Over the past 10 years, Belgium has invested €1.5 billion in health care in the South. With what result? And what lessons has the administration which allocated the funds learned? Isabelle Wittoek found out.
Year on year, Belgium invests development funds in sectors such as agriculture, education and health care. Over the years, the amounts can be high. Isabelle Wittoek, a diplomat at the FPS Foreign Affairs, added up the total amount of aid to the health care sector over the period 2009-2017. She came to a figure of roughly €1.5 billion.
'A considerable sum, although it needs to be put in context,' she explains. 'Because if you express it in per capita terms, it looks much more modest. For example, we only spent €0.50 per inhabitant in DR Congo in 2014. In donor orphan Niger the figure was €0.18, in donor darling Rwanda it was €1.46. The total per capita expenditure on health care by developing countries also remains limited. Rwanda - the leading country of those surveyed - spends €113.3, while Congo spends €29. Belgium spends €4,247 per capita on its own population.
This does not prevent the investments in health care from having an effect. But what exactly are the results and how can things be improved? The FPS Foreign Affairs has a Special Evaluation Service which regularly audits the programmes. But a comprehensive analysis of an entire sector over a longer period does not happen often. Isabelle Wittoek took up the challenge. The result was a hefty document of 228 pages.
Strengthening health care systems
From the early days of its development cooperation in the 1960s, Belgium has always been strongly committed to health care. In a sense, this was the legacy of the effective health system that Belgium had implemented in Congo during the colonial period. This is also where the roots of the Institute of Tropical Medicine (ITG) can be found, which today is an important partner of the Belgian government. See Health care in Congo: a model for the world. (Dutch and French only)
‘Our country systematically chooses to strengthen health care systems as a whole', says Wittoek. ‘At the same time, Belgium tries to ensure that everyone has access to health care, including through mutual health organisations. We work on the assumption that everyone has the right to health care’. A lot of attention is also paid to effectively training medical staff, through the ITG and university development cooperation. See also Belgium, pioneer in health care. (Dutch and French only).
Belgium's approach is not so much towards combating specific diseases, for example via vaccinations. Rather, it aims to strengthen health care systems in such a way that countries can effectively treat the various diseases themselves.
As such, Belgium's approach is not so much towards combating specific diseases, for example via vaccinations. Rather, it aims to strengthen health care systems in such a way that countries can effectively treat the various diseases themselves. This approach is closely in line with the vision of the UN World Health Organization (WHO). Wittoek: 'It is not the easiest approach, but it is the most sustainable one'.
How does a health care system like this one work in the South? In Belgium, if we have a common complaint, we go to a general practitioner, a "liberal profession". Basic or primary health care in Belgium is therefore in private hands. In the South, people go to a health centre. "Often there aren't even any doctors there. The first person the patient sees is usually a nurse. All health workers receive their wages from the state. This allows development aid to be more focused on the system itself. That way, funding can be provided based on results. ‘For example, paying a health worker a premium if he or she does a good job’.
The rest of the health system is more similar to the Belgian system. If the symptoms are more serious, the health centre sends the patient to a hospital. The "reference hospitals" are a step higher. 'They have more possibilities. In the same way that only a limited number of our hospitals have a few advanced scanners at their disposal'.
In the South, people go to a health centre. Often there aren't even any doctors there. The first person the patient sees is usually a nurse.
Difficult to measure
Another constant element in Belgian policy is the focus on fragile and least developed countries. These are countries that suffer from weak public institutions. This also makes development cooperation more difficult and constantly requires adjustments to projects.
'These policy choices have another consequence,' says Wittoek. 'It is not easy to measure exactly what effect your intervention had. With a vaccination campaign, it's easier.' Then you can tell exactly how many people you have vaccinated and how much less prevalent the disease is subsequently. 'The only reliable indicator for our work is the fall in maternal mortality. Not within a health centre, but among the entire population of the country. One disadvantage is that as a donor you cannot claim that a reduction in maternal mortality was entirely thanks to you. There are always multiple donors involved. You also have to look at it over a period of at least 10 years'.
You can also measure whether more people are being treated in health centres after the intervention. That gives you an idea, but is still an imperfect indicator. Indeed, it is not easy to interpret, and it does not reflect the entire health care system.
The only reliable indicator for our work is the fall in maternal mortality. Not within a health centre, but among the entire population of the country.
The Belgian Development Agency Enabel analysed how satisfied people are with health care in Benin. To this end, it used a user platform (see box 'success story'). 'In any case, it works better than simply counting the number of patients treated and checking whether there are sufficient medicines in stock, as the World Bank often does. The World Bank actually took inspiration from Enabel in Benin'.
Despite the fact that measuring is difficult, we can say that Belgium has actually succeeded in improving the quality of and access to the health care systems in the regions that have been supported.
