In this study, the authors reviewed the available literature on modelled estimates of the cost of providing antiretroviral therapy (ART) to different populations around the world, and they suggest alternative methods of characterising cost when modelling several decades into the future. In past economic analyses of ART provision, costs were often assumed to vary by disease stage and treatment regimen, but for treatment as prevention, in particular, most analyses assume a uniform cost per patient. This approach disregards variables that can affect unit cost, the authors note, such as differences in factor prices (i.e., the prices of supplies and services) and the scale and scope of operations (i.e., the sizes and types of facilities providing ART). They go on to discuss several of these variables, and then present a worked example of a flexible cost function used to determine the effect of scale on the cost of a proposed scale-up of treatment as prevention in South Africa. Adjusting previously estimated costs of universal testing and treatment in South Africa for diseconomies of small scale, i.e., more patients being treated in smaller facilities, adds 42% to the expected future cost of the intervention.
Resource allocation and health financing
The cost of a highly accurate, rapid diagnostic test for tuberculosis (TB) has been reduced by 40% under a new agreement between the US government, the Bill and Melinda Gates Foundation, and the health financing mechanism, UNITAID. GeneXpert is recommended by the World Health Organisation and it provides a two-hour diagnosis of TB, the TB/HIV co-infection, and drug-resistant TB. To date, the high unit cost of Xpert MTB/RIF cartridges has proven a barrier to their introduction and widespread use in low- and middle-income countries. According to the WHO Stop TB Partnership, 45 developing countries and those with a high TB burden will benefit from the price cut. Research suggests that increased use of the test in countries with high TB burdens could allow the rapid diagnosis of 700,000 cases of TB, and save health systems in low- and middle-income countries more than $18 million in direct costs. The test can be used outside of conventional laboratories because it is self-contained and does not require specialised training.
The primary aim of this research paper was to analyse interventions for the prevention of mother-to-child-transmission of HIV (PMTCT) included in HIV proposals approved for funding by the Global Fund to fight AIDS, Tuberculosis and Malaria. A total of 345 original HIV proposals approved for funding from Rounds 1 to 9 were reviewed according to the four components of the global PMTCT strategy. The researchers found that performance across the components varied. On one hand, prevention of unintended pregnancies in HIV-infected women (component 2) was the least represented, appearing in 34% of the proposals, while on the other, PMTCT (component 3) was present in approximately 90%. Component 2 was the only component that consistently increased throughout the Rounds, with signs of the greatest increase between Rounds 3 and 7. The authors call on countries to support comprehensive PMTCT interventions that are balanced across the four components. Their study highlights interventions that countries could capitalise on to scale-up PMTCT efforts as well as synergise efforts in linking with other global and national initiatives in maternal, reproductive and child health.
Health and education budgets are cut in times of financial crises despite the fact that the opposite should be happening, according to South African health department Director-General Precious Matsoso. Addressing the plenary at the 3rd People’s Health Assembly Matsoso said that while the country was supposed to be rolling out National Health Insurance (NHI), it had to do so with only R11-million per pilot district from Treasury. She argued that social services should not suffer when there is a crisis, the opposite should happen. Instead, she said, we see that when there is a financial crisis, there is a cut in social spending and health. Prior to this, Professor Di McIntyre, who is also a key NHI advisor to the health minister, reiterated that NHI was about the comprehensive reform of the health system. She said one of her key concerns while establishing NHI was the underfunding of the NHI pilot sites by Treasury and the “enormous pressure to protect the positions of the high income groups and private sector profits”.
This paper discusses the range of mechanisms to improve domestic financing that have been utilized worldwide, from which Ministries of Health and Finance can draw a context-specific toolkit for strengthening domestic financing for women’s and children’s health. While evidence exists about how mechanisms have been used in different settings, there remains limited cost-effectiveness data to help guide decision-makers in low and middle income countries on when and where such mechanisms are most effectively and efficiently deployed. Financing mechanisms must be carefully coordinated and integrated to promote universal coverage and avoid fragmentation of health systems.
