Depending on decisions taken by politicians and parliamentarians, a large part of the additional US$36–45 billion needed in 2015 could be available in an entirely predictable and sustained manner. Most of the gap will need to be filled by domestic resources contributed by national governments and citizens. But even if governments in low-income countries give more priority to health, they will still be unable to meet the required costs of scaling up health systems and providing free essential health services. If low-income countries are to reach the health millennium development goals, international funding will have to complement domestic health resources. Development partners are strongly urged to fulfil the commitments they have already made. Innovative development finance is the way forward, with non-traditional applications of official development assistance (ODA), joint public-private (or private) mechanisms and flows that support fund-raising, engage partners as stakeholders and deliver financial solutions to development problems on the ground.
Resource allocation and health financing
While the worldwide AIDS community bemoans the global economic crisis and its impact on funding streams for the HIV and AIDS response, several speakers at the Fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention, which took place in Cape Town, South Africa, from 19–22 July, called on implementers to start doing more with less. Dr Stefano Bertozzi of the National Institute for Public Health in Mexico said choosing interventions more strategically would help, he said, citing abstinence programmes as one example of an approach that lacked evidence to support it. Focused, well-managed programmes targeted at populations with the greatest need were the most cost-effective, as were programmes integrated with services for related health issues, such as tuberculosis. Programmes that worked towards long-term goals, such as training new doctors and nurses, empowering women, and changing social norms, were more efficient than those with short-term targets, which looked good on annual reports but did little to change the course of the epidemic.
In Oxfam's press release after the 35th G8 summit, held in Italy from 8–10 July 2009, Jeremy Hobbs, its executive director, noted: ‘A stalemate persists because, in the past eight years, rich countries have used the talks to continue to push to open up new export markets. Developing countries have resisted, saying they were promised a deal that would give them space to protect their farmers and new industries, an end to rich country trade-distorting agricultural subsidies, and more access to rich markets for their farmers and industries. This summit has been a shambles, it did nothing for Africa, and the world is still being cooked. Canada 2010 is the end of the road for the G8 – all the promises they have made are due. They have 12 short months to avoid being remembered as the ones who let the poor and the planet die. Millions of children are out of school, millions more dying from curable diseases. This is shameful and the Canadians must move fast to fix it. There won’t be any second chances.’
The national health insurance (NHI) system that is envisaged for South Africa would be more akin to the excellent publicly funded health systems found in countries such as Costa Rica, where the NHI as a large, single purchaser of health services is able to improve resource use in the overall health system and to get ‘value for money’ for its citizens. However, services in South Africa’s public health sector are of poor quality at present. Actions that would be required to improve quality include: addressing health worker conditions of service through implementing the long-awaited occupation specific dispensation (or OSD); increasing staffing levels by at least 80,000; funding the maintenance and repairs of buildings, equipment and other infrastructure; and granting greater management autonomy to public sector hospitals to reduce red tape. Strong political commitment and genuine civil society involvement are essential to successful implementation.
There is general agreement that donors made more progress in 2008 in terms of increasing aid to Sub-Saharan Africa than in 2006/7. While, in 2007, the G8 countries were significantly off track, the encouraging performance in 2008 demonstrates that if performance is maintained at the same level, most of the countries will meet the targets set for 2010, 2011 and 2013. But there are some, notably Italy and France, who will not deliver. Italy has so far delivered only about 3% of the US$8 billion it pledged in additional funding and may actually be planning cut, not increase, aid in the coming years. Developed countries can help by fast-tracking the process of debt relief under the Highly Indebted Poor Country Initiative (HIPC) Initiative. Donors can ensure that African Diaspora is protected from attacks and discrimination. Trade should be further liberalised in favour of the products of poor countries so that there can be compensation for any loss of aid. And the available resources should be invested in the most productive sectors so as to gain the highest return.
International donors must continue meeting their commitments to HIV/AIDS, even in the face of the economic downturn, United Nations (UN) Secretary-General Ban Ki-Moon has urged. In 2006, the Assembly pledged to achieve universal access to comprehensive HIV prevention, treatment, care and support by 2010. UNAIDS has said that achieving these targets in the timeframe would require an estimated US$25 billion. In 2008, the Global Fund to Fight AIDS, Tuberculosis and Malaria was forced to cut funding by 10% and the World Bank projects that the global recession could place the treatment of more than 1.7 million at risk by the end of 2009. ‘I fear that many governments are resigned to reducing programmes and diminished expectations,’ said Miguel D'Escoto, President of the UN General Assembly. ‘But it is precisely when times are difficult that our true values and the sincerity of our commitment are most clearly evident. If we allow cuts now, we will face increased costs and great human suffering in the future.’
Donor funding has fuelled a vast increase in service delivery, medical research and clinical trials throughout the developing world, yet, with pressures to spend funds quickly and achieve results, projects may not pay sufficient attention to internal monitoring and security systems to protect against embezzlement. This U4 Brief analyses how this type of corruption occurred in a donor-funded project, and what can be done to minimise the risk. While not widely publicised, many organisations have dealt with the frustrations of financial mismanagement, embezzlement and theft. Recommendations include tighter financial controls, better management policies and channels for disclosure. For projects that are just beginning, establishing a sound financial system should be a priority. Changes in policies, procedures and reporting can help promote a culture of compliance and avoid corruption.
This study aimed to provide a comprehensive assessment of development assistance for health (DAH) from 1990 to 2007. It used several data sources to measure the yearly volume of DAH in 2007 United States dollars, and created an integrated project database to examine the composition of this assistance by recipient country. It found that DAH grew from $5.6 billion in 1990 to $21.8 billion in 2007. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and the Global Alliance for Vaccines and Immunization having a central role in mobilising and channelling global health funds.
Over the past decade, an increasing number of developing country governments, working with donors and NGOs, have been implementing cash transfer programmes — regular transfers of cash to individuals or households. These programmes are united by common assumptions: that income poverty has a highly damaging impact on people’s health and nutrition, and that cash empowers poor individuals and households to make their own decisions on how to improve their lives. This report examines three key questions: What contribution can cash transfers make to reducing child mortality? What are the broader economic benefits of investing in cash transfers? How can child-focused cash transfers be affordable in developing countries? The report argues that cash transfers have a critical role to play in accelerating reductions in child mortality, as well as broader economic benefits. It estimates current costs and finds that child and maternity benefits are possible on a large scale, even in developing countries.
According to the Human Sciences Research Council’s (HSRC) Olive Shisana, ‘The NHI [national health insurance] system presents itself as an ideal mechanism for achieving equitable access to quality health services in South Africa: firstly, because it satisfies the fundamental principles of a unitary health system enshrined in our constitution; secondly, because it promotes redistribution and sharing of health care resources between the public and private sectors thus meeting our transformation agenda; and thirdly, because research evidence suggests that South Africans are generally willing to contribute to a financing system that caters for them and those unable to contribute.’ If NHI can overcome the inefficiencies of the private sector with its failing medical aid funding arrangement, and if it can address the quality-of-service issues of the public sector, it will indeed be a winning formula.