Targeting to identify the poorest or those most in need of exemptions has proven a major challenge under exemption schemes in terms of protecting the poor from financial risk. In this presentation given at the Second Global Symposium on Health Systems Research in November 2012, the author discusses her research into Madagascar’s Equity Fund, which is intended to exempt the poorest in Madagascar from costs such as user fees at health facilities. She assessed the accuracy of the Fund’s targeting process to determine who receives benefits by examining whether the socio-economic status of equity fund beneficiaries was lower than that of non-beneficiaries, as well as identify factors influencing the targeting outcomes. Results suggested that beneficiaries were reasonably well targeted; however, both leakage and under-coverage occurred. Coverage remains very low, with conflicts of interest between health administrators and village level agents. The local health administration could not monitor or influence village level agents’ behaviour during beneficiary identification. Monitoring, decision-making and managerial mechanisms were re-shaped to allow health administrators to influence the number of indigents registered on the list. In addition, a re-orientation of the policy objectives changed the emphasis of equity fund operations to favour financial performance.
Resource allocation and health financing
In this study, researchers conducted a whole-system analysis - integrating both public and private sectors - of the equity of health-system financing and service use in Ghana, South Africa and Tanzania. They used primary and secondary data to calculate the progressivity of each health-care financing mechanism, catastrophic spending on health care, and the distribution of health-care benefits. Overall, health-care financing was found to be progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries. These findings raise questions over the appropriate financing mechanism for the health care of people outside the formal sector. Physical and financial barriers to service access must be addressed if universal coverage is to become a reality.
South Africa is in the process of implementing a National Health Insurance (NHI) scheme to address drastic inequalities in the health sector and transform the health system. In particular, NHI is expected to have a significant positive impact on females, who are disadvantaged under the current system, with higher rates of poor health and lower rates of medical scheme membership. Despite NHI’s transformative potential, however, the public discourse on NHI as portrayed in the media suggests that it is an unpopular policy. The authors of this paper assessed the general public’s opinion on NHI and explored gender differences in perceptions, using data from a 2010 survey of the South African population that looked at social attitudes. They found that there is broad public acceptance of NHI, with an overwhelming majority of South Africans preferring an NHI system to the current two-tiered system. More females than males said they supported NHI, reflecting the potential of the NHI system to have a positive impact on gender equality and the health of women and girls. It appears that support for NHI has increased since similar studies in 2005 and 2008, with the simultaneous growth of public discourse on the policy.
In this report, the authors assess the potential of results-based approaches to deliver long-term and sustainable results by measuring the performance of different initiatives against widely agreed aid effectiveness principles. They found that, in general, results-based approaches are not particularly good at supporting aid effectiveness principles but broader approaches do appear to be better aligned with the principles. Ownership tends to be higher when the responsibility for designing programmes falls on recipient governments. This does not mean that funder-led approaches cannot achieve significant degrees of ownership, but results are likely to be less consistent, have higher costs and impose a significant burden on host governments and civil society. Results-based approaches tend to reinforce accountability to external funders and in doing so, undermine mutual accountability. In general, the problem is less acute with country-wide initiatives and it is most pressing when working through third party service providers. In addition, the level of harmonisation of results-based approaches is low because of their widespread use of parallel structures. Eligibility and public financial management criteria demanded by funders can further influence and limit the type of country systems that recipient countries can implement.
Despite progress in the fight against AIDS over the past few years, this report warns that the gains that the world has made are in danger of being lost. There is not yet shared global responsibility for achieving the goal of ending AIDS, nor have stakeholders mapped out a collective plan for how to achieve the goal with specific responsibilities or time-bound milestones. ONE argues that there must be a renewed effort to examine, improve and scale up the financial, political and programmatic efforts needed to turn vision into action. In this report, ONE monitors progress on improving access to treatment and reducing new HIV infections; provides an assessment of the G7 countries’ and the European Commission’s past and current efforts in the fight against HIV and AIDS globally; and sets a baseline for monitoring future progress towards the beginning of the end of AIDS. The organisation calls on external funders from the West to work in closer partnership with each other and with African governments, emerging economy governments, the private sector and civil society groups to leverage unique skill-sets and resources, all aimed towards the achievement of common targets. While funding remains one of the largest hurdles in making progress towards this vision, additional efforts to address the AIDS pandemic cannot come at the expense of financing for other global health and development initiatives.
