Microfinance among people living with HIV and AIDS (PLWHAs) faces some opposition and remains understudied. This literature review examines microfinance’s evolution and impact on a variety of social and health indicators and its emerging implementation as a primary prevention tool for HIV and economic intervention for PLWHAs. There is an abundance of literature supporting the apparent utility of microfinance. However the author argues that understanding of the subject remains clouded by the heterogeneity and methodological limitations of existing impact studies, the still limited access to microfinance in this population and inadequate understanding of the specific challenges posed by the socioeconomic and health issues of PLWHA. The author concludes that carefully designed studies are needed to assess the role of microfinance for PLWHA.
Resource allocation and health financing
In its annual World Health Report, the World Health Organization (WHO) shows how all countries, rich and poor, can adjust their health financing mechanisms so more people get the health care they need. It highlights three key areas where change can happen – raising more funds for health, raising money more fairly, and spending it more efficiently. WHO says that in many cases, governments can allocate more money for health. In 2000, African heads of State committed to spend 15% of government funds on health, a goal that three countries – Liberia, Rwanda and Tanzania – have already achieved. If the governments of the world’s 49 poorest countries each allocated 15% of state spending to health, they could raise an additional $15 billion per year – almost doubling the funds available, notes the report. Countries can also generate more money for health through more efficient tax collection, and find new sources of tax revenue, such as sales taxes and currency transactions. A review of 22 low-income countries shows that they could between them raise $1.42 billion through a 50% increase in tobacco tax. The report also cites the role of the international community, noting that most donors still need to allocate 0.7% gross domestic product (GDP) to official development assistance. Smarter spending could also boost global health coverage anywhere between 20-40%, the report points out, highlighting 10 areas where greater efficiencies are possible, including the use of generic drugs wherever possible – a strategy that saved almost US$2 billion in 2008.
What is the relevance of the aid commitments embodied in the Paris Declaration on Aid Effectiveness (2005) and the Accra Agenda for Action (2008) to development actors in South-South co-operation? While research on South-South co-operation is increasing, this article notes that it appears to be largely focused on financial flows or on a limited number of emerging economies, but not on the experiences of practitioners of South-South (SS) co-operation themselves. The article offers two reasons why aid matters for SS partners. First, aid effectiveness is important for partner countries. The effectiveness commitments embodied in the Paris Declaration and the Accra Agenda for Action have failed to promote behavior change, for example, in increasing the use of country systems and in making aid more predictable. One possible solution is the internationally recognised Survey on Monitoring the Paris Declaration, which tracks the implementation of the Paris commitments. Second, development actors need to go beyond the conventional ‘donor-recipient’ relationship, especially as the development co-operation architecture is becoming more diversified and complex. The Accra Agenda for Action in 2008 opened the door to encourage an inclusive and effective development partnership with civil society, parliamentarians, private sector, providers of South-South co-operation, foundations and global programmes. More actors are taking ownership of the aid effectiveness agenda by shaping it with their own views and experiences. One such example is the Dili Declaration (April 2010), in which a group of fragile states, including the Democratic Republic of Congo, have adapted aid effectiveness principles to their situations of national conflict and fragility.
This report aims to call health leaders’ attention to the importance and feasibility of establishing the systems and institutions needed to pursue universal health coverage (UHC). It also seeks to quantify the transition costs associated with reforming a health system away from one that relies on out-of-pocket payments and towards one in which health expenditures are more evenly distributed and that can supply UHC. Although models for UHC vary by country, governments are re-organising national health systems to share health costs more equitably across the population and its life cycle, instead of concentrating the burden on the few who face catastrophic illness in any given year. Using examples from four countries that have made tremendous strides toward achieving universal coverage, including Rwanda, the report puts an approximate price tag on these investments. It concludes that relatively small early investments can set countries on the path toward UHC.
Many of the 68 priority countries in the Countdown to 2015 Initiative are dependent on official development assistance (ODA). This study analysed aid flows for maternal, newborn, and child health for 2007 and 2008 and updated previous estimates for 2003—06. It found that, in 2007 and 2008, US$4.7 billion and $5.4 billion, respectively, were disbursed in support of maternal, newborn and child health activities in all developing countries, reflecting a 105% increase between 2003 and 2008, but no change relative to overall ODA for health. Targeting of ODA to countries with high rates of maternal and child mortality improved over the six-year period, although some of these countries persistently received far less ODA per head than did countries with much lower mortality rates and higher income levels. Funding from the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria exceeded core funding from multilateral institutions, and bilateral funding also increased substantially between 2003 and 2008, especially from the United States and the United Kingdom. However, the authors caution that these increases do not reflect increased prioritisation relative to other health areas.