Wittoek believes that Belgium generally makes coherent policy choices. Yet she also highlights a contradiction. 'Belgium still donates a lot of money to the Global Fund that specifically combats AIDS, tuberculosis and malaria. This clashes with the approach to primarily strengthen health care systems. The Global Fund has done some excellent work, for example in the fight against AIDS. But these days, AIDS is treatable within existing health care systems. Special structures don't need to be set up in that regard.'
Wittoek believes that Belgium needs to learn a lot more lessons from its own activities. These lessons also need to be shared more among the various Belgian players active in the health care sector (see box). There is already a platform in this respect, in particular 'Be-cause Health', but this is clearly still insufficient. 'For example, as a donor, Belgium may find it useful to draw on the experience of the 'Damiaanactie' and 'Memisa' in their discussions with the Global Fund. And although Belgium actively participates in the board of directors of the WHO, this is not sufficiently documented anywhere. And that would be handy.’
Belgium needs to learn a lot more lessons from its own activities. These lessons also need to be shared more among the various Belgian players active in the health care sector.
It is also essential that a long-term approach is taken. 'Yet this is not guaranteed anywhere in the law or in binding provisions for governmental cooperation. These provisions are negotiated every four years and the partner country makes its own choices. Nevertheless, we see in reality that we are active in the health care sector for a long time. This is of course more obvious for NGOs, since they have their own right of initiative and cooperate with local partners'.
Belgium therefore needs to continue focusing on health care. After all, the needs remain considerable. The countries that receive support are still not spending enough to ensure a minimum level of care. And people still have to bear too much of the health costs themselves.
'But the various players should work together more effectively on the ground. For example, Enabel and Memisa in Congo - an extremely fragile context - should play their complementary role more effectively'. But all in all, Wittoek believes that Belgium is clearly a valuable donor in the health care sector. The decades of experience are bearing fruit. Other donors and multilateral institutions can also learn from Belgium.
The players in health care
Belgium organises its development cooperation via 3 channels.
(1) The governmental cooperation – from government to government – is implemented by Enabel, the Belgian development agency. Enabel performs a "double anchoring". On the one hand, it cooperates with the Ministry of Health of the beneficiary country: a civil servant closely monitors the project. On the other hand, a "decentralised" project is set up in a hospital or health care centre. This makes it possible to check whether the policy decisions of the ministry are producing the desired results.
Due to the limited size of the Belgian projects - for example in comparison with the World Bank - Enabel usually sets up "pilot projects". If the approach is successful, it can then be applied throughout the country or district. In the best case, an intervention lasts 10 years: 2 projects of 4 years plus an exit scenario of 2 years.
(2) Among the non-governmental players, we mainly find non-governmental organisations (NGOs). They have a right of initiative. They do not necessarily need to focus on strengthening health care systems, but in practice they do. For example, that is the case for Memisa. The 'Damiaanactie', which primarily tackles leprosy and tuberculosis, also mainly strengthens the health care structure. NGOs do not work together with the national ministry, but with a local or provincial health care centre. In general, they are there for the long term. The universities and the ITG mainly carry out research and organise training.
(3) Finally, Belgium supports a raft of multilateral institutions. Most of the Belgian contributions are funnelled into a general fund that the institutions are free to spend. That's why it is tricky to pinpoint exactly what the Belgian funds have achieved. The main partners in the health sector are the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Health Organization, the UN Population Fund (UNFPA) and the World Bank.
The European Union is a separate case. It has the characteristics of a multilateral institution, but it is also a donor itself.
10 years of health care support in figures (euros)
Total expenditure 2009-2017: 1.45 billion.
60% of which goes to bilateral assistance (= governmental + non-governmental), i.e. assistance that can be allocated to a given country; 40% to multilateral assistance (= worldwide expenditure via multilateral institutions).
Of the bilateral assistance, 590 million goes to Africa, 92 million goes to the Americas and 58 million goes to Asia.
Top 5 receiving countries: Congo (189 million), Rwanda (101 million), Burundi (62 million), Uganda (35.5 million), Benin (35 million).
Top 5 receiving multilateral institutions: Global Fund (163 million), WHO (72 million), UNFPA (67 million), European Development Fund (51 million), World Bank (50 million).
Success story: users platform in Benin
In Benin, Enabel uses a user platform to measure the satisfaction of health care users. This kind of platform includes various stakeholders: representatives of local (municipal) councils, NGOs, civil society, health care organisations, community workers, etc. It monitors the effectiveness of care by carrying out random satisfaction surveys among patients in health care centres and district hospitals.
It has turned out to be an excellent formula. Over the years, the platforms have built up competence and legitimacy. They have given a voice to patients and become fully-fledged defenders of their rights. They also handle complaints.
Less successful: electronic information management in Burundi
In Burundi, Enabel planned to develop an electronic information system to manage data from the health care sector. It turned out to be a step too far. The electricity blacked out too often and the internet was poor quality. Although Enabel tried to make up for this, there was nothing it could do about another problem: the shortage of skilled computer scientists on the Burundian labour market. Maintaining the Open Clinic application - and its regular updates - could therefore not be guaranteed.