Resource allocation and health financing

Access for the poor and powerless: How changes to health funding have influenced church health service provision in low- and middle-income countries
Ascroft J, Semos I and Macintyre A: University of Melbourne, June 2013

The authors of this study conducted a review of the international literature on funding issues faced by church- and faith-based service providers in Africa and in Papua New Guinea. They found that funding constraints have been overcome in some cases through greater collaboration between government and church health providers, through the restructuring of user fees to minimise the impact on the poor and through more streamlined and transparent financial reporting. However, failure to fully implement agreed government funding to church health services can cause facility closures and reduced treatments, driving up costs for government and increasing the burden on public provision. The authors also report mixed findings as to whether greater engagement by church health services with government has translated into broader participation in policy formulation, as well as of implementation of community-based health insurance schemes and micro-insurance. Funding constraints influenced the retention of skilled staff by church health services, as workers move from church-managed, rural and remote facilities to public facilities in urban centres.

Access to antiretroviral therapy in resource-poor settings

Of the 40 million people that are infected with HIV globally, approximately 95% live in severely resource-constrained settings. From a humanitarian perspective alone, not bringing antiretroviral therapy to those in need implies accepting a number of casualties that is difficult to imagine and impossible to accept. But there is another important argument to take up the challenge: HIV/AIDS mainly affects adults in their productive prime, leaving the very young and old to cope alone. This severely hampers economic growth and development of countries concerned. There is little doubt that poverty facilitates the spread of HIV/AIDS, but conversely HIV/AIDS perpetuates poverty. Generalizing HIV/AIDS into a problem of poverty will paralyze an effective and specific response to it, and conflicts with the "art of the soluble" principle that we should adhere to.

ACCESS TO HIV PREVENTION: CLOSING THE GAP

This report authored by the Global HIV Prevention Working Group assesses the shortfall in access to HIV prevention services worldwide, detailing the specific shortfall in the regions of Sub-Saharan Africa, Asia and the Pacific, Eastern Europe and Central Asia, and North Africa and the Middle East. It discusses regional prevention priorities for each and identifies funding gaps. The document calls for the scale up of treatment and care programs, in coordination with prevention work. The authors finally call on political leaders, both nationally and in donor countries, to increase their commitment to effective prevention programmes.

Access to sexual and reproductive health commodities in East and Southern Africa: a cross-country comparison of availability, affordability and stock-outs in Kenya, Tanzania, Uganda and Zambia
Ooms G; Kibira D; Reed T; van den Ham H; et al: BMC Public Health 20(1053) doi: https://doi.org/10.1186/s12889-020-09155-w, 2020

Price, availability and stock-out data was collected in July 2019 for over fifty lowest-priced sexual and reproductive health (SRH) commodities from public, private and private not-for-profit health facilities in Kenya, Tanzania, Uganda and Zambia. Affordability was calculated using the wage of a lowest-paid government worker. Accessibility was illustrated by combining the availability and affordability measures. Overall availability of SRHC was low at less than 50% in all sectors, areas and countries, with highest mean availability found in Kenyan public facilities. Stock-outs were common; the average number of stock-out days per month ranged from 3 days in Kenya’s private and private not-for-profit sectors, to 12 days in Zambia’s public sector. In the public sectors of Kenya, Uganda and Zambia, as well as in Zambia’s private not-for-profit sector, all were free for the patient. In the other sectors unaffordability ranged from 2 to 9 SRH commodities being unaffordable. Accessibility was low across the countries, with Kenya’s and Zambia’s public sectors having six SRH commodities that met the accessibility threshold, while the private sector of Uganda had only one meeting the threshold. Accessibility of SRH commodities remains a challenge. Low availability in the public sector is compounded by regular stock-outs, forcing patients to seek care in other sectors where there are availability and affordability challenges. The authors propose that the findings be used by national governments to identify the gaps and shortcomings in their supply chains.

Accountability for reasonableness framework could improve transparency and effectiveness of Global Fund projects
Kapiriri L, Martin D: Bulletin of the World Health Organization (WHO): the International Journal of Public Health, 2006

This article argues that the suspension of funding to Uganda from the Global Fund could have been avoided. The article outlines how the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) suspended five grants to Uganda following an audit report that exposed gross mismanagement in the Project Management Unit. The authors argue that this could have been avoided if a legitimate and fair decision-making process was used and that this lesson should be applied to other countries.

