The world is not on track to achieve the health-related targets of the Millennium Development Goals (MDGs) by 2015. As a solution, this article proposes a global fund for health Millenium Develelopment Goals, which will focus on measurable improvements in health outcomes, with a performance evaluation framework that looks at coverage with services relating to reproductive, maternal, newborn, and child health, HIV, malaria and tuberculosis, other infectious and non-communicable chronic diseases, quality of care, and fairness of financial contribution to the health system. Clear mandate and funding criteria that address key bottlenecks in health systems (including long-term predictable support for recurrent costs) are needed. A rights-based approach to health is the ideal, supported by new model of globally shared financial sustainability. The fund should have the capacity to disburse resources beyond the public system and beyond health sector when this represents appropriate and cost-effective approach to improve health outcomes. Its governance and accountability structure will be open to civil society at global and country levels and will be flexible enough to provide support to public sector on-budget or off-budget, in form of grants and not loans, unconstrained by financial ceilings.
Resource allocation and health financing
Recognising the limitations of disease-specific approaches and the shortcomings of a fragmented international architecture for health, Save the Children UK welcomes the process of harmonisation among the World Bank, the Global Fund and the GAVI Alliance of their support to health systems strengthening programmes and activities. Save the Children supports the establishment of a joint funding and programming platform for health system strengthening by the three financiers of international health in line with the principles of the International Health Partnership and related initiatives (IHP+). To make the new joint mechanism completely aligned to the IHP+ principles, Save the Children recommends that the new entity operates in full transparency and openness, with a governance structure open to civil society at both global and country level, and that, in addition to striving for harmonisation among funding agencies, the new platform explicitly adopts the objective of better alignment to national needs.
The cost of artemisinin-based combination treatments (ACTs), the only truly effective antimalarials, is far beyond the reach of the average family in Africa, let alone poorer populations. The Affordable Medicines Facility for malaria (AMFm), an initiative of the Global Fund to Fight AIDS, Tuberculosis and Malaria, offers a radical solution: the possibility for countries to procure heavily subsidised ACTs that will reduce the price for patients so it is similar to that of chloroquine. One of the main reasons for mortality from malaria in Uganda is the exorbitant price of non-effective antimalarials and of ACTs in the private sector, which is the first port of call for more than 60% of Ugandans. A pilot study in Uganda, led by the Ministry of Health and Medicines for Malaria Venture, showed that availability of subsidised ACTs led to rapid growth of stocks of these drugs. Drug shops seemed to charge reasonable markups. Supportive interventions, such as communication and training, were essential to ensure accessibility and uptake of ACTs. Affordability of drugs rose in the private sector with a concomitant increase in uptake by children younger than five years. Augmented ACT uptake also eroded the market share of ineffective antimalarials such as chloroquine.
This budget analysis report focused on expenditure allocated to the health and HIV/AIDS sectors. While a promising increase in funding was achieved overall, questions remain about the allocation of funds. There is little regard of last year’s budget analysis findings and the Malawi Health Equity Network (MHEN) urges government to more actively engage with civil society now, and in the future, to ensure that the people’s voice is represented within the budget. In last year’s analysis, the key issues raised were health service financing; drug availability; health worker incentives; human resource development and management; and the health service impact of HIV and AIDS. Unfortunately many of these issues have not received the desired attention within this budget. MHEN recommends keeping the Abuja Commitment, ensuring efficient and transparent implementation and reporting, building capacity and pro-poor funding to district assemblies, increasing drug allocation and mainstreaming gender and youth issues.
This paper attempts to measure herding behaviour in the allocation of foreign aid, proposing different indexes that try to capture the specific features of aid allocation. The authors chose to use two measures initially developed in finance and adapted them to the specifics of foreign aid. However, the different estimates all reject the hypothesis of no herding. They describe pure herding behaviour, which create pendulum swing effects comparable to those in financial markets, and identify different indexes for detecting donor herding - its exact size depending on the measure adopted. The preferred index, relying on three year disbursements which indicates a significant level of herding, is similar to that which is found on financial markets. There is no, or very limited, herding among multilateral donors, in contrast to bilateral donors, who are frequently subject to herding behaviour. Yet, observable determinants actually explain little of the herding levels, leaving a large part of herding unexplained. The paper concludes that more research is needed and that the preferred measure finds a herding level around 11%. In other words, in a world where 50% of all allocation changes are increases, the average recipient experiences 61% of its donors changing their allocation in the same direction.
