services  will  comply  with  the  Accra  commitments  and  maximise  use  and 
development of local expertise. 

e)  Contribute, in collaboration with EU Member States, to quality assessment 
and dialogue in global health fora such as the WHO Executive Board, the 
World  Health  Assembly  and  the  relevant  UN  summits.  Commission 
services will also engage in a dialogue on health and development matters 
with other major partners such as USAID, the African Union Commission 
and the health policy agencies of Brazil, China and India.  

EN 

12 

   EN 

 
f)  Commission  services  will  contribute,  from  the  resources  of  the  thematic 
programme  ‘Investing  in  People’,  to  development  of  a  workforce  of 
excellence  in  global  health  analysis  and  policy  dialogue  based  on  the 
existing EU public health networks.  

g)  In  health  emergencies,  opportunities  to  build  national  capacity  from  the 
start of EU humanitarian actions will be analysed for linking humanitarian 
aid to longer-term reconstruction and development of the health sector. The 
Linking Relief Rehabilitation and Development (LRRD) analysis of health 
needs  should  provide  input  for  the  annual  meetings  on  division  of  labour 
for health referred to above. 

c.  How?  

1. 

To comply with aid effectiveness commitments: 

a)  In  line  with  the  Paris  and  Accra  commitments  in  aid  effectiveness  and  the 
proposed target in the Communication, the Commission will allocate, by 2015, at 
least  80%  of  its  health  aid  using  country  systems  (public  finance  and 
procurement) and 66% through programme based assistance. 

b)  In countries where the IHP JANS and country compacts are not in place or where 
there  is  insufficient  assurance  of  the  quality  of  health  strategies  and  public 
financing  and  notably  in  fragile  contexts,  opportunities  for  “shadow  alignment 
processes” and enhanced capacity-building will be explored so as to prepare the 
ground for aligned and predictable health aid. 

c)  Commission services will organise information sessions with the IHP Secretariat 
for  EU  Member  States  to  inform  them  and  encourage  them  to  consider  joining 
the IHP principles and its country compact commitments. 

d)  Commission  services  will  call  for  joint  EU  positions  on  the  boards  of  global 
health initiatives (the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria 
and  the  Global  Alliance  for  Vaccines  and  Immunisation)  encouraging  them  to 
comply  with  IHP  commitments.  This  will  imply  gradually  expanding  the  scope 
of  their  activities  and  the  predictability  of  their  grants  to  adapt  to  national 
expenditure frameworks and to country strategies and using the JANS process as 
a basis for their funding. 

2. 

To support developing countries’ efforts: 

a)  In  relation  with  the  Council  conclusions  of  November  2008,  Commission 
services  will  convene  joint  EU  dialogues  with  partner  countries  to  facilitate 
progress  towards  their  commitments  on  allocation  of  domestic  revenue  to 

EN 

13 

   EN 

 
 
 
 
 
health19. This dialogue will be closely linked to public expenditure reviews and to 
regular monitoring of budget support and MDG contracts. 

b)  In  compliance  with  the  Council  conclusions  of  November  2008,  Commission 
services  will  support  development  of  social  protection  frameworks  aimed  at 
improving access to quality health services and mitigating the economic impact 
of ill-health, giving priority to action in the most disadvantaged communities. 

•  Commission services, in collaboration with the WHO, ILO and 
initiatives  such  as  ‘Providing  for  Health’  or  the  International 
Centre  of  Progressive  Financing,  will  develop  specific 
guidelines  on  assessment  and  dialogue  at  country  level  on 
health  financing  schemes  and  strategies  to  improve  their 
contribution to universal coverage. 

•  Commission  services  will  facilitate  exchanges  of  experience 
between the EU and other regions on different models of health 
financing  schemes  based  on 
the  common  principles  of 
solidarity, equity, universality and quality of care and adapted to 
local contexts. 

•  Commission  services  will  monitor,  in  collaboration  with  the 
WHO and WHO-Afro, the progress towards the target set in the 
EU-Africa  Strategy  on  progressive  abolition  of  user  fees  for 
basic  healthcare,  its  impact  and  the  lessons  learned  from  those 
processes.  Based  on 
this, 
Commission services will adjust its sector policy guidelines.   

the  experience  gained  from 

3. 

To address the multi-sectoral nature of health: 

Commission  services  will  stress,  in  EU  coordination  and  in  the  dialogue  with 
partner countries, the multi-sectoral dimension of health, particularly the links to 
gender equality and access to education (MDGs 2 and 3), nutrition (MDG 1) and 
water and sanitation (MDG 7). 

a)  Commission  services,  in  collaboration  with  the  WHO,  UNFPA  and 
UNIFEM,  will  assess  progress  and  promote  policy  dialogue  at  country 
level  on  the  gender  dimensions  of  national  health  strategies,  ensuring 
universal  access  to  reproductive  health  and  a  better  gender  balance  in 
human  resources  for  health.  It  will  focus  on  the  EU  efforts  in  this  area, 
such  as  the  EU  Action  Plan  on  Gender  Equality  and  Women’s 
Empowerment,  and  promote  greater  collection  and  use  of  data  on  health 
giving a breakdown by gender. 

b)  Commission services will continue to explore, with the UN, diverse leads 

19 

Africa  Union  in  Abuja  target,  other  ACP  countries  in  Brussels  declaration:  both  calling  for  15 % 
national budget allocations to health. 

EN 

14 

   EN 

 
 
 
                                                 
on food security and nutrition, ways to support stronger UN leadership and 
a  global  multi-sectoral  action  plan  on  nutrition,  as  agreed  by  the  WHO 
Executive  Board  in  2010.  At  country  level,  Commission  services  will 
continue  to  address  nutrition  in  the  policy  areas  of  food  security,  food 
assistance,  social  protection  and  health  and  to  support  development  of 
national nutrition plans which are multi-sectoral with clear leads, mandates, 
services and targets. Commission services will ensure that health strategies 
include  basic  nutrition  services  and  links  with  the  key  sectors  on  food 
security  and  social  protection.  The  wider  relations  between  health  and 
nutrition  and  access  to  adequate  food  will  need  to  consider  the  important 
concept of the right to food, making use of tools such as the FAO Right to 
Food Methodological Toolbox. 

c)  Commission  services  will  continue  to  collaborate  with  UN  organisations 
and  other  partners  to  speed  up  the  contribution  made  by  water  and 
sanitation  services  to  improving  health.  Commission  services  itself,  and 
whenever  calling  for  joint  EU  action,  will  promote  aid  effectiveness  and 
the  link  between  comprehensive  and  multi-sectoral  national  health 
strategies  and  availability,  access  and  rational  use  of  safe  water  and 
hygienic sanitation with the aid of links with the sectors and/or ministries 
responsible at country level. The link between health strategies and water 
includes  considering  the  national  legal  definition  of  the  human  right  to 
water and sanitation and its relationship to other civil, cultural, economic, 
political  and  social  rights.  At  operational  level,  attention  will  be  paid  to 
measuring  water-  and  sanitation-related  indicators  in  the  health  and  other 
related sectors (mainly, the incidence of water-borne diseases and endemic 
parasitic infections which, together, are responsible for a large share of the 
burden of disease in developing countries). 

EN 

15 

   EN