Implications of the fair processes for financing UHC report for development assistance: reflections and an application of the decision-making principles to PEPFAR

Abstract

The framework presented in the World Bank report Open and Inclusive: Fair processes for Financing Universal Health Coverage effectively connects proposed decision-making principles with practical examples that country governments can use to pursue greater fairness. In this commentary, we consider the suggestion that international development partners might use the report's criteria to examine their own processes. We consider what the report's primary Fair Process principles – equality, impartiality and consistency – imply for development partners. Specifically, we address two questions in turn: (i) how relevant the Fair Processes report is to development assistance for health; (ii) if it is deemed relevant, what practical implications does the report have for how aid works? We address the second question by briefly applying the framework to a particular global health initiative, namely the United States President's Emergency Plan for AIDS Relief (PEPFAR). Our analysis suggests that development partners' additional sets of accountabilities, particularly linked to funding sources, may pose more fundamental challenges to impartiality than to equality and consistency in decision-making processes. A question inviting further examination, then, is how development partners can redesign their processes to optimise impartiality given institutional constraints that bind them independently of the populations they purport to serve.

1. Introduction

The decision-making framework presented in the World Bank report Open and Inclusive: Fair processes for Financing Universal Health Coverage effectively connects the proposed decision-making principles with practical examples that country governments can use to pursue greater fairness (World Bank, 2023). In considering how to extend the framework's utility, we were struck by the suggestion that international partners might use the report's criteria to examine their own processes (World Bank, 2023: 11 and 39). Since the 2005 Paris Declaration on Aid Effectiveness (Organisation for Economic Co-operation and Development, 2005), a stream of global health literature has examined how international partners operate in low- and middle-income-country (LMIC) settings and what kinds of principles should guide how they invest.

The Paris Declaration, and subsequent declarations such as the Accra Agenda for Action (Organisation for Economic Co-operation and Development, 2008) and the Busan Commitment (Organisation for Economic Co-operation and Development, 2020) were motivated by a desire to ‘improve the quality of aid and its impact on development’ (Organisation for Economic Co-operation and Development, 2005: 1). This ambition responded to two key concerns. First, there was growing evidence that development spending was more effective in contexts with strong government ownership and financial systems to manage aid (Burnside and Dollar, 2004). Second, there was mounting evidence of the waste and duplication that results from multiple, poorly coordinated development partners (DPs) operating in the same environment (Cassels and Janovsky, 1998). The Paris Declaration (see Table 1) encouraged LMIC governments to take clearer ownership of their development agendas and called for DPs to then align behind these agendas.

Table 1. Five principles of the Paris Declaration on Aid Effectiveness

While the push towards stronger aid ownership and alignment abated a little during the 2010s, discussion around good practices for DPs has recently regained momentum, underscoring national ownership. The Global Financing Facility, a partnership hosted at the World Bank, acknowledged that in the worst instances poorly aligned aid has ‘challenged national leadership and disrupted policy and implementation processes in partner countries’ (Global Financing Facility, 2021: 1). Some of this thinking culminated in the 2023 Lusaka Agenda, a multi-government process that sought to promote ‘sustainable impact’ for Global Health Initiatives like the Global Fund to Fight AIDS, TB and Malaria, and Gavi, the Vaccine Alliance (Future of Global Health Initiatives, 2023).

Neither the goal of the Paris Declaration, to promote aid effectiveness, nor the purpose of the Lusaka Agenda, to strengthen sustainability, aligns directly with the goal of the Fair Processes report to support fair processes and equity. However, we believe that the Fair Processes report has utility in providing a framework to guide the processes through which DPs pursue investments in global health, and that its focus on fair process and equity is particularly important for DPs, given recent emphases amongst such organisations in promoting diversity, equity and inclusion (International Development Innovation Alliance, 2024).

This commentary addresses two questions in turn: (i) how relevant the Fair Processes report is to development assistance for health and, (ii) if it is deemed relevant, what practical implications the report has for how aid works? As this is a short commentary, we address the second question through a brief application of the framework to a particular global health initiative, namely the United States President's Emergency Plan for AIDS Relief (PEPFAR). These are significant questions to pursue: development assistance for health accounted for 27.7 per cent of total health expenditure in low-income countries during 2019 (Institute for Health Metrics and Evaluation, 2023), and rose substantially during the COVID-19 pandemic; accordingly, improved processes amongst DPs could have profound impacts.

