Poverty and poor health are closely linked. New targeted interventions, such as increased immunisation coverage, have contributed to improved child health in many countries. At the same time, global campaigns against certain diseases have led to an increasing fragmentation of the efforts to improve health. There is therefore a danger that other important health-service functions may be given a lower priority. Norway should help to combat this.
Illustration Supernøtt Popsløyd
It is possible to break the vicious circle of poverty and poor health, but this demands major efforts from several sectors of society. Employees in the health sector have an important role to play, not only by virtue of performing curative and preventive work, but also by trying to influence politicians and act as whistle-blowers about unacceptable conditions. The health sector must be developed to contribute to better health at a manageable cost.
Fragmentation
An increasing number of public-private partnerships have been established in the past 15 years to strengthen the efforts against diseases such as malaria, tuberculosis, HIV/AIDS and other poverty-related diseases (1 ). Since the turn of the millennium many new initiatives have been taken to achieve the UN Millennium Development Goals (2 ). Health-related development assistance from Norway has tripled in the last 10 years (3 ), and Norway has set aside one billion US dollars for the improvement of maternal and child health over a ten-year period (4 ). The efforts by Norway, other donor countries and international actors such as the Bill & Melinda Gates Foundation – for example through the GAVI Alliance – have contributed to reductions in child mortality in many countries (5 ). With the financial resources that were promised at the donor conference of the GAVI Alliance in London in June 2011 (6 ), the Alliance can begin to significantly scale up pneumococcal and rotavirus vaccination of children.
The many global campaigns against particular diseases or for special target groups have, however, led to an increasing fragmentation of efforts to improve health in low- and middle-income countries. There is still a great and unmet need for treatment, care and prevention of many common diseases, and new initiatives can lead to a draining of personnel and resources from the existing health-care system. By promoting the allocation of more funding to support the health-care systems, Norway can help ensure that international initiatives do not weaken but rather strengthen important health-service functions.
Better coordination
In order to improve coordination between the different actors, an international health partnership (IHP) was established in September 2007 (7 ), launched by prime ministers Gordon Brown and Jens Stoltenberg, with many countries of Europe, Africa and Asia as partners. Together with related initiatives, a coordinating process has been established with a common work plan (IHP+). The effect has been that in many countries national health plans are now being drawn up (8 ). One of the objectives is to help fulfil the health-related Millennium Development Goals through an improved coordination of the efforts between recipient countries and donors to achieve a greater coverage of effective interventions and necessary health-care services.
Results-based financing
IHP+ has placed emphasis on results-based financing (RBF) as an important strategy to improve health and health-care services in low- and middle-income countries. (9 , 10 ). Norway has been a driving force for the strategy and has pledged 105 million US dollars to the World Bank for use in the period 2009 to 2013 for this purpose (11 ). This is somewhat surprising, given that a report by an IPH+ working group (12 ) shows that we lack reliable data on the benefits of introducing results-based financing in low-income countries. For example, the working group writes that this type of financing can encourage corruption and lead to valuable services being neglected because they are not covered by the scheme(s). A systematic review of the literature undertaken by researchers at the Norwegian Knowledge Centre for the Health Services also points to many unfortunate effects of results-based financing (13 ).
A randomised study carried out recently in Rwanda shows that interventions based on this financing strategy led to more women giving birth in institutions and more children being seen at health institutions (14 ). However, it may be difficult to generalise on the basis of a country such as Rwanda, with its relatively strong health-care system and high level of donor funding (15 ). Moreover, the study did not measure impacts on morbidity and mortality.
There is also little evidence that results-based financing in itself is effective (16 ), and we do not know whether this kind of strategy will create sustainable changes (13 ). For countries and initiatives that choose to use such a strategy, sufficient resources should be devoted to research which not only assesses the short-term effect of such financing on the service targeted by the intervention and on the disease(s) in question, but also assesses the long-term effect on health-care services performance.
Comprehensive health services
To achieve lasting improvements in countries with weak health systems and failing infrastructures requires a long-term commitment to a comprehensive health service, in addition to targeted interventions for the improvement of specific challenges, such as maternal and child health (17 ). This should be combined with processes of change in many sectors, where education is of particular importance. Without a well-educated national leadership both in the health sector and in other areas, effective and sustained development aid through locally based programmes and partnerships will be difficult to achieve.
