The district hospital has been considered a critical avenue for the delivery of child-saving interventions. It has been suggested that improving the performance of district hospitals would reduce child mortality by 3-30% in the areas they serve. It has however been
shown that the quality of care delivered in these hospitals in Kenya is inadequate. To improve the quality of care of children admitted in district hospitals in Kenya, the study developed clinical guidelines
in selected district hospitals. The guidelines were linked with health
worker training, job aids, follow-up and supervision and performance feedback termed the 'Emergency Triage and Treatment Plus (ETAT+) strategy. The strategy improved the quality of care of children admitted in hospitals by 25%. The total cost of scaling up the intervention was calculated at about US$ 3.6 million, estimated to be only 0.6% of the annual child health budget in Kenya. The ETAT+ strategy is argued to be cost-effective in improving the quality of care of children admitted in hospitals in Kenya.
Resource allocation and health financing
The global financial transaction tax (FTT) is a key proposal that civil society campaigned for at the G20 Cannes Summit, hosted in Cannes, France, from 3-4 November 2011. It has the potential to raise billions of dollars to support social justice goals – estimates of the amount that FTT could generate range from about US$50 billion to as much as $250 billion if a wide range of transactions are included. The author identifies seven global taxes that could be included as ‘further transactions’. 1. A tax of 5% on First and Business class air tickets already funds UNITAID, and raises US$200 million annually – if generalised, it could raise $8 billion globally. 2. A tax on polluting activities, amounting $20-25 for every ton of CO2 would raise $300 billion, while taxation of air and sea international transportation could raise US$40 billion. 3. An additional tax on top of national taxes on transnational societies would eliminate tax havens and would turn these companies into global tax payers, thereby raising $100 billion. 4. A tax on arm sales could garner US$30 billion a year. 5. A tax on capital profits could amount to US$50 billion if it was generalised, if it covered all tax havens and if it was controlled. 6. The tax on currency exchange transactions limited to a rate of 0.005%, and applied to principal currency exchange markets (US$, pound and yen) would generate at least US$33 billion – if increased to 0.1%, this tax would raise $150-300 billion, as well as becoming an efficient instrument against rampant speculation. 7. A tax of $0.05 on every pack of cigarettes in rich countries (and of $0.01 in poorest countries) would raise an additional $7.7 billion.
This paper presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana. Secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used, triangulated with data from the Ministry of Finance and other relevant sources, and further complemented with primary household data collected in six districts. Results showed that Ghana's health care financing system is generally progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes, which account for close to 50% of health care funding. The national health insurance (NHI) levy (part of VAT) is mildly progressive and formal sector NHI payroll deductions are also progressive. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are regressive form of health payment to households. For Ghana to attain adequate financial risk protection and ultimately achieve universal coverage, it needs to extend pre-payment cover to all in the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the National Health Insurance. Furthermore, the pre-payment funding pool for health care needs to grow so budgetary allocation to the health sector can be enhanced.
Tiered pricing - the concept of selling drugs and vaccines in developing countries at prices systematically lower than in industrialised countries - has received widespread global support as a way to improve access to medicines for the poor. Researchers in this study carried out case studies based on a review of international drug price developments for antiretrovirals, artemisinin combination therapies, drug-resistant tuberculosis medicines, liposomal amphotericin B (for visceral leishmaniasis), and pneumococcal vaccines. They found several critical shortcomings to tiered pricing: it is inferior to competition for achieving the lowest sustainable prices; it often involves arbitrary divisions between markets and/or countries, which can lead to very high prices for middle-income markets; and it leaves a disproportionate amount of decision-making power in the hands of sellers rather than consumers. In many developing countries, resources are often stretched so tight that affordability can only be approached by selling medicines at or near the cost of production. Policies that ‘de-link’ the financing of research and development from the price of medicines merit further attention, the authors argue, since they can reward innovation while exploiting robust competition in production to generate the lowest sustainable prices.
The advent of South Africa’s National Health Insurance (NHI) scheme opens up a political space to campaign for a health service that will best address South Africa’s health crisis and reduce the extreme inequities between poor and rich, rural and urban, and public sector and private health service users. The authors argue that such a campaign must counter powerful groups with vested interests who portray public systems as inefficient and second-best, and see the NHI as an opportunity to preserve a private health system (which is innately inequitable because of the need to profit from disease). They further argue that the NHI will not only render health care more accessible and equitable, but also create many more jobs and indirectly improve health by reducing the prevalence and depth of poverty. Rationalisation, standardisation and expansion of the skills of community-based care workers is urgently needed, as is improvement of their insecure employment conditions. The proposed ‘Re-engineering of Primary Health Care’ initiative puts forward a healthcare model that is similar to Brazil’s successful Family Health Programme, and would be substantially cheaper than the current private sector model, and more cost-effective than the current hospital-dominated public sector.
