Despite the strengths of microfinance, this article argues that it has thus far been largely inaccessible to the absolute poorest communities. The poorest communities continue to depend on public spending and external funding, unable to benefit from microcredit or microsavings because of an absolute lack of capital. Microfinance may alleviate some financial burden on the public sector by providing coverage for some of these people, but its ability to provide for extremely poor people remains to be seen. The article calls on international organisations such as the World Health Organization and the World Bank to continue to make microfinance for health a consideration in technical advice given to governments on health-care financing and social protection. They should also fund systematic, evaluative research so that science can back up what seems to be a logical and useful approach to health-care financing for the poor, particularly as it emphasises prevention and health promotion. The large-scale delivery of these tools will depend on repeated local adoption that must grow from communication of demonstrated success and advice on implementation of effective models. The article concludes that we already have enough knowledge to recognise that microfinance is an important tool in protecting health and that what is required now is further action.
Resource allocation and health financing
Southern African countries have some of the world's worst income distribution, but can often afford social transfers, which have proved an efficient means of reducing the number of poor, according to regional experts. They say that funds can always be found by governments that have the political will to generate and dedicate money to social transfer schemes. Social transfers cover the various forms of social assistance for low-income or no-income individuals and households, and can include child support grants, non-contributory pensions, school feeding schemes, and agricultural or other inputs. In South Africa, social transfers like old-age pensions, and the child support grants introduced in the early 1990s, have managed to improve the lot of at least 47% of people living on less than US$2 a day, according to this article. Six countries in Southern Africa - Botswana, Lesotho, Mauritius, Namibia, South Africa and Swaziland - provide non-contributory social pensions modelled on European social welfare policies. Mozambique, Malawi and Zambia, among others, are experimenting with some cash transfer programmes.
The United States (US) President's Emergency Plan for AIDS Relief (PEPFAR) has boosted its assistance to Uganda's AIDS programme with an emergency supply of antiretroviral (ARV) drugs worth more than US$5.5 million - enough to put an estimated 72,000 HIV-infected people on the treatment over the next two years. But it has also served notice that Uganda must find new sources of funding if its HIV programmes are to be sustainable. The drugs are expected to help bridge the gap in the availability of ARV drugs in Uganda and prevent stock-outs and are included as part of an increase in funding recently announced by PEPFAR, following appeals from Ugandan AIDS activists and health providers struggling to put patients on ARVs. Uganda is the biggest recipient of PEPFAR funds.
The Africa Public Health Alliance & 15% Plus Campaign has welcomed the laudable decisions by the July 2010 African Union Heads of State Summit on various health policies and budget commitments, especially the restatement of the 2001 Abuja commitment to allocate at least 15% of annual budgets to health. The Alliance has identified six key areas requiring improvement. 1. More investment is needed in immunisation, in social determinants of health, in integrated health services and population and social development as this is crucial to reducing child mortality and improving healthy life expectancy. 2. The absolute level of per capita investment in health is as important as percentage allocation and should be increased to above at least $38 per capita. 3. Integrated health, education and labour policies are crucial to resolving health workforce shortages – and meeting all health Millennium Development Goals. 4. Ensuring gender equity in health budgeting is crucial, especially regarding adolescent and youth health. 5. The capacity for production, purchase and distribution of pharmaceuticals, essential medicines and commodities must be improved to prevent stock outs. 6. There should be at least one well-staffed and properly equipped primary health care clinic per community.
At the close of the African Union (AU) Heads of State Summit, health experts and activists from across Africa expressed grave concern that leaders are not delivering on fundamental commitments to expand investments in maternal and child health and other life-saving health services, including treatment and prevention for HIV, tuberculosis and malaria. Although the AU Summit asserted that universal access to quality healthcare is a human right, the advocates expressed disappointment at the overall outcome – particularly regarding mobilising additional resources needed to save lives and advance maternal and child health. For example, the Declaration on Maternal and Child Health has committed AU Members to ‘enhancing domestic resources’ but not to a concrete, time bound increase in domestic investment in health. Activists also challenged donor governments to keep their health funding promises, including the commitment to scale up investments in order to reach universal access to HIV treatment and prevention.
At the end of their meeting on 27 July 2010 in Kampala, Uganda, members of the African Union (AU) reaffirmed that they would strive to spend 15% of their national budgets on health, but health experts like Chikezie Anyanwu, Africa Advocacy Advisor to Save the Children, which works to promote children's rights, were unsure of how effectively the money would be spent. According to him, countries could spend more than 15% and still show no real reduction in the deaths of children younger than five, or among women during or after childbirth, as specified in the Millennium Development Goals (MDGs) set by the United Nations. Rwanda, Liberia and Tanzania are the only three African countries devoting more than 15% of their national spending on health, said Anyanwu, citing a 2010 World Health Organization (WHO) report, based on data from 2007. But they have made insufficient progress in meeting MDGs 4 and 5, which aim to reduce maternal and child mortality. In South Africa, one of the most developed and richest countries in the continent, the infant mortality rate has escalated and the country will probably not achieve the MDG target by the deadline of 2015.