2. Relevance of the fair processes report to development assistance for health

The Fair Processes report aims to inform decision-making around health financing policies that may affect equity. While development assistance for health is typically not driven through high-level national policies, the entities involved in development assistance (including multilateral funders such as the Global Fund to Fight AIDS, TB and Malaria, or the World Bank; bilateral agencies such as the US Agency for International Development; and Foundations such as the Bill & Melinda Gates Foundation) all have organisational policies that shape how they contribute funds to recipient countries. These organisational policies should be subject to scrutiny in light of the report's recommendations.

The report considers the three health financing functions – revenue raising, pooling of resources and purchasing of services – and identifies equity considerations linked to each. Consideration of revenue raising appears less pertinent to DP funding: while there are clear domestic equity issues regarding how funds are raised relating to the tax regimes in donor countries, or other equity issues regarding contributory policies for international agencies, these do not directly affect equity within LMICs and so we consider them out of scope for this commentary. There are, however, important equity issues related to how DPs (a) pool and manage their resources and (b) make purchasing decisions. Table 2 illustrates a range of types of DP decisions and their equity implications.

Table 2. Development partner (DP) decisions and equity implications

Table 2 indicates a set of decisions that DPs make that have equity consequences, but this leaves unaddressed the question of whether the benefits associated with fair decisions by DPs are comparable in significance to those of fairness in government decision-making. It is possible, for various reasons, that fair processes in DP decision-making will have less impact on equity, legitimacy, trust and effective implementation of programmes, i.e. those factors that the report argues are critical for government decision-making in health financing. However, we think that the frameworks and principles introduced in the World Bank report could have positive impacts on fairness in DP processes, and ultimately yield greater equity in health financing for LMICs. Further, the final reason offered in the report, i.e. effective programme implementation, applies logically to governments and DPs alike.

There are at least two reasons why fair processes may appear less relevant to DPs than to governments. First, DPs have accountability to additional stakeholder(s). Rules governing bilateral DP operations are typically set by their own governments to ensure accountability to elected domestic officials, on behalf of populations in the DP's own country, who have certain expectations about how their tax revenues are used for development assistance. For foundations' spending decisions, legal accountability centres on founders or their trustees.

This bifurcated set of accountabilities – one to the source of funds, and the other to the people where funds are being spent – complicates matters. While the definition of the term ‘philanthropy’ is contested, some definitions contrast philanthropy with charity and in so doing emphasise (a) that philanthropy seeks to address the root cause of problems (not just provide gifts to address current need) and (b) philanthropy is more than simply the intent to do good (Sulek, 2010). If indeed philanthropy is addressing complex problems and requires actual positive impact (not mere intent) then it seems that DPs at a minimum should seek to understand beneficiaries' views, and ideally give in ways that empower them. Moreover, so far as applicable conceptions of global health justice require development assistance for health to be designed and implemented according to explicit norms of fairness, respect for recipients' agency is essential. It would be problematic therefore if, through neglect of fair process, DPs were to make decisions that disregarded beneficiaries' empowerment, exacerbated inequities or undermined trust in government. Accordingly, while DPs need to balance their obligations to people in recipient countries with obligations to those who originally provided the funding, this does not obviate the requirement to apply fair processes in policies and decision-making that affect recipients.

Second, while legitimacy of policy decisions and trust in government are important reasons that the report gives for governments to adopt fair processes in health financing policy, the nature of DP spending may have less impact on legitimacy and trust than how a government spends its own funds. To that extent, fair processes in DP spending may appear less relevant to ultimate equity outcomes of health financing in LMICs. From our own observations in the field, however, many people in LMIC contexts have limited awareness of the source of funds for different services. This is understandable given the complexity of DP funding arrangements, with multiple DPs funding activities, sometimes through government and sometimes through other implementing partners. There is a real risk that decisions made by DPs that do not demonstrate fair process will reflect negatively on government, undermining trust in government and legitimacy in the decisions undertaken.

In conclusion, while some lines of reasoning suggest that DPs need to worry less about fairness in financing and how they spend their funds, we believe that these have limited impact on the overall arguments and that the principles set out in the Fair Processes report remain relevant.

