Years after graduating from dependence on the International Monetary Fund (IMF), many African countries are having to call upon the fund for assistance to cope with a global economic crisis that is not their fault. African economies are struggling against collapsing demand for their products, volatile commodity prices and falling foreign investment. Among countries seeking IMF aid are Kenya and Tanzania – two of Africa's biggest economic reformers. The IMF on Friday approved a total of US$545 million in emergency funding for the pair of East African countries. Meanwhile, Ghana and Mozambique are in talks with the fund to secure financing support. Other countries that have sought fresh help from the IMF in recent months include Ivory Coast, Ethiopia, Sao Tome and Principe and Zambia.
Resource allocation and health financing
To compound the apparent inadequacy of the G8, the meeting in Italy got off to an inauspicious start. The Italian hosts were not only under fire for not preparing a constructive agenda, preferring the US to take the lead, but were threatened with expulsion from the G8 for unabashedly reneging on aid pledges to double aid to Africa made at the Gleneagles summit in 2005. According to ActionAid, Italy is US$1.037bn behind in aid arrears, France is further in arrears with US$1.249bn, Germany US$497m, the United States US$263m, Canada US$186m and Japan US$138m. Only Britain is on course to hit its target. This lack of spending is having a devastating effect on Africa’s ability to reach its Millennium Development Goals’ (MDGs) targets. As the new UN MDGs 2009 report states ‘for many developing countries, lower levels of aid would not only impede further progress, but could reverse some of the gains already made.’ Indeed, the proportion of undernourished per population is rising again in sub-Saharan Africa after concrete advances had been made.
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.
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.