1 IHP+ membership is associated with better country performance in relation to development cooperation effectiveness
2 Performance by governments and development partners are correlated
3 Partner countries continue to deliver on commitments to establish health sector strategies, measure results and strengthen accountability  
  Establishing a country results framework Progress
  Engagement of civil society in health policy and planning Stagnation
  Joint assessment of national strategy including targets and budgets Progress
  Implementation of policies and procedures for mutual accountability Stagnation
4 Development partners increasingly align and continue to participate in accountability processes at country level  
  Support for and use of country results framework and proportion of funds monitored using the country results framework Progress
  Support to CSOs for participation in health policy processes Progress
  Participation in mutual assessment of progress in implementing health commitments Stagnation
5 Partner countries improve the financing and to some extent financial management of the health sector  
  Proportion of budget allocated to health and level of budget execution Progress
  Predictability of health funding over next 3 years through rolling budget or MTEF Progress
  Public financial management strength according to CPIA Stagnation
6 Performance of development partners on financing and financial management has declined  
  Level of health sector support budget execution in 2013 Decline
  Proportion of support to government registered in national health budget Stagnation
  Predictability of funding communicated to government for 2015-17 Decline
  Proportion of support using national financial management procedures Decline

Development effectiveness

The fourth performance monitoring round documented an overall improvement of performance by partner countries. Both mutual accountability and financing indicators improved in the majority of countries, although many countries continue to have weak financial management systems. Overall performance scores were positively correlated with the number of years since countries joined the IHP+, as well as with the level of external funding of the health sector, a proxy indicator for the intensity of the partnership network in the country.

Almost all development partners improved their performance on mutual accountability indicators, and some on indicators for the alignment of financial assistance with national systems. But overall, the indicators for effective financial cooperation by development partners documented a decline. The performance of development partners was correlated with the performance of partner countries. This underlines the fact that the performance of a partnership depends on the behaviours and quality of interaction between all partners.

The country-based approach

Consultations in the two focus countries strongly supported the country-based approach. It injected new dynamism in the national dialogue on development cooperation in health and helped identify areas that required more attention, for instance the engagement of civil society in the health policy dialogue, and the sharing of financial information between Ministries of Health and their development partners. It also widened participation to non IHP+ signatories and INGOs. 

The experience of the monitoring round also suggests that this approach requires a differentiated level of support depending on the capacity and leadership strength of the MOH. While in some countries this approach can be implemented by the Ministry of Health without significant external support, other countries require extensive technical assistance. As the experience in the DRC suggests, this assistance is most effective when it is provided within the country by a national consultant or organisation.

The country-based approach to performance monitoring also highlighted the need to improve routine monitoring of health sector cooperation. The intention of IHP+R to prioritise the harvesting of data from existing data bases was only realised in rare instances. Most of the time, reliable data were not available and had to be assembled by the Ministries and development partners through onerous processes of data collection and validation. In both focus countries, stakeholders strongly recommended that development performance monitoring data should be integrated in routine national information systems.

Civil society engagement

The participation of civil society in the national partnership for health continues to be an issue that elicits major discussions. The consultations in the two focus countries underlined that there are different perceptions among governments, development partners and civil society organisations about effective engagement of civil society. The question of who should represent civil society in the national health dialogue is largely unresolved and hampers effective CSO participation. Limited participation in the health policy and development effectiveness dialogue at country level may explain that knowledge and interest in the IHP+ among health-focused NGOs at the country level is at best limited. This was also confirmed by the very low response rate to a survey launched by IHP+R via a large number of international civil society networks. IHP+ has taken a number of steps to promote the participation of CSOs in policy and planning processes, including inter alia through including CSOs in IHP+ governance structures and providing country-level grants to support CSO capacity (through the Health Policy Action Fund). However, there remain unresolved questions on the difficult issue of whether the CSO participation is meaningful, and a strategic and adequate resourced approach is required.

Mutual accountability

Accountability among IHP+ partners for the effectiveness of cooperation in health depends on mutuality. Implementation has to overcome two main difficulties: first, the relationship between international partners in development cooperation is highly asymmetrical; and second, there is no institutional mechanism to enforce accountability among partners. Asymmetrical relationships reflect major structural power differentials among stakeholders in health sector development that risk undermining the implementation of mutual accountability processes. Providers of development assistance have powerful financial instruments to hold recipients to account. The instruments of recipient governments to hold their partners to account are, however, limited. Governments can also impose legal and financial sanctions on civil society actors while the ability of civil society to hold governments to account is highly variable. Although the processes and tools adopted by the IHP+ may have mitigated some of the effects of the asymmetry among partners, it has not overcome them.