UK Bilateral Aid Should Prioritise Government-Led Expansion of Health Services

Last Thursday, the UK announced cuts to bilateral aid programmes in order to meet the new budget envelope of 0.3 percent of GNI. This includes over 50 percent cuts to programmes in Africa. Guided by the International Development Minister’s call to shift aid from “service delivery to system support,” officials are now finalising the design of the remaining health programmes.

To inform these decisions, we have been reviewing the portfolio of UK global health programmes. We argue that, while “system support” is often thought of as a narrow set of donor-led “heath system strengthening” (HSS) activities (namely technical assistance [TA] and capital investment), supporting recipient governments to expand their service delivery is itself a form of system support. Further, we argue that government-led expansion of service delivery should be the default form of system support since it has a stronger evidence base, can save lives in the short term, and has the potential to build systems in the long term.

The UK’s current system support programmes are poorly justified

We found the UK global health programmes can be categorised into four groups:

1. multi-country targeted interventions (e.g., Choices for Reproductive Health),
2. single-country targeted interventions (e.g., family planning in Tanzania),
3. multisectoral humanitarian projects (e.g., in Yemen), and
4. broad health system support projects, such as in Nigeria, Ethiopia, and Malawi.

Shifting “from service delivery to system support” presumably means deprioritising targeted intervention programmes where possible, since they typically support specific services or disease areas, rather than the health system as a whole. Broad health system support programmes appear to align most closely with the minister’s shift. They also have potential to be impactful and sustainable in the face of current severe aid volatility.

That said, the UK’s system support programmes are often complex sets of interventions—the business cases are opaque, and the underlying rationale and assumptions unclear or poorly justified. As a result, decision-makers may not have the information required to differentiate a well-designed, high-impact system support programme from a weaker one. For example, impact calculations for the Lafiya programme in Nigeria appear to be based on an assertion that the program would decrease maternal mortality by 0.5 percent more than the baseline—without any justification for this. Thirty-four percent of the Umoyo Wathu programme in Malawi is allocated to technical assistance (TA), but the business case does not detail what this entails nor what quantitative impact this could have—in contrast to the service delivery component which is well-evidenced and shown to be extremely cost-effective.

System support is better delivered by expanding government service delivery

Better system support programming starts with clarity of objectives. We propose there are two broad categories of activities which could be considered “system support” (Figure 1): 1) government-led expansion of health service delivery; and 2) donor-led HSS activities, centred on capital investment and TA for institutional reform.

Figure 1. Expanding government service delivery is not considered a traditional HSS activity, but is an important form of health system support

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We argue that the first type is—at least in some contexts—the best way to realise the shift to system support, although we acknowledge this could be in tension with the third ministerial shift from “grants to expertise.” Our review (see Table 1) found evidence that government-led expansion of service delivery can be very cost-effective. For example, the Umoyo Wathu programme business case, based on independent in-depth research on designing an essential health package in Malawi, estimated a cost per DALY of just USD 8.55 to expand primary care through a pooled Health Sector Joint Fund. It may also support sustainability and whole-of-health system strengthening by building government experience with delivery of a broad, high quality, cost-effective service delivery package at scale—especially if the recipient government leads the planning and if funds flow through government public financial management systems. Thus, pooled funds and on-budget funding can be particularly transformative.

On the other hand, the evidence for donor-led capital investment and TA is often uncertain and highly contextual. Effective implementation requires thorough understanding of local systems, sustained political support, and impeccable timing. These conditions rarely align, and are even more unlikely with smaller budgets and fewer health advisors. Capital investment has recurrent costs, but who will cover these in the long run is not always considered. And while recipient governments may accept free external TA, there is often insufficient political will for this TA to translate into meaningful reform within the lifetime of the program. Therefore, we argue that the UK should stop treating donor-led HSS as the default form of system support. While there may be exceptions where a donor-led HSS programme is the appropriate choice—for example, a TA programme requested by the recipient government focused on a proven area such as developing priority-setting institutions—government-led expansion of service delivery should be the default when designing system support programmes.

Table 1. Expanded government service delivery is the best form of system support

As officials are now developing and reviewing plans for the next three years of UK global health aid, we encourage them to scale back TA and instead focus on financing government-led expansion of health service delivery as a good option for “system support.” This is particularly important following last week’s announcement that Nigeria and Ethiopia—countries with broad health system support projects—will be among the few countries continuing to receive substantial UK development support. Using pooled funding to expand government delivery of a basic healthcare package can save lives now while also helping recipient governments to build the experience, systems, and legitimacy needed to strengthen their own health systems over time. It represents a modern form of UK development partnership.