In this paper, the authors consider how best to promote financial protection and access to needed health care for those outside the formal employment sector through prepayment funding, with a particular focus on the African context. The authors reviewed literature on alternative domestic prepayment funding mechanisms in relation to the three dimensions of universal coverage: population coverage, service coverage and cost coverage. Key messages from their review are the challenges of contribution arrangements for this population, even where legal provisions make membership mandatory. The authors recommend that additional health financing arrangements to cover poor and vulnerable groups (e.g. tax funding and innovative financing approaches) are adequately explored in terms of the principles of fair financing. This should be done before countries move towards implementing contributory schemes for those outside the formal sector which, as indicated in this review, have limited capacity to offer adequate financial risk protection to their members.
Resource allocation and health financing
At the 2011 summit in Beijing, China, leaders of the BRICS countries (Brazil, India, China and South Africa) confirmed that public health is an essential element for social and economic development and should be reflected accordingly in national and international policies. Furthermore, they agreed to establish and encourage a global health agenda for universal access to affordable medicines and health commodities. However, achieving universal coverage will only be achieved if formal assessment becomes an acceptable key component, the author of this article argues. The BRICS development bank will require evidence of value for money to invest in health. The current approach asserts that health technology assessments have a major role in health services development. One criticism of this approach has been that an emphasis on efficiency means that equity and fairness are sacrificed. However, there are now initiatives in place that address these concerns, the author argues, and new approaches to value-based prioritisation are being developed to respond to concerns expressed about a health economic perspective, particularly by those advocating a rights-based approach.
Unless the concept is clearly understood, universal health coverage (UHC) can be used to justify practically any health financing reform or scheme, says the author of this paper. He unpacks the definition of health financing for universal coverage as used in the World Health Organisation’s World Health Report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. For health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed at improving coverage, financial protection, efficiency, equity in health resource distribution, transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level, the author concludes.
This report is the first ever to track what developing countries are spending on the Millennium Development Goals (MDGs), finding that recent spending increases explain the rapid progress on the MDGs. But the vast majority of countries are spending much less than they have promised, or than is needed. Aid cuts, low implementation rates and low recurrent spending all threaten to reverse existing progress. This Government Spending Watch report suggests that developing countries need to make data on MDG spending more accessible to their citizens; to strengthen policies for revenue mobilisation (notably combating tax avoidance and tax havens), debt and aid management; and to spend more on agriculture, water, sanitation and hygiene, and social protection. External funders need to report and repatriate illicit outflows; end laws and investment treaties which reduce poor countries’ revenues; increase innovative financing such as financial transaction and carbon taxes; put more aid through developing country budgets; maximise budget and sector support to make spending more accountable; and report planned disbursements to developing countries. The International Monetary Fund also needs to sharply increase space for sustainable spending in its programmes.
As Uganda’s government programming is so dependent on external funding (aid), recent funding cuts will be felt across nearly every sector, says the author of this article. The withdrawal of external funding is affecting policy goals and work in agriculture and health and government salaries for teachers, health personnel and local administrators. The rehabilitation and integration of Northern Uganda, still struggling to recover following protracted conflict, and programmes in Karamoja region are likely to be affected. Shifting the burden to taxpayers for initiatives formerly funded by external funders is unlikely to be accepted unless issues of corruption and effective spending are addressed, argues the author. Regardless of whether government programmes are funded externally or from taxpayers, citizens seek greater transparency through consistent and open procedures in financial management.
The new consensus towards universal health care (UHC) suggests that an evidence-based approach to policy may finally be prevailing over an ideologically driven approach. While the new consensus shifting in favour of UHC is to be welcomed, the author argues that the international health community cannot dismiss the unnecessary suffering and harm caused by the reckless adoption of ideologically driven user fees policies over the last 30 years. It is incumbent on the international health community to reflect and take stock of what went so badly wrong that led to the widespread application of user fees in the world’s poorest countries and take steps to determine accountability for those responsible. The past victims of user fees must have their voices heard and all potential avenues for compensation must be fully pursued, as their right to health was violated for so long. More broadly, the current lack of accountability and liability in the economics profession should be of concern to the international health community as it increasingly relies on the advice and direction of health economists.
Since 2008 there has been much debate about where agencies, NGOs, programmes and countries might turn to for sustainable funding. One thing is very clear, says the author of this blog: Global Health, including HIV, no longer enjoys the same enthusiasm it once did. The relative ease of garnering financing for malaria bed nets or innovations in drug distribution that NGOs and agencies experienced in 2005 has yielded to tough slogging for basic financing in 2013. For ministries of health and country-based health programmes this shift ushers need to look to domestic sources for support. South Africa is the first significant aid recipient to set a goal for complete health self-reliance, and actually meet most of its targets en route. Combined with a package of new taxes on everything from cell phone use to plane flights, alcohol and tobacco levies could garner African countries an additional $15.5 billion. Two obstacles obviously stand in the way, according to the author: The political will for governments to implement what undoubtedly would be unpopular use taxes, and the monumental fights within government over allocation of those revenues. Just because a country gleans a fresh $1 billion from such taxes by no means assures the government will allocate most, or even any of it, to health programmes.
In this speech to the World Health Assembly, World Bank Group President Jim Yong Kim outlines five specific ways the World Bank Group will support countries in their drive towards universal health coverage. First, he pledges the bank will continue to ramp up its analytic work and support for health systems. Second, he highlights the World Bank’s commitment to support countries in an all-out effort to reach Millennium Development Goals 4 and 5, on maternal mortality and child mortality. The third commitment is that, with the World Health Organisation and other partners, the World Bank Group will strengthen its measurement work in areas relevant to universal health coverage. Fourth, the Bank will deepen its work on what is called ‘the science of delivery’, a new field that the World Bank Group is helping to shape, in response to country demand. Fifth and finally, the World Bank Group will continue to step up its work on improving health through action in other sectors, such as agriculture, clean energy, education, sanitation, and women’s empowerment. Kim argues that the fragmentation of global health action has led to inefficiencies: parallel delivery structures; multiplication of monitoring systems and reporting demands; and ministry officials who spend a quarter of their time managing requests from misguided international partners. He calls for integrated management of health issues facing the world today.
The 2005 Paris Declaration on Aid Effectiveness sets targets for increased use by external funders (donors) of recipient country systems for managing aid. This study investigates the degree to which external funders ' use of country systems is in fact positively related to their quality, using indicators explicitly endorsed for this purpose by the Paris Declaration and covering the 2005-2010 period. The author shows that external funders
appear to have modified their aid practices in ways that build rather than undermine administrative capacity and accountability in recipient country governments.
The Global Fund to Fight AIDS, Tuberculosis and Malaria announced a goal of raising US$15 billion so that it can effectively support countries in fighting these three infectious diseases in the 2014-2016 period. The Fund aims to help turn these three high-transmission epidemics into low-level endemics, essentially making them manageable health problems instead of global emergencies. It said that together with other funding, including an estimated US$37 billion from domestic sources in implementing countries and US$24 billion from other international sources, a US$15 billion contribution would allow the Fund to address close to 90% of the global resource needs to fight these three diseases, estimated at a total of US$87 billion. This aggregate level of funding would mean that 17 million patients with tuberculosis and with multidrug-resistant tuberculosis could receive treatment, saving almost 6 million lives over this three-year period.