An inability to access adequate funding is crippling efforts by community-based organisations (CBOs) to help some of Malawi's most vulnerable children. For example, Monkey Bay, 125km east of the capital, Lilongwe, has some of the highest poverty and HIV-prevalence rates in the country, according to the government's National Statistics Office. Yet a recent report by the Regional Network for Equity in Health in East and Southern Africa (EQUINET), ‘Promoting and protecting health of orphans and vulnerable children in Monkey Bay, Malawi’, said many community-based organisations (CBOs) in the area could not access government funding to support interventions targeted at orphaned and vulnerable children. Donald Makwakwa, programme officer for the Malawi Network of AIDS Service Organisations (MANASO), which provides technical support to CBOs, explained that many grassroots bodies could access technical assistance, but faced periodic funding shortages due to late allotments by the National Aids Council.
Resource allocation and health financing
The South African government has proposed a national health insurance (NHI) system, but it will face three key challenges as it seeks to re-build trust in the health system. First, discussions so far about NHI have been highly technical and held behind closed doors, will little civil contribution except for interest groups. Second, many public health workers are tired of frequent workplace changes and may view having to adapt to NHI systems as simply making their work more difficult, especially when employees note that their employees often fail to deliver on promises made: ‘I don’t trust them,’ said one nurse. Third, implementing an NHI remains a complex exercise and cannot be achieved with just legislation. The steps of policy implementation must be laid out so that initial actions build the basis for success in subsequent actions. For NHI to succeed, we must strengthen the public health system by increased investment, despite the current global economic downturn.
Taskforce on Innovative International Financing for Health Systems: 2009
The Taskforce's proposals aim to meet a US$10 billion funding gap through a number of means including the expansion of a mandatory solidarity levy on airline tickets, the increased use of the International Financing Facility for Immunisation and the strengthening in capacity of government in their health sector. Following the success of a series of meetings and consultations in Doha, London, Johannesburg, Abuja and Paris over the past seven months the Taskforce has finalised its recommendations on innovative international financing for health systems, which it calls on the participants of the G8 summit to support. The intention is spur world leaders on to strengthen the urgency for a combined effort to tackle the issue of providing adequate health systems for developing countries and increase vital aid flows. Strong political backing for each of the initiatives recommended is critically important. Successful implementation of these recommendations requires purposeful engagement with civil society, both in donor countries and recipient countries.
This report calculates that, if financial commitments are met, there is on average, across all countries, no financing gap in 2015. However, donors and recipient governments are currently far from delivering on agreed targets, and the economic recession is making this more difficult. If current relationships of health spending to GDP remain unchanged, the financing gap is will be US$28–37 billion in 2015. If commitments are met, for sub-Saharan Africa (SSA), there will be a funding gap of US$3–5 billion. In the no-change scenario, the funding gap for SSA is predicted by 2015 is US$26–24 billion. Financing arrangements must ensure sustainable and equitable domestic financing structures, predictable external finance, improved risk pooling over time, and effective purchasing of priority services. Service delivery arrangements should reflect the most cost-effective ways of providing services that are accessible, responsive to users, and equitable, taking advantage of both public and private providers where appropriate.
Depending on decisions taken by politicians and parliamentarians, a large part of the additional US$36–45 billion needed in 2015 could be available in an entirely predictable and sustained manner. Most of the gap will need to be filled by domestic resources contributed by national governments and citizens. But even if governments in low-income countries give more priority to health, they will still be unable to meet the required costs of scaling up health systems and providing free essential health services. If low-income countries are to reach the health millennium development goals, international funding will have to complement domestic health resources. Development partners are strongly urged to fulfil the commitments they have already made. Innovative development finance is the way forward, with non-traditional applications of official development assistance (ODA), joint public-private (or private) mechanisms and flows that support fund-raising, engage partners as stakeholders and deliver financial solutions to development problems on the ground.
