As you might have read in the Global Fund Observer article First look: the new Global Fund Strategy Narrative, one of the Global Fund’s four “mutually reinforcing contributory objectives” is to mobilize increased resources. This is because more financing is needed for health systems around the world but especially in low- and lower-middle-income countries (LICs and LMICs). However, governments in those countries are struggling to balance their budgets. This article explores the role of parliamentarians and how, with better knowledge and support, they can contribute to the debate and help achieve increased domestic financing of health.

Background

The economic case for more investment in health has never been more evident. Through 2020 and 2021 governments around the world have had to increase their spending on health to fight the COVID-19 pandemic. Despite this, the general under-investment in health – as evidenced by shortages of facilities, equipment, and personnel – remains. Nowhere is this more apparent than in the LICs and LMICs. With their health systems struggling to cope with the effects of the pandemic, the governments of those countries have had to secure additional grants and loans. With a lower income and higher debt burden, it is difficult to convince governments that they should nonetheless increase spending on health in 2022 and beyond. This is where parliamentarians can play an important role by engaging with their constituents and decision-makers and garnering support for increased investment in health.

In many of those countries, parts of the health system are reliant on donor support, notably the disease programs which are supported by the Global Fund. Donor support will not continue indefinitely, and so such systems will not be sustainable without increased domestic expenditure on health. This was clear before the pandemic but now, with uncertainties about the levels of continuing donor support, the case for increasing government spending on health has become all the stronger.

National groups supportive of increased investment in health

While this article examines what parliamentarians can do to help bring about more investment in health, we must mention the other groups that have an interest in the subject. First are the people who work in the health sector. They include doctors, surgeons, anesthetists, laboratory technicians, nurses, health assistants, ambulance drivers, and so on. They know better than anyone the needs of the communities they serve and the deficiencies in the health system where they work. While their voice is important, their interest may be very local and they may not be aware of the cost implications and the best media for conveying their views.

Next are the people served by the medical professionals, i.e., the population at large. They have varying interests in the topic. for example, expectant mothers, people with infections, groups in need of repeat medical prescriptions, and persons awaiting surgery all have an interest in the health services that affect them individually. Some family members of those individuals will also share that interest.  But how can the general public convey their health concerns?  This applies especially to the poor: one of the many serious consequences of the COVID-19 pandemic has been that millions more low-income households in Africa, who spend a high proportion of their income on health-related expenses, have been pushed below the extreme poverty line (see, for example, Updated estimates of the impact of COVID-19 on global poverty: Turning the corner on the pandemic in 2021?) Meanwhile, persons not in need of health services or who lack knowledge of the benefits of services that could be made available to them may remain apathetic.

Persons involved in charities that support persons with particular medical conditions will also be keenly interested in the topic.

Finally, the Ministry of Health, which often mediates between the aforementioned groups and the Government, is at the centre of the debate. However, persons in the Ministry may come and go, a factor that often contributes to weak accountability for health sector performance.

How parliamentarians can influence the discourse and decisions

Parliamentarians are especially well-placed to generate interest and influence decision-makers. After all, their primary role is to represent their constituents. Some may represent urban constituencies that, due to their high population density, are likely to have a large hospital. Others may represent rural populations served by small medical centres or mobile services. Wherever they were elected, from time to time they meet with constituents and usually have an office that receives letters and messages on matters of concern to the people they represent.  They should know what their constituents want and should be informing them of what is being done by the government and what to expect. In some cases, they will have ready access to trade union representatives, employers’ associations and other groups for whom health is an important subject.

In most countries the Parliament – or it may be referred to as the National Assembly, as in Kenya – has an oversight mandate which includes exercising oversight over national revenue and its expenditure. So parliamentarians have a direct say in what is spend on health, as well as in other sectors. In parliament they have the opportunity to speak on the topic in open debate; and they can exchange views with other members of parliament, with personnel in the Ministry of Health, and with Cabinet members and other decision-makers.

Access to the media, both locally and nationally, is a major advantage afforded to parliamentarians. That can provide the opportunity to convey information on health needs, the level of investment required and spending by government and other parties.

The parliamentarian’s skillset

A parliamentarian is a successful politician with the ability to communicate. Speaking – whether in parliament, at press conferences or in constituency meetings – is a key part of the job. Convincing listeners is easy when the audience is friendly but, on occasion, the audience may be hostile. A politician, however well briefed, must be able to think on her/his feet and maintain composure.

Parliamentarians recognize the importance of retaining allies and forming alliances. These are required to build a reputation with a wider field of influence. Those alliances can also help spread the message about increasing health spending.

Informing parliamentarians

The Global Fund places high importance on its interactions with parliamentarians. Not only are they influential for the reasons explained above, but they are also well placed to monitor health spending and ensure its efficient usage. However, for parliamentarians to convey the right messages and to be able to respond convincingly to questions on health investment, they need to be prepared and have the necessary data readily available. Therefore, in countries where there is a good prospect of engaging with parliamentarians, the Global Fund prepares briefing papers for them. Those papers provide comprehensive information on the health system status and expenditure history in the country, including the health financing sources. These might be published in due course as they would be of interest to a broad spectrum of readers.

If it proceeds with its current plan, the Global Fund will, over the next few years, help organize National Financing Dialogues (NFDs) in selected African countries. It will be interesting to observe how parliamentarians participate in and contribute to these NFDs.