In March 2009, the Task Force for Innovative International Financing for Health Systems recommended a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others, and the Health Systems Funding Platform was soon launched. Despite its potential significance, there has been little comment in peer-reviewed literature, though some disquiet in the international development community around the scope of the Platform and the capacity of the partners, which appears disproportionate to the available information. This case study uses documentary analysis, participant observation and 24 in-depth interviews to examine the processes of development and key issues raised by the Platform. The findings show a fluid and volatile process, with debate over whether ongoing engagement in health system strengthening by the Global Fund and GAVI represents a dilution of organisational focus, risking ongoing support, or a paradigm shift that facilitates the achievement of targeted objectives, builds systems capacity, and will attract additional resources. The tensions, however, appear to have been resolved through a focus on national planning, applying International Health Partnership principles, though the global financial crisis and key personnel changes may yet alter outcomes. Despite its dynamic evolution, the Platform may offer an incremental path towards increasing integration around health systems that has not been previously possible, the authors conclude.
Resource allocation and health financing
The authors of this paper argue that substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. The authors propose a strategic investment framework that is intended to support better management of national and international HIV and AIDS responses than exists with the present system. The framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV and AIDS. The framework is cost effective at US$1,060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.
According to this report, coverage of Ghana's National Health Insurance Scheme (NHIS) has been exaggerated and could be as low as 18% - less than a third of the coverage suggested by Ghana’s National Health Insurance Authority and the World Bank. Every Ghanaian citizen pays for the NHIS through VAT, but as many as 82% remain excluded. Twice as many rich people are signed up to the NHIS as poor people. Those excluded from the NHIS still pay user fees in the cash and carry system. Twenty five years after fees for health were introduced by the World Bank, they are still excluding millions of citizens from the health care they need. An estimated 36% of health spending is wasted due to inefficiencies and poor investment. Moving away from a health insurance administration alone could save US$83 million each year, Oxfam argues, which is enough to pay for 23,000 more nurses. Oxfam calls on the Ghanaian government to move fast to implement free health care for all its citizens.
According to the People’s Health Movement (PHM), the World Health Organisation (WHO) is initiating reform process to enable the organisation to more effectively respond to today’s global health challenges and particularly to its financing challenges. The PHM proposes that reforms are needed in five areas to enable the WHO to exert its global health leadership role: Giving real voice to multiple stakeholders; improving its transparency, performance, and accountability; providing closer oversight of regions; exerting its legal authority as a rule-making body; and ensuring predictable, sustained financing. To fulfil its mandate the WHO needs a budget that is adequate, predictable and untied. PHM argues that WHO’s state of financing is untenable; only 18% of WHO’s funding comes from core, assessed contributions. The rest is cobbled together from multiple streams of voluntary donations, grants and in-kind support, much of which is conditional. A high proportion of voluntary contributions by member states undermines the organisation’s independence and results in huge inefficiencies. Increasing dependence on private philanthropies and corporates carries serious risks of further distorting WHO's priorities. PHM calls for the assessed contributions formula for countries to be reviewed and revised to help create fair and adequate system of public financing for the WHO. PHM proposes that member states collectively commit to increasing assessed funding so that it reaches 50% of the overall budget over the next five years and warn against WHO pursuing public-private partnerships without ensuring safeguards against corporate influence over policy making and pernicious conflicts of interest.
Is performance-based financing just a donor fad or a catalyst for wider reform? Looking at the broader evidence, the author offers several arguments against performance-based financing, based on three main issues. First, there is the issue of its effect on worker motivation in the health sector. It is argued that the introduction of financial incentives into a working environment characterised by a high degree of idealism might actually erode workers’ intrinsic motivation. Second, performance-based financing focuses on a certain range of indicators, resulting in the neglect of non-remunerated aspects of work and the focus on remunerated ones. Third, the hidden costs of performance-based financing are not limited to emotional costs (concerning the self-esteem of health workers) and technical costs (due to misdirected focus on indicators). There are considerable costs (both financially and in working hours invested) in establishing a performance-based financing system that continuously monitors the quantity and perceived quality of health-sector performance. The author notes that all these negative side-effects of performance-based financing are consistently depicted in broader reviews as well as in detailed examination of its use in Rwanda.
In their white paper on foreign aid, the Chinese government notes that, currently, the environment for global development is not favourable. With the repercussions of the international financial crisis continuing to linger, global concerns such as climate change, food crisis, energy and resource security, and epidemic of diseases have brought new challenges to developing countries, aggravating the imbalance in the development of the global economy, and widening the gap between North and South, rich and poor. The international community should strengthen co-operation and jointly rise to the challenges facing development, according to the paper. Against this background, China has a long way to go in providing foreign aid. The Chinese government will make efforts to optimise the country's foreign aid structure, improve the quality of foreign aid, further increase recipient countries' capacity in independent development, and improve the pertinence and effectiveness of foreign aid. China further pledges to continue to promote South-South co-operation, gradually increase its foreign aid input on the basis of the continuous development of its economy and promote the realisation of the UN Millennium Development Goals.