The financial transaction tax (FTT) proposed by France and Germany and due to be discussed in the November G20 Summit, could help save millions of lives if a percentage were allocated to global health, according to an issue brief released today by the international medical humanitarian organisation Medecins Sans Frontieres (MSF). MSF’s issue brief, Five Lives, outlines through five personal stories the transformative impact an FTT allocation to global health could have. The report looks at interventions that can prevent a child from becoming severely malnourished to begin with; protect children from deadly measles outbreaks; prevent a baby from acquiring HIV through childbirth; get people on life-saving tuberculosis treatment sooner; and save lives while dramatically reducing the spread of HIV through treatment. It is estimated the funds raised by an EU FTT could reach 55 billion euros per year. Even a portion of that sum would be a significant boost to tackling global health crises.
The question of how developing countries can improve domestic resource mobilisation (DRM) was one of the main topics under discussion at the latest International Tax Compact (ITC) meeting held from 12 to 14 September 2011 in Bonn, Switzerland. The communiqué identifies five main issues facing developing countries looking to improve DRM: taxation and public financial management; taxation and state-building; taxation for economic growth; extractive resource taxation; and international taxation. Although each of these has been the focus of research, the most interesting questions and issues appear to lie at the intersection of each of these, such as how to align public financial management reforms relating to tax with the objectives of promoting economic growth and state capacity. Many of the issues were touched upon during the ITC meeting, and the discussions highlighted the important research being conducted on both the nature of the challenges developing countries must overcome and the technical and governance aspects of tax reforms. Enhancing tax revenues is not an end in itself, participants emphasised, as taxation is at the centre of resilient state-society relations and must therefore be linked with governance efforts and public service delivery and should be undertaken ‘with an overarching view to make tax systems more pro-poor’.
On 12 September 2011, the European Union (EU) signed a grant for €10 million (US$14 million) with the United nations Children’s Fund (UNICEF), in support of the Essential Medicines Support Programme (EMSP) in Zimbabwe. The money will be used to buy essential drugs and medical supplies which will be distributed to health centres by Natpharm, the supply arm of the Ministry of Health and Child Welfare. Since 2008, availability of essential medicines in Zimbabwe's public health sector has improved largely due to a funding collaboration between the government, UNICEF, the EU, the United Kingdom, Australia, Canada and Ireland. Since 2008, EMSP has received US$52 million in funding, according to UNICEF. The contribution has resulted in 82.5% of the primary health care facilities having 80% of essential medicines available, meaning that there have been virtually no stock outs of essential medicines so far in 2011.
The crowd of health issues jostling for a share of Kenya's inadequate health budget is expanding, with activists calling for an increase in resources for the management of non-communicable diseases (NCDs), which account for more than 50% of hospital deaths and admissions, according to Plus News. At the same time, against a backdrop of two consecutive rejections for funding by the Global Fund to fight AIDS, Tuberculosis and Malaria and flat-lined funding from the United States President's Emergency Plan for AIDS Relief, Kenyan AIDS activists worry that any move to increase funding for NCDs could mean less for HIV and AIDS. Just 440,000 out of 1.5 million HIV-positive Kenyans have access to treatment, and more than 100,000 new HIV infections occur annually. Activists have identified the problem as a combination of scarce resources and a lack of political will by the country’s leadership. They claim that the government pays lip service to the global health issues in vogue – last year it was maternal health, while this year it is NCDs – without any significant improvements in health services. The medical superintendent of Mbagathi District Hospital in Nairobi says government has policies and guidelines in place for the management of NCDs, but there is a lack of strategic focus on operational implementation.
While the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria has recently come under scrutiny about how well it tracks the money it disburses, the author of this article argues that the Fund represents one of the better examples of global funding initiatives for health. He believes that its high level of transparency sets it apart from other bilateral and multilateral institutions, and it is precisely this transparency and accountability that means that any problems in this regard tend to be widely reported. In early 2011, the Fund commissioned an independent panel to evaluate how it can improve its operations and effectiveness. The panel’s recommendations, which were in line with the Global Fund’s own reform agenda, were met by the Global Fund Board’s commitment in October 2011 to deliver on the recommendations and to continue to adjust practices to use its resources as efficiently as possible. Still, some feel that the Fund isn’t going far enough, saying that even very small amounts of money that cannot be accounted for should be grounds for cutting off that country’s grant monies from the Fund. Yet the author argues here that global funding bodies all face some degree of risk from irregularities and, although the Fund should continue to aspire to the highest degrees of effective stewardship of resources and accountability, a perfect score card is not a practical possibility. He cautions that, in pursuit of such rigorous policies, external funders should be careful of unwittingly stifling innovation and new approaches and ultimately reducing impact on health outcomes.