Donor funding has fuelled a vast increase in service delivery, medical research and clinical trials throughout the developing world, yet, with pressures to spend funds quickly and achieve results, projects may not pay sufficient attention to internal monitoring and security systems to protect against embezzlement. This U4 Brief analyses how this type of corruption occurred in a donor-funded project, and what can be done to minimise the risk. While not widely publicised, many organisations have dealt with the frustrations of financial mismanagement, embezzlement and theft. Recommendations include tighter financial controls, better management policies and channels for disclosure. For projects that are just beginning, establishing a sound financial system should be a priority. Changes in policies, procedures and reporting can help promote a culture of compliance and avoid corruption.
Resource allocation and health financing
This study aimed to provide a comprehensive assessment of development assistance for health (DAH) from 1990 to 2007. It used several data sources to measure the yearly volume of DAH in 2007 United States dollars, and created an integrated project database to examine the composition of this assistance by recipient country. It found that DAH grew from $5.6 billion in 1990 to $21.8 billion in 2007. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and the Global Alliance for Vaccines and Immunization having a central role in mobilising and channelling global health funds.
Over the past decade, an increasing number of developing country governments, working with donors and NGOs, have been implementing cash transfer programmes — regular transfers of cash to individuals or households. These programmes are united by common assumptions: that income poverty has a highly damaging impact on people’s health and nutrition, and that cash empowers poor individuals and households to make their own decisions on how to improve their lives. This report examines three key questions: What contribution can cash transfers make to reducing child mortality? What are the broader economic benefits of investing in cash transfers? How can child-focused cash transfers be affordable in developing countries? The report argues that cash transfers have a critical role to play in accelerating reductions in child mortality, as well as broader economic benefits. It estimates current costs and finds that child and maternity benefits are possible on a large scale, even in developing countries.
According to the Human Sciences Research Council’s (HSRC) Olive Shisana, ‘The NHI [national health insurance] system presents itself as an ideal mechanism for achieving equitable access to quality health services in South Africa: firstly, because it satisfies the fundamental principles of a unitary health system enshrined in our constitution; secondly, because it promotes redistribution and sharing of health care resources between the public and private sectors thus meeting our transformation agenda; and thirdly, because research evidence suggests that South Africans are generally willing to contribute to a financing system that caters for them and those unable to contribute.’ If NHI can overcome the inefficiencies of the private sector with its failing medical aid funding arrangement, and if it can address the quality-of-service issues of the public sector, it will indeed be a winning formula.
The author of this paper argues that there are a number of critical aspects which must be considered when reflecting on a national health insurance (NHI) scheme in South Africa. The benefit package ideally should cover a comprehensive package of primary and preventative benefits, with the main aim of providing the most benefits for the most people, given the pool of funds available. Experts will have to cost this package, which will be challenging because using public sector data will be difficult because ICD 10 coding (diagnosis codes) are not routinely used and collected, and the tariff schedule used in the public sector is not reflective of the actual costs of providing the benefit as it does not take into account costs such as infrastructure. Another key aspect is revenue collection. Assuming that the costing had been accurately done, and that a reasonably comprehensive benefit package was affordable, the author suggests that an earmarked tax from payroll seems the most logical manner in which to collect these funds. Critical to this process will be buy-in from labour and employers alike.
Participants at the Abuja Consultation recommend that the High Level Task Force recognise the right of all people to essential health care, pursue policies that will reduce inequity and social disparities, promote democratic and pro-poor reforms to the governance of the global economy as a means of creating a long-term and sustainable foundation for health financing, and add (not substitute) ‘innovative financing’ to existing commitments of governments, which must be fulfilled. The Task Force should also improve the efficiency, impact and accountability of current development assistance for health and place transparency and accountability at the heart of all proposed solutions. The health financing agenda must be moved forward according to principles of progressive finance, optimal pooling of finance, equitable and needs-based budgeting and expenditure, accountable planning and financial management, and the full engagement of civil society.
This briefing proposes that while prospects for developing countries are often shaped by domestic and regional politics and aid, it is necessary to looks at beyond aid at issues like trade, migration, investment, environmental issues, security and technology. The authors explore the progress made towards policy coherence and conceptualise a three-phase cycle: phase 1 includes setting and prioritising objectives, which requires political commitment and policy statements; phase 2 looks at policy coordination and the implementation mechanisms by establishing formal mechanisms at inter-ministerial level for coordination and policy arbitration; and phase 3 is about effective systems of monitoring, analysis and reporting. The paper concludes by recommending that the Beyond Aid agenda could help drive faster progress towards partnerships for community development and policies that are more ‘development-friendly’, in practice as well as on paper.
Following a meeting in London on March 5, civil society representatives from across Africa and Asia gathered in Johannesburg on 13 and 14 May. The purpose of the meeting was broadly the same as the earlier session held in London in April: to allow individuals and groups with first-hand experience of the challenges around healthcare provision and funding to feed their views into the Taskforce’s deliberations. Delegates turned their attention to a series of key issues, including ways to bridge gaps in existing resources, provide more of those resources, and link such measures to existing international and national health system frameworks.
They also had the chance to quiz members of the Taskforce secretariat in plenary sessions, which provoked valuable debate on issues such as stakeholder participation in potential solutions and the way in which the Taskforce operates, as well as airing challenges to be overcome in individual countries. Mrs. Graca Machel, Taskforce member and President of the Foundation for Community Development in Mozambique, addressed delegates on both days of the meeting. In her opening remarks, Mrs. Machel seized on the ‘monumental’ nature of the challenge to meet the health-related MDGs by 2015. Existing crises in food and fuel had been compounded in 2008 by a financial crisis; left unaddressed, these combined crises will cause over 200,000 additional deaths. She called on delegates to consider, in their discussions, how solutions could be ‘country-owned’, but also internationally credible, with monitoring systems implemented which focus firmly on results.
Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. This study documents the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy three years after its implementation. Data was collected in two districts, Kwale and Makueni, and focus group discussions and patient exit interviews were conducted. Adherence to the policy was poor in both districts, and drug shortages, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy. In conclusion, reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. Caution must be taken when deciding on how to reduce or abolish user fees and all potential consequences should be carefully considered.
The objective of this study was to measure the direct cost burdens (health care expenditure as a percentage of total household expenditure) for households in rural South Africa, and examine the expenditure and use patterns driving those burdens in a setting with free public primary health care and hospital exemptions for the poor. Data was drawn from a cross-sectional survey of 280 households. The low overall mean cost burden of 4.5% suggests that free primary care and hospital exemptions provided financial protection. However, transport costs, the difficulty of obtaining hospital exemptions, use of private providers, and complex treatment patterns undermined this. The significant non-use of care shows the need for other measures such as more outreach services and more exemptions in rural areas. Fee removal anywhere must be accompanied by wider measures to ensure improved access.