Dutch Aid & Trade in health at odds with health equity

For the last 10 years, the Netherlands has been pursuing an Aid & Trade agenda. It combines development in low and middle-income countries (Aid) with the interests of Dutch companies and investors in these countries (Trade). The idea is to create a win-win situation. Our paper ‘In the interest of Health for All?’ shows that this agenda is also being rolled out in Africa’s health sector, strengthening the private-for-profit sector in healthcare delivery. We wanted to know what the Aid & Trade (A&T) policy instruments look like and what their impact is on health systems and progress towards universal health coverage (UHC).

In our paper we take a closer look at the financial instruments that support A&T – in the form of grants, loans, guarantees or equity investments – in healthcare in sub-Saharan Africa. We analyse their characteristics and how they are used. Also, we describe a case study, that we conducted with representatives of Kenyan civil society organisations (CSOs), on projects supported with Dutch A&T funds with an explicit win-win approach. While Dutch A&T instruments are aimed at strengthening business and the business climate, we applied a health lens to look at their possible impact.

Part of the Dutch A&T support in the healthcare context is explicitly aimed at Dutch companies’ success in their business in African countries’ healthcare sector. For example, through support for the fast realisation of public-private partnerships in primary healthcare in Kenya. Many members of the African civil society and health professionals’ organisations we spoke to for this paper are concerned about the influence of this type of development assistance.

COVID-19: a harsh wake-up call
Global health advocate Barbara Fienieg: “The COVID-19 crisis is a harsh wake-up call of how important a well-functioning public healthcare system and truly universal access to essential health services actually are to us all. When any population or individual is excluded from health services, or cannot afford the fee, then not only their right to health is in jeopardy. It is a threat to everyone’s health security!”

Our study shows how Dutch A&T instruments in healthcare prioritise private sector development and push for public-private partnerships in primary healthcare without using sufficient evidence regarding their expected health and UHC outcomes. CSOs in Africa and scientific literature point at the risks of this approach. Barbara: “A&T in health may unintendedly hinder instead of support countries’ progress towards universal and equitable access to health services. Moreover, general principles of development effectiveness, including the untying of aid, transparency and democratic ownership, are at stake.”

We conclude our paper with a number of recommendations for future policy and implementation in the best interest of health for all.

This discussion paper is relevant to actors engaged in access to health services and/or effective international cooperation. It bears special relevance to the debates around the effectiveness of the Dutch A&T agenda that will follow this year upon the announced release of the official evaluation of this agenda.

Missed our online session at the Civil Society Policy Forum session on 2 October? Watch it here!

UHC requires sufficient public resources for health to invest in a system that is universally accessible, based on need and not the ability to pay. To make sure donor support enhances countries’ progress towards UHC, it is important to understand what countries with large funding gaps and limited fiscal space need. On October 2nd we held the online session ‘Fiscal space for UHC & social protection after the COVID19 pandemic: how to prevent austerity’ during the Civil Society Policy Forum ahead of the Annual Meetings of the IMF and World Bank. You can search for and watch the recording of the session here.

Photo: “Dollar bill roll” by Vitaly Taranov via Unsplash is licensed under CC BY 2.0


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