The International Health Partnership and Related Initiatives (IHP+) was launched in 2007 with a commitment by developing country governments and Development Partners to ‘work effectively together with renewed urgency to build sustainable health systems and improve health outcomes in low and middle-income countries’. This independent review has found that the participating country governments and Development Partners made some progress in improving how effectively they were delivering and using health aid by 2009. These findings are broadly consistent with those from the OECD 2008 Paris Declaration monitoring survey, which is conducted at the national level (i.e. does not capture sectoral performance), and covers a larger number of countries and Development Partners. Ethiopia, Mali and Mozambique have seen the most improvements in Development Partners actions to meet their IHP+ targets. Burundi, Djibouti, DRC, Niger and Nigeria have benefitted less. However, these results might be expected given the length of time since each country joined the IHP+ (Djibouti only signed up to the IHP+ Global Compact in July 2009, Niger and DRC in May 2009) and the relative strength of these countries systems and processes.
This report offers a comprehensive view of trends in public and private financing of development assistance for health (DAH), with preliminary estimates of how the economic downturn is affecting health financing in 2010. The Institute for Health Metrics and Evaluation (IHME) notes that the global economic recession appears to be contributing to a slowing of the rate of growth in DAH. Estimates show continued growth through 2010 to a total of $26.87 billion by year’s end, but the rate of growth was cut by more than half from an annual average of 13% between 2004 and 2008 to 6% annually between 2008 and 2010. Spending on HIV and AIDS programmes continued to rise at a strong rate, making HIV and AIDS the most funded of all health focus areas. Maternal, newborn and child health received about half as much funding as HIV and AIDS in 2008. Tuberculosis funding grew steadily from 1990 through 2008. Malaria funding rose more dramatically than any other health focus area between 2007 and 2008. Despite much discussion about the need for general health sector support, funding for that area has grown slowly since 2006, according to the report. Non-communicable diseases receive the least amount of funding compared with other health focus areas. Uncertainty about the future of DAH underscores the importance of tracking global health spending to ensure resources are directed as efficiently as possible to the world’s most pressing health needs.
In this study, the authors cross-validated the global cost of scaling up child survival interventions to achieve the fourth Millennium Development Goal (MDG4) as estimated by the World Health Organization (WHO) in 2007 by using the latest country-provided data and new assumptions. Twenty-six countries were included. The authors fund that country-level validation caused a 53% increase in original cost estimates (i.e. 9 billion 2004 United States dollars [US$]) for 26 countries owing to revised system and programme assumptions, especially surrounding community health worker costs. The additional effect of updated population figures was small; updated epidemiologic figures increased costs by US$ 4 billion (+15%). New unit prices in the 26 countries that provided data increased estimates by US$ 4.3 billion (+16%). Extrapolation to 75 countries increased the original price estimate by US$ 33 billion (+80%) for 2010–2015. In conclusion, country-level validation had a significant effect on the cost estimate. Price adaptations and programme-related assumptions contributed substantially. An additional 74 billion US$ 2005 (representing a 12% increase in total health expenditure) would be needed between 2010 and 2015. Given resource constraints, countries will need to prioritise health activities within their national resource envelope.
According to this article, the Forum on China-Africa Co-operation is the main mechanism whereby China’s Ministry of Foreign Affairs and its Ministry of Commerce are starting to align their respective responsibilities toward more effective co-ordination and implementation of a Chinese foreign policy and aid policy toward Africa. Figures on China’s aid disbursements to Africa remain vague, the authors note, in absence of a central Chinese aid agency to monitor funding flows to the continent. Part of China’s strategic industrial plan for Africa is to establish five preferential trade and industrial zones for Chinese business entry in Africa: Zambia, Mauritius, Egypt, Nigeria and possibly Tanzania. In 2007, The Chinese Development Bank was designated to manage the US$5 billion China-Africa Development Fund, but the authors cautions that, even though it is termed a ‘development fund’, it has been actually put in place to finance the market entry of Chinese firms into the African economy. In conclusion, the authors provide recommendations to relevant stakeholders that are engaged in the aid process. Recommendations for African countries include developing a better understanding of the Chinese approach to aid; facilitating regional co-ordination; avoiding poor co-ordination which may lead to Chinese aid fatigue; avoiding the division between traditional and emerging donors; strengthening the African voice; improving the reporting mechanisms within recipient countries; and improving debt reporting.