Mozambique is referred to as being a success story after seventeen years of civil war and economic and social decline. The country is highly dependent on external aid. Long before the Paris Declaration on Aid Effectiveness, the Government of Mozambique (GoM) and a group of donors made efforts to coordinate and harmonise external aid. Therefore, it is interesting to study the evolution of external aid mechanisms to the country. The general objective of the research is to contribute to the agenda, discussion and results of the Ghana High Level Forum on aid effectiveness, reporting on progress and concerns regarding the implementation of the Paris Declaration. In the specific case of Mozambique, the research aims to examine critically the aid system and the mplications of the Paris Declaration, especially concerning ownership and accountability in the external aid system.
Resource allocation and health financing
The Paris Declaration on Aid Effectiveness may have the effect of circumscribing national sovereignty and country autonomy over development policies contrary to its stated principles of country ownership and mutual accountability, research has shown. Two recent studies have highlighted the propensity of new modalities of aid and aid harmonisation processes under the Paris Declaration framework to increase rather than reduce donor interventions in aid recipient countries and exacerbating the imbalances of power between donor and recipient countries.
Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV/AIDS is displacing funding for their own concerns. Even organizations dedicated to HIV/AIDS prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically. This paper attempts to do so by considering donor funding for four historically prominent health agendas—HIV/AIDS, population, health sector development and infectious disease control—over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee, supplemented by data from other sources. Several trends indicate possible displacement effects, including HIV/AIDS’ rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV/AIDS control receives in US funding, and HIV/AIDS aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV/AIDS acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.
If health insurance is to cover broader population strata in sub-Saharan Africa and to assure satisfactory health services, schemes will require continuous and long-term subsidies to bridge the gap between household capacity to contribute financially and the real costs of health care. The development of approaches addressing this dilemma should be considered as a research priority. They might include initiatives of north–south risk pooling. This necessity is underpinned by the capacity of health insurance to formalise social protection and create a market between health service providers and their “customers”, simultaneously alleviating poverty and empowering communities. Yet, available evidence points out that to play these roles, health insurance needs subsidies.
Cost-effectiveness analysis as an aid to decision making has been increasingly publicized and discussed during the past two to three decades. However, the total body of cost-effectiveness analyses in health care is actually rather small, and high-quality studies are rather rare. Furthermore, the applications of economic analysis to health policy have been hampered by a number of problems, including those that are methodological and contextual. We consider a number of areas of public health policy but pay special attention to a growing area of inquiry and application: the overall coverage of health services. Cost-effectiveness analysis has played a relatively small role in general coverage decisions, but in recent years, it has been applied increasingly to decisions concerning pharmaceutical coverage. We speculate on concerning reasons for this particular focus in cost-effectiveness analysis. Future progress will depend heavily on discussion and consensus building.
Policy makers and programme managers require more detailed information on the cost and impact of packages of evidenced-based interventions to save newborn lives, particularly in South Asia and sub-Saharan Africa, where most of the world's 4 million newborn deaths occur. This study estimated the newborn deaths that could be averted by scaling up 16 interventions in 60 countries. We bundled the interventions in a variety of existing maternal and child health packages according to time period of delivery and service delivery mode, and calculated the additional running costs of implementing these interventions at scale (90% coverage) in sub-Saharan Africa and South Asia. The phased introduction and expansion of interventions was modelled to represent incremental strategies for scaling up neonatal care in developing country health systems. Low-cost, effective newborn health interventions can save millions of lives, primarily in South Asia and sub-Saharan Africa. Modelling costs and impact of intervention packages scaled up incrementally as health systems capacity increases can assist programme planning and help policy makers and donors identify stepwise targets for investments in newborn health.
How does health insurance affect health? After reviewing the evidence on this question, we reach three conclusions. First, many of the studies claiming to show a causal effect of health insurance on health do not do so convincingly because the observed correlation between insurance and good health may be driven by other, unobservable factors. Second, convincing evidence demonstrates that health insurance can improve health measures of some population subgroups, some of which, although not all, are the same subgroups that would be the likely targets of coverage expansion policies. Third, for policy purposes we need to know whether the results of these studies generalize. Solid answers to the multitude of important questions about how specific health insurance policy options may affect health seem likely to be forthcoming only with investment of substantial resources in social experiments.
Informal payments for health services are common in many countries, especially in transitional and developing countries. As part of a larger study focusing on health worker performance in Tanzania, one objective was to investigate the nature of informal payments in the health sector, and to identify mechanisms through which informal payments are affecting the quality of health services. A more profound understanding of these mechanisms is of interest because it may improve knowledge of how quality may be enhanced within a system where informal payments are common practice. The findings reveal a variety of positive and negative mechanisms through which informal payments may impact on the quality of health care. Furthermore, they show that informal payments add to health workers' incomes, thus contributing to the retention of workers in the health sector and to avoiding a further escalation of the current health worker shortage.
In the face of the dual TB/HIV epidemic, the ProTEST Initiative was one of the first to demonstrate the feasibility of providing collaborative TB/HIV care for people living with HIV (PLWH) in poor settings. The ProTEST Initiative facilitated collaboration between service providers. Voluntary counselling and testing (VCT) acted as the entry point for services including TB screening and preventive therapy, clinical treatment for HIV-related disease, and home-based care (HBC), and a hospice. This paper estimates the costs of the ProTEST Initiative in two sites in urban Zambia, prior to the introduction of anti-retroviral therapy. This study shows that coordinating an integrated and comprehensive package of services for PLWH is relatively inexpensive. The lessons learnt in this study are still applicable today in the era of ART, as these services must still be provided as part of the continuum of care for people living with HIV.
Save the Children called on African leaders to fulfil their promises made in Abuja in 2001 to spend at least 15% of their annual budgets on health. In the briefing ‘Not another one, not another day’ they look at how African governments, despite commitments in 2001 and 2005, still aren’t spending enough on health. It also shows that the EU is failing to support the development of health systems in Africa, with most member states still falling short of their commitment to spend 0.7% of their gross national income on aid. It includes a list of recommendations to get the AU and EU back on track to meet the Millennium Development Goals.