Module 6. Analysing Health Sector Financing and Expenditure : Previous page | 1,2,3,4,5,6,7,8,9,10,11

Contextualising sustainability

Table of contents Contents and Introduction Sources of Financing The present resource envelope Composition of health expenditure in severely under-funded public sectors Patterns of allocative decision-making Forecasting the future resource envelope, in a recovery perspective Contextualising sustainability Recommended Reading References Annex 6a: Annex 6b:

Sustainability is continuously invoked as a key criterion to assess any aid-induced activity or initiative. Sometimes, the concept is given the weight of a decisive argument. Thus, to declare something 'unsustainable' may sound as equivalent of 'worthless' or even 'harmful', in this way overruling any other consideration. A shift in the meaning assigned to sustainability is imposed in the context of failed states, severe poverty and increased health needs, such as in Congo and Afghanistan. During protracted periods (most likely decades), these countries will be unable to survive by relying only on their own means. A 'sustainable' health service must therefore be intended as an activity guaranteed on an uninterrupted basis, even if financed by external resources. Rather than downplaying performing health services provided to a population in need of them, on the sole basis of its external source of funding, the scrutiny should shift from this dimension to the predicability of such funding and to the possible attached strings. Such a change of perspective would be sufficient to correct the prevailing approach.

Donors are reluctant to accept the dire fact that a country ravaged by a long-lasting conflict and lacking basic resources and capacity is unsustainable and will remain so for long, even after the customary set of 'remedies' has been applied. Donors face a hard choice that they usually prefer to elude: either to disengage totally and irreversibly (and accept the increased mortality, morbidity and poverty related to that decision), or to commit themselves to guaranteeing that key health services are provided without interruptions over time or quality slumps. If the chosen approach is the latter, no new health activities should be started without ensuring their funding over a long period of time.

Unfortunately, donors frequently prefer to opt for the middle grounds: short funding cycles, repeated assessments of the benefits of continuing such funding, frequent change of activities to be supported and of programming approaches, and repeated interruptions of aid flows are commonplace. In this way, disparate initiatives repeatedly take off, without having a chance of taking roots. The recent donor trend towards introducing cost-sharing schemes even in severely-ravaged contexts is worrisome (Poletti, 2003). In this case, a misplaced sustainability concern seems to foster further inefficiency and inequity in situation already marked by distress, crippling poverty and serious operational constraints.

Sustainability tends to be employed as an all-encompassing term, but it seems useful to distinguish between technical sustainability, which relates to the capacity to carry out certain functions, and financial sustainability, which results from resource availability, fiscal capacity and the relative priority of health care provision. In fact, a government might have the absolute means to sustain health services, but prefer to allocate its resources to some other area. A third dimension to be considered related to political sustainability. For instance, a needed but unpopular policy may be abandoned by a government unsure of their tenure. The same holds for donors, whose frequent and drastic policy shifts are well known.

Whereas the various aspects of sustainability are equally important in determining the future of a health activity implanted with external support, the discussion about it tends to overemphasise the financial side of the problem. This unfortunate bias, usually strong in donor circles, may only perpetuate the assumption that adequate financing removes most or all obstacles. By neglecting capacity constraints and political concerns, wasteful initiatives are encouraged. This bias in favour of financial sustainability overlooks the harm done to technical capacity during a protracted crisis. The longer and severe the disruption, the longer the recovery is likely to take. And capacity could have been abysmally low even before the crisis.

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