This study found that international financing for malaria control has increased by 166% (from $0.73 billion to $1.94 billion) since 2007 and is broadly consistent with biological needs. African countries have become major recipients of external assistance, but countries where malaria continues to pose threats to control ambitions are not as well funded. Twenty-one countries have reached adequate assistance to provide a comprehensive suite of interventions by 2009, including twelve countries in Africa. However, this assistance was inadequate for 50 countries, representing 61% of the worldwide population at risk of malaria - including ten countries in Africa and five in Asia that co-incidentally are some of the world’s poorest countries. Approval of external funding for malaria control does not correlate with gross domestic product, the study found. In conclusion, funding for malaria control worldwide is 60% lower than the US$4.9 billion needed for comprehensive control in 2010. This includes funding shortfalls for a wide range of countries with different numbers of people at risk and different levels of domestic income. More efficient targeting of financial resources against biological need and national income should create a more equitable investment portfolio that with increased commitments will guarantee sustained financing of control in countries most at risk and least able to support themselves.
In this report, the World Health Organization maps out what countries can do to modify their financing systems so they can move more quickly towards the goal of universal health coverage and sustain the gains that have been achieved. The report builds on new research and lessons learnt from country experience. It provides an action agenda for countries at all stages of development and proposes ways that the international community can better support efforts in low income countries to achieve universal coverage and improve health outcomes. To ensure universal coverage, countries must raise sufficient funds, reduce the reliance on direct payments to finance services, and improve efficiency and equity. The report proposes three ways for governments to raise money: increase the efficiency of revenue collection, re-prioritise government budgets and put innovative financing mechanisms in place.
The deputy speaker of Uganda’s Parliament, Rebecca Kadaga, has accused finance ministers in Africa of being insensitive by failing to prioritise the health sector during allocation of funds. She accused finance ministers of being unaware of the realities of everyday health care. She recommended that the ministers should be invited to conferences like the regional meeting of the Southern and Eastern Africa Parliamentary Alliance of Committees on Health near Kampala, where she was speaking. Kadaga said Uganda had registered progress in various sectors of development, including education, women’s empowerment and HIV and AIDS, but women and infant health had lagged behind. She attributed this to the country’s ‘weak health system, as well as inadequate human resources for health, especially reproductive health’. The reproductive health and family planning services, Kadaga said, remain mainly urban-based yet most women live in rural areas. Kadaga also decried the high population growth rate in Africa, saying it was a major challenge to the Governments' efforts to reduce poverty.
Direct facility funding (DFF) links facility funding levels to general indicators of facility size and workload rather than specific output targets. To reduce user fees, DFF was piloted in Coast Province, Kenya, with health facility committees (HFCs) responsible for managing the funds. This study evaluated the implementation and perceived impact 2.5 years after DFF introduction. Quantitative data collection at 30 public health centres and dispensaries included a structured interview with the staff member in-charge, record reviews and exit interviews. In-depth interviews were also conducted with the in-charge and HFC members at 12 facilities, and with district staff and other stakeholders. DFF procedures were well established and it made an important contribution to facility cash income, accounting for 47% in health centres and 62% in dispensaries. DFF was perceived to have a highly positive impact through funding support staff such as cleaners and patient attendants, outreach activities, renovations, patient referrals and increasing HFC activity. A number of problems were identified, such as inadequate HFC training, and lack of DFF documentation at facility level. Charging user fees above those specified in the national policy remained common, and understanding of DFF among the broader community was very limited. The study concludes that relatively small increases in funding may significantly affect facility performance when the funds are managed at the periphery. Kenya plans to scale up DFF nationwide and the authors indicate this is warranted, but should include improved training and documentation, greater emphasis on community engagement, and insistence on user fee adherence.
Overall, this paper found that health care in South Africa is very ‘pro-rich’, with the richest 20% of the population receiving 36% of total benefits (despite having a ‘health need share’ of less than 10%) while the poorest 20% receive only 12.5% of the benefits (despite having a ‘health need share’ of more than 25%). The findings indicate that there is a lack of cross-subsidies in the overall health system in South Africa. Although health care financing is ‘progressive’, this is largely due to the richest groups bearing the burden of medical scheme funding. However, the richest groups are the exclusive beneficiaries of these funds. The study shows that benefit incidence in South Africa is inequitable and notes that, in terms of a solution, the only component of the current South African health system that could contribute to overall income and risk cross-subsidies is tax funding. However, the strongly progressive component of personal income tax is to some extent offset by the regressivity of excise taxes and fuel levies and the proportional impact of VAT. In the context of the degree of income inequalities that exist in South Africa, the paper calls for a move to a health system where South Africans contribute according to ability-to-pay and benefit according to need for health care.