Despite the enormous progress that has been made over the past decade, there are still huge gaps and deficiencies in national plans, budgets, and expenditure tracking systems, according to this paper. Few countries have developed detailed cost estimates of their national strategic plans. All too often, they do not specify how limited resources will be allocated, nor how priorities will be set if they are unable to achieve their goals. The paper argues that, even if AIDS costs are almost certain to rise between now and 2031, the cost trajectory can be significantly influenced by our actions today. Policy choices have different price tags – ranging from $397 billion to $722 billion over the 22-year period. Reducing costs will demand stronger political will and AIDS financing capacity, but the potential payoff in making the right choices is great, leading to fewer infections and more lives saved. Governments and development partners could be much more effective in the AIDS activities they back, and more financially efficient, if they focused resources on prevention programmes that are more closely aligned with specific epidemics. The paper also argues that showing that money for AIDS can be used more efficiently and to achieve greater benefits will also help to maintain political support and enthusiasm for the large-scale efforts that will need to be sustained for decades to come. These steps will require global creativity, national and international leadership, and improved policies and programmes.
Community home-based care is the Botswana Government's preferred means of providing care for people living with HIV. However, according to this study, primary (family members) or volunteer (community members) caregivers experience poverty, are socially isolated, endure stigma and psychological distress, and lack basic care-giving education. Community home-based care also imposes considerable costs on patients, their caregivers and families in terms of time, effort and commitment. The study estimated the cost incurred in providing care for people living with HIV through a stratified sample of 169 primary and volunteer caregivers drawn from eight community home-based care groups in four health districts in Botswana. The results show that the mean of the total monthly cost (explicit and indirect costs) incurred by the caregivers was US$ 90.45, while the mean explicit cost of care giving was $65.22. This mean of the total monthly cost is about one and a half times the caregivers' mean monthly income of $66.00 and more than six times the Government of Botswana's financial support to the caregivers. In addition, the cost incurred per visit by the caregivers was $15.26, while the total expenditure incurred per client or family in a month was $184.17. The study concludes that, as the cost of providing care services to people living with HIV is very high, the government of Botswana should substantially increase the allowances paid to caregivers and the support it provides for the families of the clients. The overall costs for such a programme would be quite low compared with the huge sum of money budgeted each year for health care and for HIV and AIDS.
This report provides the latest data available on donor funding based on data provided by governments. The year 2009’s totals reflect a substantial increase in funding provided by the United States (rising from US$3.95 billion in 2008 to $4.4 billion in 2009), which helped to offset reductions in support from Canada, France, Germany, Ireland, Italy, and the Netherlands. According to the report, the United States remains the largest donor nation in the world, accounting for more than half (58%) of 2009 disbursements, followed by United Kingdom (10.2%), Germany (5.2%), the Netherlands (5%) and France (4.4%). UNAIDS estimates that $23.6 billion was needed to address the epidemic in low- and middle- income countries in 2009, which suggests a growing gap of $7.7 billion between available resources and need. In 2009, donor governments disbursed $5.9 billion bilaterally and earmarked funds for HIV through multilateral organisations, as well as an additional US$1.6 billion to combat HIV through the Global Fund to Fight AIDS, Tuberculosis and Malaria and US$123 million to UNITAID.
This report starts with a brief overview of the Paris/Accra approach to aid effectiveness and a definition of global funds and partnerships and their role in the overall aid architecture. It summarises strategies for allocating funds across countries, including challenge funds and results-based aid, as well as specific model examples used by selected global funds and partnerships. It found that global funds, like external funders in general, seek to maximise the impact of their assistance and use a variety of allocation mechanisms to ration their funds. Overall, country sub-sectoral support can vary in modality (including sectoral budget support) and may make use of indicative country allocations based on need and performance. The difference between the approaches of global funds and of Paris/Accra ‘horizontal’ aid is not whether they seek to achieve results. Instead, the differences lie in how the fund allocation strategies are designed and implemented to achieve these results. A key issue for all approaches to linking finance to results is the relative emphasis between short- and medium- to longer-term results and between results per se and intermediate steps that bring them about. In this context, this report also emphasises three issues related to achieving medium- to long-term results: predictability, sustainability and capacity.