Efforts to finance HIV responses have generated large increases in funding, catalysed activism and institutional innovation, and brought renewed attention to health issues and systems. The benefits go well beyond HIV programmes. The substantial increases in HIV funding are a tiny percentage of overall increases in health financing, with other areas also seeing large absolute increases. Data on health funding suggest an improved pro-poor distribution, with Africa benefiting relatively more from increased external flows. A literature review found few evidence-based analyses of the impact of AIDS programmes and funding on broader health financing. Conceptual frameworks that would facilitate such analysis are summarised.
Resource allocation and health financing
International health financing and the response to AIDS
Lieberman S, Gottret P, Yeh E, de Beyer J, Oelrichs R and Zewdie D: Journal of Acquired Immune Deficiency Syndromes 52: S38–S44, November 2009
National Health Insurance is a boost to health
Shisana O: Health-e News, 9 November 2009
The author argues that the accusation that those who developed the policy on National Health Insurance (NHI) will be depriving South Africans of choice is very much unfounded. The development of the NHI policy is evidence-based; in a national survey South Africans were asked if they would support a NHI scheme if it limited their choice of doctors or if waiting lists for non-emergency services were introduced and half of the respondents indicated that they would not support it. Those who prepared the policy on NHI took into account the sentiments of the public by recommending that individuals will choose a provider within their district, whether in the public or private health sector and register for service delivery. They also proposed that the benefits must be portable, meaning that patients are covered even when they are away from their usual place of health care. Long waiting lists for non-emergency care are largely due to a shortage of health workers, particularly doctors in some areas. For this reason, the ANC proposal recommends a set of actions to mitigate overcrowding, which will reduce waiting times; these are increase of doctors through retention, increased intake of students into medicine and importation of doctors.
A global fund for the health MDGs?
Global AIDS Alliance: The Lancet 373: 1500–1502, 2 May 2009
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.
Consultation on principles guiding joint programming and a funding platform for health system strengthening
Save the Children UK: 2009
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.
Further details: /newsletter/id/34413
Cost is killing patients: Subsidising effective antimalarials
Talisuna A, Grewal P, Rwakimari JB, Mukasa S, Jagoe G and Banerji J: The Lancet 374(9697): 1224–1226, 10 October 2009
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.
Financing Malawi’s health service: A policy brief based on Malawi Health Equity Network’s 2009/2010 Health budget analysis report
Malawi Health Equity Network: July 2009
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.
Herding in aid allocation
Frot E and Santiso J, OECD: 2009
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.
On the non-contractual nature of donor-recipient interaction in development assistance
Murshed M, Institute of Social Studies: 2009
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.
Pre-requisites for national health insurance in South Africa: Results of a national household survey
McIntyre D, Goudge J, Harris B, Nxumalo N and Nkosi M: South African Medical Journal 99(10): 725–729, October 2009
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.
Today’s aid, tomorrow’s problem
Pearson M: Compass 9, October 2009
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.