Achieving a shared goal: Free universal health care in Ghana
Oxfam: March 2011

According to this report by Oxfam, coverage of the National Health Insurance Scheme (NHIS) in Ghana could be as low as 18%. Every Ghanaian citizen pays for the NHIS through Value added Tax (VAT), but as many as 82% remain excluded. They report that 64$ of people in the highest wealth quintile are signed up to the NHIS, compared with 29% of the lowest wealth quintile. Those excluded from the NHIS still pay user fees. They report that the administration of health insurance costs US$83 million each year, enough to pay for 23,000 more nurses. They propose that improved progressive taxation of Ghana’s own resources, especially oil, could increase spending to US$54 per capita, by 2015.

Achieving a shared goal: Free universal health care in Ghana
Oxfam: 2011

According to this report, coverage of Ghana's National Health Insurance Scheme (NHIS) has been exaggerated and could be as low as 18% - less than a third of the coverage suggested by Ghana’s National Health Insurance Authority and the World Bank. Every Ghanaian citizen pays for the NHIS through VAT, but as many as 82% remain excluded. Twice as many rich people are signed up to the NHIS as poor people. Those excluded from the NHIS still pay user fees in the cash and carry system. Twenty five years after fees for health were introduced by the World Bank, they are still excluding millions of citizens from the health care they need. An estimated 36% of health spending is wasted due to inefficiencies and poor investment. Moving away from a health insurance administration alone could save US$83 million each year, Oxfam argues, which is enough to pay for 23,000 more nurses. Oxfam calls on the Ghanaian government to move fast to implement free health care for all its citizens.

Activists Criticize Global Fund Director's Statements Regarding Fund's Financial Health

Some activists have already called for the resignation of Richard Feachem, even though he has not yet signed a contract to become the first director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Boston Globe reports. Feachem, the founding director of the Institute for Global Health at the University of California-San Francisco, was named as the fund's first director in April by the fund's board but has come "under fire" from some activists because of comments regarding the amount of money in the fund. According to comments that first appeared in the Memphis Commercial Appeal, Feachem said that the fund had "plenty" of money to get started. Northeastern University law professor Brook Baker and Gorik Ooms, head of Medicins Sans Frontieres in Tanzania, last week in an e-mail demanded that Feachem step down from his prospective position unless he "distanced himself" from his comments. Baker said that Feachem, as the head of the "grotesquely underfunded" fund, should be "a drum major who is marching at the head of the pack and demanding the money" and should not be "making 'nice nice' with politicians in the hope that they will become more forthcoming in the future." Feachem, who could "as early as today" sign a $200,000 annual tax-free contract to become the fund's first director, responded to both Baker and Ooms by e-mail, saying that he "understood ... the activists' frustration" and acknowledging that the fund "needed much more money."

Adapting global health aid in the face of climate change
Gupta V, Mason-Sharma A, Caty S, KerryV: Lancet Global health Volume 5, No. 2, e133–e134, 2017

WHO estimates an additional 250 000 mortalities between 2030 and 2050 will be attributable to climate-associated increases in malnutrition, malaria, diarrhoea, respiratory disease, water inaccessibility, and heat stress. Spillover effects on state and regional security are argued to be inevitable. The World Economic Forum has identified climate change as the single greatest threat to global stability because of its considerable consequences on the health and stability of developing nations. The complex interaction between climate change, health system burdens, and poor health outcomes, and their subsequent impact on politics, security, and society can be captured within the concept of a so-called climate-health-security nexus. Many of the world's poorest and most politically fragile nations lie at the centre of this nexus. Within this nexus, poverty, state fragility, poor pre-existing health outcomes, and high susceptibility to climate change converge to amplify the effects of future famines, droughts, and neglected tropical diseases. This amplification subsequently leads to worsened economies, social instability, and reliance on external support. The nations most at risk for climate-triggered health crises are primarily scattered throughout sub-Saharan Africa and south Asia and are already afflicted by the highest rates of disease burden globally (table, appendix). Notably, most of these countries are low-income nations without the resources to adequately contend with climate-related challenges.

Adding it up: The costs and benefits of investing in family planning and maternal and newborn health
Singh S, Darroch JE and Ashford LS: Alan Guttmacher Institute, 2010

This report indicates that family planning and maternal and newborn services fall well short of needs in developing countries, particularly in the world’s two poorest regions, South Asia and Sub-Saharan Africa. The authors argue that helping women and couples have healthy, wanted pregnancies in these regions will help achieve social and economic gains beyond the health sector. Several barriers to services were identified, such as weaknesses in health systems that need to be addressed, including insufficient capacity, weak contraceptive supply systems and poor financial management systems, as well as prejudice among providers toward unmarried, sexually active young people, or toward women who have had unsafe abortions. The authors suggest that the additional funds needed for improving services could come from a combination of domestic and international resources. Furthermore, decision makers need to recognise that changes outside the service environment (e.g. social changes) may improve demand for sexual and reproductive health care.

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