Moving towards a predominantly publicly funded health system with a specified role for private voluntary health insurance will take time, according to this article. What is required in the short term is for Treasury to be responsive to submissions to gradually increase the allocations to the health sector from general tax revenue, to enable the Department of Health to implement its plans to strengthen substantially both primary healthcare and hospital services, as outlined in the National Health Insurance (NHI) Green Paper and other recent policy documents. It is likely that it will be necessary to supplement this with additional taxes dedicated to the health sector, such as an income tax surcharge, payroll tax on employers and/or ‘sin taxes’ on tobacco and alcohol, which can be phased in after initial improvements to the public health system have been achieved. The author argues that when universal entitlements to specified services are formalised in legislation, it will be important to specify the complementary role of private voluntary insurance. Through this overall process, the relative distribution of healthcare funding across different financing mechanisms will, it is argued, shift gradually to the pattern seen in countries that have already achieved universal coverage.
In this study, researchers compared two task-shifting approaches to the dispensing of antiretroviral therapy (ART): Indirectly Supervised Pharmacist’s Assistants (ISPA) and Nurse-based pharmaceutical care models against the standard of care which involves a pharmacist dispensing ART. A cross-sectional mixed methods study design was used. Patient exit interviews, time and motion studies, expert interviews and staff costs were used to conduct a costing from the societal perspective. Six facilities were sampled in the Western Cape province of South Africa, and 230 patient interviews conducted. The ISPA model was found to be the least costly task-shifting pharmaceutical model. However, patients preferred receiving medication from the nurse. This related to a fear of stigma and being identified by virtue of receiving ART at the pharmacy. While these models are not mutually exclusive, and a variety of pharmaceutical care models will be necessary for scale up, it is useful to consider the impact of implementing these models on the provider, patient access to treatment and difficulties in implementation.
The authors of this paper identify three integrated innovative financing mechanisms - GAVI, Global Fund, and UNITAID - that have reached a global scale. However, resources mobilised from international innovative financing sources are relatively modest compared with external assistance from traditional sources. Instead, the real innovation, they argue, has been establishment of new integrated financing mechanisms that link elements of the financing value chain to more effectively and efficiently mobilise, pool, allocate, and disburse funds to low-and middle-income countries and that create incentives for improved implementation and performance of national programmes. These mechanisms provide platforms for future health funding, especially as efforts to grow innovative financing have faltered. The lessons learned from these mechanisms can be used to develop and expand innovative financing from international sources to address health needs in low- and middle-income countries.
In this paper, the authors discuss the economics of occupational safety and health (OSH) from a microeconomic point of view. While investments in occupational safety and health factors are perhaps most commonly promoted through ethical arguments, they argue instead that a cost-benefit analysis of OHS should rather be the rationale for implementing OHS. Good OHS may be part of profit maximisation and cost minimisation solutions for businesses, as the costs of ensuring safety are outweighed by savings in reducing the number of accidents and damage. Improvements in worker health can lead to an effective reduction in costs and greater productivity as well. This, in turn, can improve efficiency and thereby heighten the sustainable profitability of businesses compliant with OSH. Labour productivity is also improved by reducing the number of people who retire early or who are unable to work due to injury and illness, thereby cutting the healthcare and social costs of injury and illness, increasing the ability of people to work by improving their health, and improving total productivity by stimulating more efficient capital, equipment, machineries, working methods and production technologies.
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.