According to this study, a major challenge in the governance of research funding is agenda-setting, given that the priorities of funding bodies largely dictate what health issues and diseases are studied. The challenge of agenda-setting is a consequence of a larger phenomenon in global health, namely “multi-bi financing.” Multi-bi financing refers to the practice of external funders choosing to route non-core funding - earmarked for specific sectors, themes, countries, or regions - through multilateral agencies such as the World Health Organisation (WHO) and the World Bank and to the emergence of new multistakeholder initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance. These new multistakeholder initiatives have five distinct characteristics: a wider set of stakeholders that include non-state institutions, narrower problem-based mandates, financing based on voluntary contributions, no country presence, and legitimacy based on effectiveness, not process. The author concludes that this shift to multi-bi financing likely reflects a desire by participating governments, and others, to control international agencies more tightly.
Resource allocation and health financing
In this article, the authors compare domestic resource mobilisation (DRM) with foreign direct investment (FDI), arguing that developing countries, like those in Asia, that have achieved and sustained high rates of growth have typically done so largely through the DRM, and not through FDI. DRM at a significant level is essential to solidify ownership over development strategy and to strengthen the bonds of accountability between governments and their citizens. In effect, it provides ‘policy space’ to developing countries, which is often constrained under the terms and conditions of external funders. In contrast, FDI tends to be pro-cyclical and volatile, particularly affecting African countries with smaller economies, and typically flows into sectors and projects dictated by the commercial interests of the foreign investors, like natural resource extraction. While external funding or trade and investment opportunities can make significant contributions to development, they alone will not be sufficient for Sub-Saharan Africa to achieve sustainable, equitable growth and poverty reduction, the authors conclude. As happened in the 90s with Malaysia, South Korea and the other ‘Asian Tigers’, development success depends primarily on the efforts of developing countries themselves, which ultimately means enhancing their ability to mobilise their own human and financial resources.
The author of this book argues that, along with its many benefits, government aid to Africa has often meant more poverty, more hungry people, worse basic services and damage to already precarious democratic institutions. The author proposes that calls for more aid are drowning out pressure for action that would really make a difference for Africa’s poor. Rather than doubling aid to Africa, it is suggested in the book that it is time to reduce the continent's aid dependency.
In an informal address to the 4th International Conference on Priorities in Health (Oslo, 23 September 2002), Professor Jeffrey Sachs – Chairperson of the WHO Commission on Macroeconomics and Health – maintained that the real causes of the inability of the world's poorest people to receive help for the lethal diseases that burden them did not include the "usual suspects" (corruption, mismanagement, and wrong priorities). Rather, the root cause was argued to be an inherent lack of money, indicating that the burden of disease would be lifted only if rich countries gave more money to poor ones. Without taking exception to anything that Sachs said in his address, there nevertheless remain a number of justifications for efforts to improve priority setting in the face of severe shortages of resources, including the following three defences: prioritisation is needed if we are to know that prioritisation is insufficient; prioritisation is most important when there is little money; prioritisation can itself increase resources.
In 1978, from a little-known region of what was then the USSR, emerged a WHO/UNICEF statement of intent with the slogan "Health for all by the year 2000". That year has passed, leaving the Alma-Ata declaration largely unfulfilled. Indeed in some parts of the world the situation has worsened, and not just because of AIDS and civil unrest. Yet the failure of Alma-Ata is often viewed positively: the declaration was never meant to be taken literally as a target that everyone would be healthy by last year, and it is argued, reasonably, that the slogan has kept the issue of primary care to the forefront of the debate in WHO and other United Nations agencies. But this is a card--labelling a failure a success because the matter was worth raising--that must be played sparingly. As this week's Lancet shows (pp 1671,1685), The world health report 2000, published a year ago, continues to attract critical attention. Does it matter that the criticisms are serious provided the underlying objective, which is the use of national performance indices to improve health in all countries, is worthy, as it clearly is? If WHO is to become a science-led global policy body, the answer has to be Yes.
The South African Budget and Expenditure Monitoring Forum meeting in February 2010 was reported to raise a number of issues relevant to antiretroviral (ARV) tenders to ensure adequate supplies of appropriate medicines at the lowest possible prices. The meeting noted the need for co-operation between treasury and health departments to achieve a scale of procurement to use the leverage of the world’s largest ARV treatment programme to get the best possible deals from drug companies.
Ten years since its founding, the Global Fund is facing a serious financial shortfall, and the Fund’s board voted recently not to accept new grant requests until at least 2014. The author states that the question is not whether the Global Fund works, but how to ensure it keeps working for years to come, according to this article. There are four reasons this is imperative. First, the world needs to expand, not contract, access to health care because of the sheer burden of disease. Second, the Fund doesn’t simply give handouts: it takes the longer road of investing in and working with health ministries to build (or rebuild) local health systems. Third, the Global Fund proves how much multilateral organisations can accomplish, when one looks at the many lives it has helped save. While the usual players like the G-8 bear the greatest financial burden, the author urges some of the recipient countries to consider themselves partners of and contributors to the fund – India, Russia and China can play meaningful roles as both external funders and as recipients of grants. Fourth, a global recession is not an acceptable excuse for external funders to avoid the responsibility of meeting their financial commitments to the Fund.
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.
In January 2012, The UK’s Department for International Development announced a fivefold increase in its support for programmes to control neglected tropical diseases (NTDs). However, the authors of this paper point to a growing body of research that highlights hazards associated with current modes of implementing NTD control strategies, including undermining already-fragile health care systems, facing serious logistical problems and medical risks, and contributing in administrative failure. They draw on fieldwork in Uganda and Tanzania to shows that the specific political, economic, and social contexts in which mass drug administration (MDA) programmes are rolled out profoundly affects the uptake of drugs for the treatment of some NTDs. Average drug uptake in 2010 was well below 50%, an issue which remains unaddressed. The authors call for governments to deal with NTDs in a sustainable way that will involve a range of factors, including behavioural change, and promote an integrated bio-social approach, with more adequate monitoring and surveillance.