The objective of this paper was to investigate the effect of survey design, specifically the number of items and recall period, on estimates of household out-of-pocket and catastrophic expenditure on health. It used results from two surveys – the World Health Survey and the Living Standards Measurement Study – that asked the same respondents about health expenditures in different ways. In most countries, a lower level of disaggregation (i.e. fewer items) gave a lower estimate for average health spending, and a shorter recall period yielded a larger estimate. However, when the effects of aggregation and recall period are combined, it is difficult to predict which of the two has the greater influence. Therefore, it is crucial to establish a method to generate valid, reliable and comparable information on private health spending.
Resource allocation and health financing
States emerging from protracted crises struggle to provide basic services. This is no more crucial than in the health sector where vulnerable ‘post-conflict’ populations are frequently in dire need of care. However, development actors are frequently faced with difficult choices – particularly how much emphasis to place on ‘humanitarian’ emergency health relief in the face of a need for health systems building. Yet is it possible to simultaneously provide basic health services whilst also developing local health provision? This paper considers how aid mechanisms can engender a ‘twin approach’ and sustain a continuous flow of resources during the progression from humanitarian to development aid. A paradigm shift is required which allows for an integrated mix of modalities in early recovery settings. Better coordination of donor agencies at country level is also needed to determine the choice of aid instruments and their complementarity, in order to ensure that health service coverage for vulnerable populations is maintained while simultaneously (re)building the health system.
The author, working for the medical humanitarian organisation Médecins Sans Frontières (MSF), which uses the medical relief paradigm, has argued that the health development paradigm and its focus on sustainability – defined as the aim of replacing foreign assistance with domestic resources within a foreseeable future – is one of the main reasons we are not able to realise universal coverage. A new global health aid paradigm would aim for technical sustainability, as in the health development paradigm, but without aiming for financial sustainability. It would tolerate open-ended external financing, but without relying on external human resources for management and implementation. The Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund)distinguishes between technical and financial sustainability: it has abandoned financial sustainability, not technical or ‘programmatic’ sustainability. When countries use their Global Fund grants wisely and effectively, they can count on continued support from the Global Fund. In adopting this approach, the Global Fund is – implicitly – using a human rights based approach. Foreign assistance, aimed at the realisation of essential human rights, is not a matter of charity; it is a matter of fulfilling international legal obligations. There is no reason to assume that global health aid will disappear (which is the underlying assumption of the aim of financial in-country sustainability). On the contrary there are many reasons to insist that global health aid should continue and increase.
Estimated funding needs for the implementation of the World Health Organization strategy on global public health and intellectual property total more than US$2 billion for the years 2009 to 2015 in order to build capacity to innovate and to deliver health products, engage in technology transfer and in the application and management of intellectual property, promote new research and development and sustainable financing mechanisms for that research and development (R&D), and establish monitoring systems. It also budgets an additional US$147 billion for the actual cost of research, including education of researchers and infrastructure building, noting that this number is difficult to determine ahead of time.
To address the gap between health investments and financial flows worldwide, the authors identified the patterns in allocation of funds by the four largest donors — i.e. the World Bank, Bill and Melinda Gates Foundation (BMGF), the US Government, and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria — in 2005. They created a disbursement database with information gathered from the annual reports and budgets. Funding per death varied widely according to type of disease. The World Bank, US Government, and Global Fund provided more than 98% of their funds to service delivery, whereas BMGF gave most of its funds to private research organisations, universities and civil societies in rich countries and the US Government and Global Fund primarily disbursed grants to sub-Saharan Africa. Continued attention is needed to develop country ownership, particularly in planning and priority setting.
This study looked at the monitoring and evaluation (M&E) methods used to measure the equity, efficiency and sustainability of the Tanzania National Voucher Scheme (TNVS), which is used to deliver subsidised insecticide-treated mosquito nets (ITNs) to pregnant women and infants in Tanzania. The M&E focused on five key domains: ITN ownership and use among target groups, provision and use of reproductive and child health services, “leakage” of vouchers (use of vouchers by people not meant to benefit from the programme or use of vouchers to buy other things), availability of nets in the commercial ITN market and cost and cost-effectiveness of the scheme. The authors identify several successful features of this approach, namely, independence, breadth of scope, timely reporting with regular feedback, and sustainability - monitoring outcomes over time helps to identify lasting change.
The Free State health department has announced that its financial situation has reached ‘dire proportions’ forcing it to postpone all non-emergency surgery until January next year and stop all non-critical staff appointments. HIV clinics are coming under increasing threat of being closed down, as they are considered part of the outpatient services that are being stopped. The Treatment Action Campaign said it also continued to receive reports from doctors who are turning critically ill patients away from their clinics because of antiretroviral shortages. Doctors predict a large number of people are going to die over Christmas, notably poor people, because government won’t commit money to solving the problem. The measures apply to all of its 31 health facilities, including hospitals and clinics.
Millions of people in low- and middle-income countries cannot afford or obtain the medicines they need, according to this study. It is based on findings from 45 surveys carried out since 2001 in 36 countries, using a standardised methodology developed by the Health Advance Institute (HAI) and World Health Organization (WHO). Across the surveys, public sector availability of generics averaged a disappointing 38%. Even in the private sector, the availability of generics was far from ideal and sometimes unaffordable to many, yet implementing policies that increase the use of low-priced quality generics would help significantly. Policies to ensure competition and incentives for pharmacies to dispense low-priced generics are needed. Governments could also review all policies affecting medicine prices and availability.
Publish What You Fund is a new initiative to promote transparency of international aid. It consists of civil society groups from around the world, including organisations working on aid effectiveness and groups working on access to government information. They believe that, for aid to be effective, accountable and participatory, it must be transparent. Information must be available to recipient governments, affected communities and other stakeholders, as well as the general public. The campaign has been busy drafting a first set of principles. These principles have had one round of consultation (between July and August 2008) and were presented at the Accra High Level Forum on Aid Effectiveness (Ghana, 2–4 September 2008). You can add your comments on their website.
The Currency Transaction Tax (CTT) proposes a small levy on foreign exchange transactions and uses the money raised to finance development projects for the global public good. CTT is basically a tax on the benefits of globalisation. This study claims the tax would be easy to operate and difficult to evade since all foreign exchange transactions are completed in a few large centralised settlement structures. It estimated that a CTT of 0.005% on each transaction in major currencies would yield approximately US$ 33 billion. The money could be allocated for development and administered multilaterally. Critics say this tax will reduce foreign currency transactions and create inefficiencies in trading markets; however, it is specifically designed to raise money without disrupting the market.