This paper analyses the interaction between aid donors and recipients from various angles. It considers the fact that the effort associated with ensuring aid effectiveness concerns both principal and agent, which requires cooperative behaviour – something that is difficult to design and predict. The analysis comes up a number of conclusions. There is a possibility of intrinsic motivation on the part of the agent through deriving utility from poverty alleviation. The interaction between donor and recipient may be better described through simple non-cooperative games. In this context, if effort by both sides is important to achieving aid effectiveness, there could be a double moral hazard. Designing a mechanism aimed at ensuring commitment to optimal policies is problematic, although the paper suggests that there should be a single global agency to manage poverty reduction and the coordination of donor behaviour. Aid effectiveness requires a stronger commitment to rewarding credible (hence costly) signals of the recipient's commitment to change.
The objectives of this paper were to explore public perceptions on what changes in the public health system are necessary to ensure acceptability and sustainability of national health insurance (NHI), and whether or not South Africans are ready for a change in the health system. A cross-sectional nationally representative survey of 4,800 households was undertaken, using a structured questionnaire. It found dissatisfaction with both public and private sectors, suggesting South Africans are ready for health system change. Concerns about the quality of public sector services relate primarily to patient-provider engagements (empathic staff attitudes, communication and confidentiality issues), cleanliness of facilities and drug availability. There are concerns about the affordability of medical schemes and how the profit motive affects private providers’ behaviour. South Africans do not appear to be well acquainted nor generally supportive of the notion of risk cross-subsidies. However, there is strong support for income cross-subsidies. Public engagement is essential to improve understanding of the core principles of universal pre-payment mechanisms and the rationale for the development of NHI. Importantly, public support for pre-payment is unlikely to be forthcoming unless there is confidence in the availability of quality health services.
Donor support for the HIV response has increased dramatically in recent years. In parallel, the debate continues between those who argue that the money is still too little, and those who say there is too much emphasis on HIV. Often there is little relation between a country’s total funding for HIV and the actual HIV burden. This is not necessarily a problem, and in fact the same is true for other diseases. Burden of disease is not the only basis for allocating resources; other criteria used to justify donor support include cost-effectiveness, aligning funding with stated country priorities, or equity. However, there is little to suggest that current donor practices on HIV funding can be justified on any of these grounds. The HLSP Institute’s analysis also suggests that donor spending on HIV has, to some extent, crowded out other expenditure on health and population. Put simply, funding for health would have increased more rapidly had it not been for the large increase in support for HIV. If such programmes were to continue to expand (as they probably will) sustainability challenges would be even greater, and the potential for further misalignment of health sector funding would be likely to increase.
More than 50 countries have engaged in Gender Budget Initiatives (GBI), but few of these initiatives articulate an explicit connection between budgets and the Convention on Elimination of All Forms of Discrimination Against Women (CEDAW). This booklet, produced by the United Nations Development Fund for Women, articulates what it means to take an explicitly rights-based approach to government budgets. It draws on the lessons of gender budgeting experiences from around the world. It poses three questions. How can the four main dimensions of budgets – revenue, expenditure, macro economics of the budgets and budget decision making processes – be linked to governments’ commitments under CEDAW? Using these links, how can gender budget analysis then assist in monitoring a government’s compliance with CEDAW? How can CEDAW be used to set equality-enhancing criteria in budget activities and guide GBIs and other initiatives towards achieving gender equality? The booklet is intended as an advocacy and action tool for key stakeholders in the area of government budgets and women’s human rights including policy and law makers at the country level and gender human rights advocates.
Although much progress has been made towards the creation of a national health system which makes 'access to health for all' a reality, much remains to be done. These colloquium proceedings are an effort to initiate policy dialogue and critical discussion on how health services are accessed, provided and funded – and to formulate ideas, views and recommendations that could be presented to those involved in health policy development. The book is divided into three sections. Section A discusses the context for policy debates on health within a comprehensive system of social security. Section B synthesises the colloquium proceedings, beginning with a brief summary of inputs and discussions under the four key themes: the reform path since 1994; critical options for health within the context of a comprehensive system of social security; local and international evidence on health system models; and health systems reform and stakeholder engagement. Section C provides recommendations for improving implementation and taking the process of policy development forward.