Over the past 15 years, performance-based financing has been implemented in an increasing number of developing countries, particularly in Africa, as a means of improving health worker performance. Scaling up to national implementation in Burundi and Rwanda has encouraged proponents of performance-based financing to view it as more than a financing mechanism, but increasingly as a strategic tool to reform the health sector. The authors of this study argue that results-based and economically driven interventions do not, on their own, adequately respond to patient and community needs, upon which health system reform should be based. They argue that the debate surrounding performance-based financing is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the performance-based financing package.
Resource allocation and health financing
Developing countries reliant on aid want to escape this dependence, and yet they appear unable to do so. This book shows how they may liberate themselves from the aid that pretends to be developmental but is not. The author cautions countries of the South against falling into the aid trap and endorsing the collective colonialism of the OECD – the club of rich ‘donor’ countries. An exit strategy from aid dependence requires a radical shift in both the mindset and the development strategy of countries dependent on aid, and a deeper and direct involvement of people in their own development. It also requires a radical restructuring of the global institutional aid architecture. The author explains how ‘aid’ is an instrument of imperialism's strategy of domination, which he strongly contrasts with proposals for another form of aid, one rooted in the principles of international and anti-imperialist solidarity.
South Africa’s National Health Insurance (NHI) scheme is due to be piloted in April 2012. The purpose of this Green Paper is to outline the broad policy proposals for the implementation of NHI. The document is published for public comment and engagement on the broad principles. The NHI will offer all South Africans and legal residents access to a defined package of comprehensive health services. The state is committed to offering as wide a range of services as possible. Although the NHI service package will not include anything and everything, it will offer care at all levels, from primary health care, to specialised secondary care, and highly specialised tertiary and quaternary levels of care. After the consultation process the policy document or White Paper will be finalised. Thereafter draft legislation will be developed and published for public engagement. After public engagement the legislation will be finalised and submitted to Parliament for consideration. After Parliamentary approval, the Bill has to be approved by the President of the Republic. The first five years of NHI will include pilot studies and strengthening the health system in the following areas: management of health facilities and health districts; quality improvement; infrastructure development; medical devices including equipment; human resources planning, development and management; information management and systems support; and the establishment of an NHI Fund.
The authors of this short opinion piece argue that the current debate on performace-based financing (PBF) is misdirected, as external funders try to prove the effectiveness of their contribution by isolating it as the main reason for success while their opponents attempt to prove that another factor is actually the cause of an observed change. Instead, the authors call for comprehensive evaluation of PBF as part of complete health system reform. To respond to some of these key questions, health systems should be analysed using a complex adaptive systems lens. Health system ‘behaviour’ and particularly counterintuitive behaviour (unexpected changes or lack of change) can be analysed using a complex adaptive systems lens when PBF is introduced, often with a mix of other interventions such as in a context of system reform. The purpose of this analysis is not to isolate causal factors but rather to identify ‘macro’ characteristics of the system that may explain behaviour change.
This article was written as Zambia went to the polls in September 2011. The author evaluated the impact of the government’s policy to abolish user fees over the past five years. When the Zambian President announced the policy change in January 2006, only three months were allocated for planning and communication, and this he notes resulted in understaffing and a lack of resources including drugs. Measures were not taken to reduce the risk of drug stock-outs and in the first year 60% of essential drugs were unavailable. Many health facilities experienced a loss of income, as compensation for lack of income from user fees was delayed by months. Between 2004 and 2006 there was a large reduction in district non-wage and district drug expenditure (down by 13% and 34% respectively). Overall, quality of health care suffered and patients faced longer waiting times, fewer drugs, and overworked staff. The author argues that, despite the significant shortcomings of the current system, canceling free health care is not an option in a poor country like Zambia. He urges that the issues identified in the evaluation be urgently addressed by the Government of Zambia with aligned support from development partners.
Before free care for pregnant women and children was introduced in Sierra Leone, 88% of citizens said that their inability to pay was by far the greatest barrier to accessing care when sick. Just 12 months after the introduction of free care, medical care for children under five has increased by 214% and the proportion of children getting approved treatment for diagnosed malaria increased from 51% to 90%. Forty-five percent more pregnant women are delivering in formal clinics and hospitals and the number of delivery complications treated in health units increased 150%, while fatality rate in these cases fell by 61%. Success was achieved, the author of this article argues, through a high level of political commitment and leadership from the President of Sierra Leone and key staff within the Ministry of Health, as well as health worker reform including the elimination of 850 ghost workers from the payroll and salary increases of at least 100% for all staff. Over 1,000 additional workers were hired, facilities were upgraded and major resources and effort went into sorting out the key issue of medicines supply. Countries that want to implement free health care shouldn’t have to wait for external funders to get their house in order, the author concludes – like Sierra Leone, they should kick start progressive policies in the interests of their citizens that external funders will be forced to follow.
The authors of this paper suggest that the debate around performance-based financing (PBF) has become polarised, and argue for a more balanced approach. PBF is not a panacea and the provision of inputs, provider training, supervision and health-system strengthening should continue with the aim of producing results. A research agenda and an effective community of practice embracing all views on PBF is critical to understanding more about its potential for helping developing countries to reach some of the United Nations Millennium Development Goals.
Dependency on aid (external funding) among 54 of the world’s poorest countries has declined by a third over the last decade, according to this new report from ActionAid. The number of low income countries (LICs) receiving external funding equivalent to 30% of government expenditure or more has reduced from 42 to 30 in the past decade. In Zambia, for instance, external funding has fallen from 84% of government expenditure to just 44%. ActionAid notes the apparent paradox that while external funding has increased globally, dependence on the funding has reduced because of strong economic growth. Allied to growth is a new-found determination among poor countries to end 30 or more years of dependence on funding that has seldom delivered the kind of development for which they had hoped. Some of the poorest countries in the world, including Ghana, Rwanda, and Uganda, have set reducing this type of dependence as a key medium-term goal in their national development or aid-management policies. Reliance on external funding in Ghana has reduced from 46% to 27%, Mozambique from 74% to 58% and Rwanda from 86% to 45%.
The financial sector is traditionally under-taxed relative to the rest of the economy, so it is ideally suited as a source of taxes that can be used for global health, according to this brief. Taxes on the sector are also predominantly progressive, falling on the richest institutions and individuals. Harm Reduction International (HRI) proposes a financial transaction tax (FTT) that collects a tiny percentage (between 0.5% and 0.005%) of the value of each financial product that is traded. An average tax of just 0.05% on transactions (such as bond and share sales) could raise as much as US$409 billion a year, HRI notes, significant funding for disease responses and health system strengthening in poorer countries. HRI cautions that the FTT would be in addition to - not instead of - government commitments to overseas development assistance, so it could help bridge the resource gap that currently exists to achieve the Millennium Development Goals.
Low-income countries bear over 60% of the HIV disease burden, but ActionAid argue that their total annual resources for HIV went down from 2009 to 2010. This raises a gap between resources available and needed. To close this gap by 2015, UNAIDS estimate that the international community needs to raise an additional US$6 billion annually, with a parallel increase in commitments for the period 2011-2020. Proposed potential sources of funding include innovative financing mechanisms, indirect taxation (airline tickets, mobile phone usage, exchange rate transactions), front-loading mechanisms (IFF-Im) and advance market commitments. The author urges pharmaceutical companies to enter into negotiations with the Patented Medicines Pool and to ensure that the geographic scope of these licensing agreements includes low- and middle-income countries.