The dialogue found that countries challenges of high turnover of Health Ministers, shortage of human and financial resources for scaling up action, and weak health information systems. The dialogue recommended flooding health systems with low and middle level staff. The meeting called for resourcing of the Global Fund, which should also “open a window” for maternal, newborn and child health. Mobilization of more domestic resources, accountability, ownership and good coordination were reported as essential for “more money for more health”. The Assembly recommended the development and adoption of national policies, to ensure health is integrated in national development strategies and also costing of national development plans with appropriate economic and other expertise. It was concluded that national and district health accounts should be institutionalized, to track expenditures and ensure decentralization to reach to the communities. Harmonization of health initiatives by development partners was recommended to support and strengthen national plans and programmes, under national ownership and leadership.
Using South Africa as a case study, this review examines whether private health systems are susceptible to regulation and therefore able to support an extension and deepening of coverage when complementing a pre-existing publicly funded and delivered health system. The study finds that the private health system in South Africa has played an important supplementary role in achieving universal coverage throughout its history, but more especially in the post-Apartheid period. However, the quality of this role has been erratic, influenced predominantly by policy vacillation. The objective of universal coverage can be seen in two dimensions, horizontal extension and vertical deepening. Private systems play an important role in deepening coverage by mobilising revenue from income earners for health services over-and-above the horizontal extension role of public systems and related subsidies. South Africa provides an example of how this natural deepening occurs whether regulated or unregulated. It also demonstrates how poor regulation of mature private systems can severely undermine this role and diminish achievements below attainable levels of social protection. When measures to enhance risk pooling are introduced, coverage is expanded and becomes increasingly fair and sustainable. When removed, however, the system becomes less stable and fair as costs rise and people with poor health status are systematically excluded from cover.
African States are on average far from meeting key health financing goals such as the Abuja Declaration target of allocating 15% of the government budget to health. Out-of-pocket expenditure is still higher than 40% of the total health expenditure in 20 of 45 African countries, and in 22 countries the total health expenditure does not reach even the minimal level of US$ 44 per capita defined by the High Level Task Force on Innovative International Financing for Health Systems (HLTF). Only three countries have attained the Abuja Declaration and HLTF targets. Many countries have limited capacity of raising public revenue mainly because the informal nature of their economies makes collection of tax and contributions difficult. This limits their opportunities for investing in health. The paper presents trends in health financing in African countries and calls for close collaboration between the ministries of finance and health and inter-ministerial dialogue to develop a health financing strategy that supports efforts to strengthen all the other health system dimensions to move towards universal health coverage.
This report indicates that family planning and maternal and newborn services fall well short of needs in developing countries, particularly in the world’s two poorest regions, South Asia and Sub-Saharan Africa. The authors argue that helping women and couples have healthy, wanted pregnancies in these regions will help achieve social and economic gains beyond the health sector. Several barriers to services were identified, such as weaknesses in health systems that need to be addressed, including insufficient capacity, weak contraceptive supply systems and poor financial management systems, as well as prejudice among providers toward unmarried, sexually active young people, or toward women who have had unsafe abortions. The authors suggest that the additional funds needed for improving services could come from a combination of domestic and international resources. Furthermore, decision makers need to recognise that changes outside the service environment (e.g. social changes) may improve demand for sexual and reproductive health care.
The central argument of this working paper is that, given the magnitude of the investment in infrastructure that is required, especially in Africa, the role of external funding (foreign aid) in the future should be distinctly different to what it is now. While external funding will be required to continue to fill the ‘savings gap’ in some small countries and land-locked countries, in most other countries it can play a very different role in facilitating the creation of institutional mechanisms that help mobilise more funding from other sources. These include domestic revenues (which already fund a large proportion of infrastructure), investments by China and the other BRIC countries, sovereign wealth funds and infrastructure funds. There are already examples of external funding playing such a leveraging role. What is needed is to take this to a new and higher level, the authors argue. The study provides an overview of evidence on infrastructure needs and also possible magnitudes of flows from different sources for investment in infrastructure.