3. What are the implications of the Fair Process principles for DPs?

The report lays out three primary principles for fair process in financing, namely:

• • Equality that focuses on equality of access to decision-making and to information that can inform decisions;

• • Impartiality that addresses whose views and opinions have most power in shaping decisions regarding financing, and asserts that vested interests should not dominate decision-making; and

• • Consistency over time that requires decision-making processes regarding financing to be ‘stable and predictable’, and not subject to rapid or arbitrary change.

We focus on a single DP case study, PEPFAR, to provide examples illustrating how DPs may struggle to follow each of these principles, and we begin to explore the circumstances which lead to this. Since its inception in 2003, PEPFAR has spent over US$100 billion on HIV/AIDS prevention and treatment, and efforts to mitigate the social effects of HIV/AIDS. It remains a primary funding source for HIV/AIDS programmes in countries with high HIV prevalence and low GNP. For example, in 2016 PEPFAR allocations to Haiti, Mozambique and Uganda accounted for more than government general expenditure on health (Silverman, 2018).

Regarding equality in decision-making, many PEPFAR financing policies are made at headquarters level, then cascaded down to country-offices. This means that decision-making processes do not already adequately reflect the voices of in-country stakeholders who ultimately may be most affected. For instance, the 2015 Geographic Prioritisation policy focused PEPFAR financing within a country on those geographic jurisdictions (districts or counties) that had higher HIV/AIDS burden, and transitioned jurisdictions with low burden to ‘central support’, i.e. government financing. Evaluations of the policy in Kenya and Uganda indicated that while it had substantial implications for access to services among marginalised populations and for patterns of government funding, the policy was developed in PEPFAR headquarters with little to no input from country governments or indeed the people whom PEPFAR programmes were intended to serve, and limited input from US government employees in in-country offices (Paina et al., 2023).

In terms of impartiality, the 2023 reauthorisation of PEPFAR exemplifies the challenges associated with vested interests. PEPFAR funding requires reauthorisation by the US Congress every 5 years. Reauthorisation was needed in 2023 but was blocked by certain members of Congress who mischaracterised PEPFAR as a programme offering ‘abortion on demand’. While PEPFAR has never supported abortion, political posturing by those on the right – who were energised by the 2022 Supreme Court Dobbs ruling that overturned access rights to abortion in the US (Moss and Kates, 2023; PAI Washington Memo, 2023) – effectively prevented reauthorisation of US$1bn. Further, initially PEPFAR received funding for only 1 year, creating significant uncertainty in recipient countries, which was later extended for only 6 months longer (Moss and Kates, 2024). This is an extreme case where vested interests of a small number of elected officials, motivated largely by domestic US politics, have imperiled access to HIV/AIDS services for large numbers of people in LMICs who have limited to no voice in the ongoing debate. Nonetheless, from its very initiation PEPFAR programming has been substantially shaped by US politics and the influence of relatively small interest groups disconnected from populations receiving funding. For example, in 2003, PEPFAR country funding was conditioned upon adoption of the ABC approach (Abstinence; Be Faithful; Correct and Consistent Condom Use – with a heavy focus on A at least until marriage) (Buse et al., 2016), responding largely to demands of the religious right, despite lack of a strong evidence base on ABC's effectiveness in Sub-Saharan African contexts.

Finally, in terms of consistency, PEPFAR, unlike GAVI or the Global Fund to Fight AIDS, TB and Malaria, has no explicit policy or clear criteria guiding when it might withdraw funds from countries. Nonetheless, since the Lantos-Hyde Act of 2008, there has been emphasis within PEPFAR on transitioning programmes towards government funding and greater sustainability, sometimes producing unpredictable shifts in financing. For example, Silverman estimated that the PEPFAR Acceleration strategy of 2017–2018 would result in drops of funding for some countries of up to 68 per cent of their PEPFAR allocation in a single year (Silverman, 2018).

In the illustrative case of PEPFAR, the DP's capacity to fulfil the specific requirements outlined by the Report for equality, impartiality and consistency, respectively, has varying degrees of exposure to the divergence of the DP's accountabilities between funding source and people served. First, the requirements of equality include attending to the voices of marginalised and disadvantaged groups and ensuring an equally respectful hearing for everyone. While treating everyone with respect is foundational to ethically sound practice, and DP internal structures might permit such consultative processes, in practice, tight timelines for decision-making and highly structured DP processes often inhibit consultation with beneficiaries. Approaches to meaningful inclusion of marginalised and disadvantaged groups in decision-making for setting resource allocation priorities have been modelled for national health research, and have been explored with regard to procedural fairness in sub-national health system priority setting as well as substantive fairness in DPs' health-related priority-setting processes (Pratt et al., 2016; Pratt and Hyder, 2018; Kapiriri and Razavi, 2022; Razavi et al., 2022). Insights from this literature hold promise for use in efforts to improve procedural fairness in DPs' work with LMIC partners, DPs' other accountabilities notwithstanding.