While the worldwide AIDS community bemoans the global economic crisis and its impact on funding streams for the HIV and AIDS response, several speakers at the Fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention, which took place in Cape Town, South Africa, from 19–22 July, called on implementers to start doing more with less. Dr Stefano Bertozzi of the National Institute for Public Health in Mexico said choosing interventions more strategically would help, he said, citing abstinence programmes as one example of an approach that lacked evidence to support it. Focused, well-managed programmes targeted at populations with the greatest need were the most cost-effective, as were programmes integrated with services for related health issues, such as tuberculosis. Programmes that worked towards long-term goals, such as training new doctors and nurses, empowering women, and changing social norms, were more efficient than those with short-term targets, which looked good on annual reports but did little to change the course of the epidemic.
In Oxfam's press release after the 35th G8 summit, held in Italy from 8–10 July 2009, Jeremy Hobbs, its executive director, noted: ‘A stalemate persists because, in the past eight years, rich countries have used the talks to continue to push to open up new export markets. Developing countries have resisted, saying they were promised a deal that would give them space to protect their farmers and new industries, an end to rich country trade-distorting agricultural subsidies, and more access to rich markets for their farmers and industries. This summit has been a shambles, it did nothing for Africa, and the world is still being cooked. Canada 2010 is the end of the road for the G8 – all the promises they have made are due. They have 12 short months to avoid being remembered as the ones who let the poor and the planet die. Millions of children are out of school, millions more dying from curable diseases. This is shameful and the Canadians must move fast to fix it. There won’t be any second chances.’
The national health insurance (NHI) system that is envisaged for South Africa would be more akin to the excellent publicly funded health systems found in countries such as Costa Rica, where the NHI as a large, single purchaser of health services is able to improve resource use in the overall health system and to get ‘value for money’ for its citizens. However, services in South Africa’s public health sector are of poor quality at present. Actions that would be required to improve quality include: addressing health worker conditions of service through implementing the long-awaited occupation specific dispensation (or OSD); increasing staffing levels by at least 80,000; funding the maintenance and repairs of buildings, equipment and other infrastructure; and granting greater management autonomy to public sector hospitals to reduce red tape. Strong political commitment and genuine civil society involvement are essential to successful implementation.
There is general agreement that donors made more progress in 2008 in terms of increasing aid to Sub-Saharan Africa than in 2006/7. While, in 2007, the G8 countries were significantly off track, the encouraging performance in 2008 demonstrates that if performance is maintained at the same level, most of the countries will meet the targets set for 2010, 2011 and 2013. But there are some, notably Italy and France, who will not deliver. Italy has so far delivered only about 3% of the US$8 billion it pledged in additional funding and may actually be planning cut, not increase, aid in the coming years. Developed countries can help by fast-tracking the process of debt relief under the Highly Indebted Poor Country Initiative (HIPC) Initiative. Donors can ensure that African Diaspora is protected from attacks and discrimination. Trade should be further liberalised in favour of the products of poor countries so that there can be compensation for any loss of aid. And the available resources should be invested in the most productive sectors so as to gain the highest return.
International donors must continue meeting their commitments to HIV/AIDS, even in the face of the economic downturn, United Nations (UN) Secretary-General Ban Ki-Moon has urged. In 2006, the Assembly pledged to achieve universal access to comprehensive HIV prevention, treatment, care and support by 2010. UNAIDS has said that achieving these targets in the timeframe would require an estimated US$25 billion. In 2008, the Global Fund to Fight AIDS, Tuberculosis and Malaria was forced to cut funding by 10% and the World Bank projects that the global recession could place the treatment of more than 1.7 million at risk by the end of 2009. ‘I fear that many governments are resigned to reducing programmes and diminished expectations,’ said Miguel D'Escoto, President of the UN General Assembly. ‘But it is precisely when times are difficult that our true values and the sincerity of our commitment are most clearly evident. If we allow cuts now, we will face increased costs and great human suffering in the future.’