The World Health Organisation (18 ) and others (19 , 20 ) support a stronger commitment to a revitalised primary health-care strategy. This strategy is also recommended in the 2009 report on the health-related Millennium Development Goals (17, p. 17). The 2010 report (21 ) draws attention to the need for greater national ownership of various initiatives, which was also underlined by Prime Minister Jens Stoltenberg in his speech at the UN MDG Summit in New York on 20 September 2010 (22 ). He emphasised that low-income countries must contribute more from their own resources by developing better taxation systems and by combating corruption.
Changes in Norwegian health-related development assistance
In the process of developing large global partnerships for health, the nature of Norway’s health-related development assistance has changed markedly. We have moved away from broad commitments to cross-sectoral, more comprehensive programmes in low-income countries where Norwegian actors have long experience of cooperation and opportunities to develop lasting institutional links. Now health-related development assistance goes to a larger extent to selected countries where there is a commitment to more focused interventions, and where there is often less emphasis on institutional partnerships and long-term competence building. Examples include commitment to interventions to improve maternal and child health now in the process of being introduced in India, Pakistan, Tanzania and Nigeria.
Whether this is the right strategy is open for discussion. The advantage is a more rapid achievement of results that can be demonstrated in specific areas. It is less certain what the effect will be on the health services in the longer term. It should however be mentioned that Norway contributes to several important global initiatives, for example through the Global Health Workforce Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria and through the GAVI Alliance. Moreover, Norway has taken the initiative to highlight health as an important aspect of foreign policy (23 ). These and other interventions are also discussed in an article on the global health architecture as part of the series on global health in this journal (24 ).
The poorest
In his book «The bottom billion: why the poorest countries are failing and what can be done about it» (25 ), Paul Collier points out that we should be directing our attention primarily to the poorest billion who are most in need of international development assistance. Also in the 2009 report on the Millennium Development Goals, it is now stated that future development assistance should be channelled towards low-income countries with the greatest health problems (17, p. 52). It may actually be easier to reduce illness and mortality in these population groups. Through a knowledge-based effort, i.e. the introduction of a sufficiently high level of coverage of interventions that we know work, we will fairly quickly be able to achieve lower morbidity and mortality in these countries, as well as better nutrition. These are countries which perhaps would not have been chosen for development cooperation if trade or foreign policy considerations were put first. However, it is important for the poorest that development cooperation be governed first and foremost by the humanitarian needs of partner countries, in addition to their political will and their ability to carry out such interventions.
Climate change threatens global health
In his speech at the UN MDG Summit in New York in the autumn of 2010, Prime Minister Jens Stoltenberg also stressed the link between climate change and global health (22 ). In a review article in The Lancet, global warming is described as the biggest threat to global health in the 21st century (26 ). Climate change can counteract the effect of interventions for better health and development, and the prevention of serious climate changes is important to improve health and development in many low-income countries. This is further discussed in an article on climate change in the series on global health in this journal (27 ).
A better knowledge base
To understand how best to carry out the necessary changes, a stronger commitment to implementation research is needed, based in national partner institutions. Norway should follow up the new initiatives with research that not only measures the effect of the different interventions themselves, but also how they can best be implemented and scaled up. A fairer distribution of health-promoting interventions so that they can better reach marginalised population groups will help to increase their overall effectiveness, since these groups most often bear the greatest disease burden and may derive particular benefit from such interventions. By supporting research-based evaluations of new interventions and scaling-up existing ones, Norway can help tailor programmes to local conditions in an appropriate way and thereby increase their effect and strengthen their sustainability. Long-term commitment that is rooted in local institutions is a necessary requirement. Rather than major reforms, more is often achieved through incremental, knowledge-based changes that are tailored to the local conditions in different countries.
Conclusion
We have seen a significant reduction in child mortality (5 ) and signs of a reduced maternal mortality (28 ) in several low- and middle-income countries. National and international health initiatives have contributed to this progress, especially to the reduction in child mortality. However, this progress is very unevenly distributed between countries and between different population groups within most countries (5 ). Low-income countries will face great health challenges in the coming decades, also because we in many areas can expect serious health consequences as a result of climate change (26 ).
Through the continuation of strong commitment by Norway and other wealthy countries, in addition to a gradual transfer of health-related development assistance in the direction proposed in this article, we believe that Jonas Gahr Støre may be proved right when, in his speech at the launch of the 2009 report on the health-related Millennium Development Goals (17 ), he expressed the hope that «this massive mobilisation for maternal health combined with the focus on health in general was a new beginning – a new initiative – to take the global health effort forward» (29 ).
