Letter to the Editor
‘Norway will not be bullied into stopping its support for results-based health funding’
Norad Policy Director Ingvar Theo Olsen responds to an opinon article in the last issue of Development Today on Norwegian health intervientions in Tanzania.
In an opinion article in the last issue of Development Today, Victor Chimhutu claims that “Norway bullied its way into Tanzanian health sector with PM Stoltenberg’s results-based agenda”. (See DT 3-4/16) As much as I welcome the work carried out by Chimhutu on Norwegian health aid to Tanzania, as well as the bold conclusions, there are a number of misunderstandings and errors that add up to a picture I think is wrong.
It is essential to understand Norway’s role in results-based financing in the health sector in low-income countries. Norway supports countries’ own efforts to test different types of incentives for health care providers and to users. Where found successful and relevant by governments, we also support careful scaling up of programmes. However, these are incentives to different levels within countries’ own health systems, results-based financing (RBF), and not an aid modality, which may be referred to as results-based aid (RBA). Chimhutu does not distinguish between these, leaving what Norway does wide open for misinterpretation. Norway does not promote sanctions to health workers, but supports the idea of modest rewards to the facility and the workers to overcome barriers they are in control of and achieve agreed targets.
The Norway-Tanzania Partnership Initiative (NTPI) (2007) aimed at strengthening access to maternal, newborn and child health care. It consisted of RBF, strengthening health information system, support for NGOs and research. As such, when Norway re-entered the health sector in Tanzania after five years, it was with a wider scope than RBF.
It is correct that this was a result of the close collaboration between PM Stoltenberg and President Kikwete. But it was also part of a joint global effort to achieve MDG 4 & 5. The Norwegian support was initiated at the top level in Tanzania, and the President himself wanted to test RBF in the health sector. Rwanda had already introduced this and there was interest in a number of countries to explore RBF. This fact in itself shows that RBF was not being driven solely by Norway. President Kikwete, as well as the Minister of Health, should be acknowledged for their leadership in Tanzania.
Simultaneously, Norway established the Health Results Innovation Trust Fund (HRITF) in the World Bank (2007) to test and scale up RBF. This was the background for why Norad commissioned the Norwegian Knowledge Centre for the Health Services to carry out a systematic review of RBF in health, which concluded the evidence was weak. Chimhutu implies that this came as a result of the Tanzania donors’ push back. That is not correct.
Weak evidence should not be misread as no or little effect. Norway wishes to be evidence based in its development cooperation, but also to build evidence where lacking. In HRITF the result is a strong focus on impact evaluation in all RBF programmes. There are currently 36 ongoing evaluations. Preliminary findings is that where introduced well, RBF can be effective at improving service delivery and outputs for women and children.
Not all public servants and bureaucrats in Norway or in Tanzania were in favour of RBF. For some this was ideological, for others it was reluctance to try something new or to change approach, and for a few it was actually that there was not sufficient evidence. Chimhutu’s interpretation of this as being “lukewarm” is not very precise, nor is it helpful to understand policy processes. It is also not correct that responsibility for RBF was moved from MFA to Norad. NTPI was always under the Embassy.
Norway was never reluctant to channel funds through Tanzanian institutions, but was advised by both the Ministry of Health and other donors to channel a major share of the funding through the Health Basket Fund. In line with the Paris Principles this was seen as harmonised with other donors and aligned with government. It implied supporting health at district level. When the government chose to start a national roll out of RBF without piloting, Norway and other basket donors regarded this as irresponsible, and did not want basket funds to be used for this. Basket funds were thus frozen, whereas the remaining funding continued.
Almost two years later, the government started an RBF pilot in Pwani with funding from Norway. Chimhutu claims that the World Bank in Tanzania was pushed and then convinced other partners to support the pilot in 2011. This is news to me, as apart from the government’s own input, the pilot and the evaluation were funded by Norway alone. The final results from the evaluation have not yet been published, and long term effects remain to be seen. The impacts referred to by Chimhutu are at best preliminary. His own more qualitative research is clearly important and welcomed, especially now that the government is rolling out RBF in Tanzania with support from the World Bank and others. The experience from the Pwani pilot is regarded as highly relevant when implementing a revised model.
Given the low performance of the health sector in Tanzania, my question to Chimhutu is whether and how unchanged funding and implementation of health services in Tanzania will help meet the SDGs. There is a strong need to change both donor and domestic funding, and Norway is prepared to take that challenge.
Ingvar Theo Olsen is Policy Director, Norad. Olsen has been responsible for the Norway-Tanzania Partnership Initiative (NTPI) and the Health Results Innovation Trust Fund (HRITF) at the World Bank since 2007.