Regarding impartiality, however, the DP in the PEPFAR example is more structurally exposed to whatever political maladies may afflict its funding source. This problem is independent of normative questions about where to locate requirements of international distributive justice along the spectrum between ‘statist’ views (which ground distributive justice in compatriots' moral obligations to one another, limiting what they owe to non-compatriots) at one end, and ‘cosmopolitan’ views (which ground distributive justice in people's moral obligations to all other people as citizens of the world) at the other (Venkatapuram, 2023). Rather, the DP's funding reauthorisation in this example is constrained by intense moral disagreement and cultural conflict within its home polity about something else altogether, namely the permissibility of abortion.¹ In such cases, the DP's separate national identity and embeddedness in prior power structures rooted in the nation's political constitution may hinder its compliance with the principle of impartiality in working with partner countries. While we understand that structural features of DPs may compromise impartiality, we still consider it an important aspirational principle that DPs should strive for. Further we note that different types of DPs have very different processes governing financial allocations and decision-making, from participatory democratic processes (as in many bilateral aid programmes) to highly centralised decision-making in foundations, so that promoting impartiality will likely require different measures according to the nature of the DP.

The failure of consistency exemplified by PEPFAR's lack of explicit policy or clear criteria regarding withdrawal of its funds from countries is in principle remediable by forming, and publicly stating, the needed policy and criteria. For instance, if a DP is generally inclined to emphasise transition to sustainable ownership of programmes by partner countries, it could formally state this at all stages of pre-engagement and engagement so that partner countries know what to expect.

In this section, we have identified ways in which a single DP has failed to observe the principles identified in the Fair Processes report. We have used the example of that DP to consider whether, how and to what extent a DP's additional accountabilities limit its ability specifically to observe each of the three principles. We acknowledge that PEPFAR itself has recognised some of these challenges and at times has sought strategies to address them explicitly. For example, in the period 2009–2012, PEPFAR developed a series of Partnership agreements with countries that resulted from extensive negotiations with governments and set out common goals, timelines for sustainability, etc. Yet despite high initial investments, these Partnership agreements were only adhered to for a short period (Oomman, 2009).

4. Conclusions

The discussion of DP financing policies and practices to-date has largely been framed in terms of strengthening the impact and sustainability of DP programming. Nonetheless, there are also important ethical questions regarding DPs' funding processes and the ultimate impacts they have on equity of health financing in LMICs. Our analysis suggests that the principles derived in the Fair Process report are relevant to DPs. Specifically, these principles challenge prevailing operational norms in development assistance for health by shifting the ideal locus of deliberations about health financing decisions farther towards those most affected. In this commentary, we have used PEPFAR as a case study to illustrate how DP practices may not adhere to the principles set out in the Fair Processes report and have begun to explore why this is the case. Our analysis suggests that the additional sets of accountabilities that DPs face, particularly linked to funding sources, may pose more fundamental challenges to impartiality than to equality and consistency in DPs' decision-making processes. A question that invites further examination, then, is how DPs can redesign their processes to optimise impartiality in the face of institutional constraints that bind them independently of the populations they purport to serve.

A fuller review of DP financing policies and practices is warranted in light of all three principles. It would be helpful to consider a broader array of DPs with different ways of raising revenues (Foundations, bilateral donors and multilaterals) and accordingly different accountability structures to their funders.

The global health community has recently demonstrated greater interest in principles associated with Diversity, Equity and Inclusion, as well as recognising the need to ‘decolonise’ global health. This renewed focus on understanding, remedying and preventing structural inequities aligns well with increased emphasis on ethical and human rights perspectives in DP funding policies and practices. We are hopeful therefore that the Fair Processes framework has come at a moment of significant opportunity in terms of attention to how DPs operate and how to ensure greater fairness and stronger support for equity in their approaches.