Will leaders act now to save lives and make health care free in poor countries? On 23 September 2009 leaders met at the United Nations General Assembly in New York for a high-level event on health. On the table was a proposal to support at least seven developing countries to fully implement free care for women and children or to expand free health services to all, including Malawi and Mozambique. Oxfam recommends that governments of these countries make high-level commitments to introduce free health care for women and children and/or fully implement and expand free health care for all, as well as increase government spending on health to at least 15% of the national budget. The authors argue that the same commitments are required from rich country donors and multilateral aid agencies to provide additional long-term and predictable funding necessary to successfully implement free health care in all seven countries, and to officially extend the offer of financial and technical support for free health care to all poor countries who wish to remove fees and to make this event a global turning point in the fight to make health care free for all.
Resource allocation and health financing
The African National Congress has released a rough outline of how it sees the proposed National Health Insurance scheme on its website. But the document is short on detail and has no timelines. The broad objective of the NHI is to put into place the necessary funding and health service delivery mechanisms, which will enable the creation of an efficient, equitable and sustainable health system in South Africa. It will be based on the principles of the right to health, social solidarity and universal coverage.
In response to the problem of aid fragmentation, joint country assistance strategies have emerged as a preferred method to coordinate and harmonise aid. This paper determines that, to date, donor teams and recipient governments have come together in at least twelve countries to prepare joint strategies. A number of lessons were learnt and conclusions drawn. Lack of communication between stakeholders was identified, especially regarding strategy processes. Poverty reduction strategy processes should ideally be separated from the joint country strategy process to reduce government workload. An inclusive, thorough and effectively managed process has a greater chance to create the trust, cooperative spirit and follow-through during the implementation phase than one that stresses the production of a quality report without adequate venting of differing views and interests. In countries where government lacks capacity or will, the donor community may wish to identify one agency as the presumptive leader among donors for aid coordination on the ground.
This paper looks at whether aid partnerships established early or late matter significantly for aid quantities, and how this in turn affects aid fragmentation. It also details how aid partnerships have evolved over time and how donors have, if at all, shifted priorities. Furthermore the authors seek to evaluate the effect of current aid reform on aid fragmentation. It found that donor countries allocate larger shares of their aid budgets to recipients that entered early in their portfolios, while they have allocated smaller aid quantities to new partnerships. This has direct consequences for aid fragmentation, with many donors disbursing small amounts to a recipient. Fragmentation appears to be a product of portfolio expansion and it increases direct transaction and indirect costs creating dysfunctional bureaucracy and political behaviours by lowering the level of bureaucratic quality. Aid is less efficient in countries when it is fragmented. Donors' decisions to give less aid to late recipients, coupled with the sheer expansion in the number of their partnerships, has direct consequences on aid fragmentation.
This research shows that funding for health in developing countries has quadrupled over the past two decades – from US$5.6 billion in 1990 to US$21.8 billion in 2007. Private citizens, private foundations and non-governmental organisations are shifting the paradigm for global health aid away from governments and agencies like the World Bank and the United Nations and making up an increasingly large piece of the health assistance pie – 30% in 2007. However, health aid does not always reach either the poorest or unhealthiest countries. Overall, poor countries receive more money than countries with more resources, but there are strong anomalies. Sub-Saharan Africa receives the highest concentration of funding, but some African countries receive less aid than South American countries with lower disease burdens – like Peru and Argentina. HIV and AIDS took the lion’s share of funding, receiving at least 23 cents out of every dollar going into development assistance for health, while tuberculosis and malaria received less than a third of that.
This paper notes that post-conflict countries face enormous development challenges and substantive policy consequences. It calls for appropriate responses for conflict-affected nations such as financial assistance from donors, private investment and capacity building. Arguments given for resource transfers to post-conflict countries are that by increasing income, they reduce the risk of renewed conflict and also mitigate humanitarian crises left by the conflict. The second argument assumes that the humanitarian needs of conflict countries are due to conflict. The paper outlines the political market imperfections, which make post-conflict countries vulnerable – rendering political incentives to pursue long-run development and peace weak. These imperfections should shape the goals and modalities of foreign assistance to facilitate the delivery of social services, infrastructure, and capacity-building. To achieve development goals, government officials must have incentives to pursue the broad public interest in order to reduce political market imperfections that distort decision-making and deter accountability.
The Ugandan government is investigating whether a nationwide shortage of antiretroviral (ARV) drugs led to the reported deaths of HIV-positive people in northern Uganda in July. Health workers in Apac district reported that at least 17 people known to have been HIV-positive died over the past month after failing to receive their life-prolonging medication due to supply shortfalls. Health centres around the country are reporting out-of-stock ARVs, which the health ministry attributes to a lack of funding. An estimated 170,000 people are enrolled in government ARV programmes. After a massive countrywide testing drive in January, 100,000 new HIV patients were registered, many of whom needed ARVs –government and donor funding, however, had not increased correspondingly. According to officials at the health ministry, funding delays from donors, such as PEPFAR and the Global Fund, have also contributed to national ARV shortages.
Donors have many competing claims on scarce resources, and many statistics and reporting units are vastly under resourced. Much of the core project information required is already captured within donors' central management information/financial systems. For all donors, there will still be a significant amount of information that is required by users, but not currently captured in a systematic way. It is likely that to fully comply with IATI, many donors will need to consider an investment in improving their reporting systems. This scoping paper makes a few recommendations. Further analysis should be undertaken to better understand the costs and benefits to donors of complying with the potential IATI standards, and to understand what support they may require. Agreed mechanisms should be established for updating the common standards over time and arbitrating disputes. Detailed consultations with partner countries, civil society organisations and other key stakeholders should be done to determine their priorities in terms of aid information.
The author observes that there are problems with the way in which discussions concerning South Africa’s new national health insurance (NHI) are being conducted behind closed doors. A top-down management approach is seen to be not working, excluding consultation with stakeholders, especially civil society. The challenges government and civil society now face on the issue are related to leadership and accountability (visible leadership at the highest possible level and one single voice and proposal from government), positioning and values (to what extent should principles of solidarity be applied in the design of the new system), the process followed in developing the provisions (extensive and in-depth consultation and a clearly defined process with milestones and deadlines), as well as delivery (especially in administration and management to ensure sustainable benefits).
The global fight against malaria has been continually challenged by poor access to affordable, effective medicine. Growing resistance to chloroquine, the traditional treatment, has worsened the situation. Artemisinins, the successor therapy to chloroquine, are at least ten times more costly than the older drug. In developing countries, most malaria medicines are purchased in the private sector, where traditional aid mechanisms do not reach. So a new aid approach was needed. The Affordable Medicines Facility-malaria (AMFm) will efficiently supply publicly subsidised drugs to meet public- and private-sector demand in malaria-endemic countries. If artemisinins are priced more competitively, resistance to them will be delayed.