The Paris Declaration on Aid Effectiveness may have the effect of circumscribing national sovereignty and country autonomy over development policies contrary to its stated principles of country ownership and mutual accountability, research has shown. Two recent studies have highlighted the propensity of new modalities of aid and aid harmonisation processes under the Paris Declaration framework to increase rather than reduce donor interventions in aid recipient countries and exacerbating the imbalances of power between donor and recipient countries.
Resource allocation and health financing
Paris Declaration Undermines Policy Space through Aid
Tan C: Third World Network, 10 April 2008
Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050
Global Burden of Disease Health Financing Collaborator Network: The Lancet, doi: https://doi.org/10.1016/S0140-6736(19)30841-4, 2019
The authors estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance for health (DAH) from 1990 to 2018. Future scenarios of health spending using an ensemble of linear mixed-effects models were estimated, with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. Between 1995 and 2016, health spending grew at a rate of 4% annually, although it grew slower in per capita terms and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries, mainly due to growth in government health spending, and in lower-middle-income countries, mainly from DAH. The decomposition analysis identified governments’ increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending.
Patterns of Global Health Expenditures: Results for 191 Countries
Funding for health services is often cited as a major constraint for governments to be good stewards of health systems in their countries. Yet, in most cases, the data to support such claims is lacking. Making progress on a variety of health policy questions requires good national data on the sources and uses of funds in the health system, preferably comparable across countries. With such data, it is possible to begin answering questions such as the best ways to allocate limited resources toward improving health or what level of funding is needed in particular epidemiological and demographic contexts.
Paying for and receiving benefits from health services in South Africa: is the health system equitable?
Ataguba JE and McIntyre D: Health Policy and Planning 27(suppl 1), March 2012
Total health care financing in South Africa is progressive, as richer socio-economic groups spend more of their consumption expenditure on health care than poorer groups. In contrast, the overall distribution of both public and private sector health care benefits in South Africa is pro-rich, as poorer socio-economic groups are benefiting less from the use of health services than richer groups. The overall distribution of health care benefits is also not in line with the need for care: poorer groups that indicate poorer self-assessed health status receive fewer health care benefits compared with richer groups with higher self-assessed health status. In their final analysis the authors argue that the South African health system, considering both the delivery and financing of health care, is inequitable.
Payment for antiretroviral drugs is associated with a higher rate of patients lost to follow-up than those offered free-of-charge therapy in Nairobi, Kenya
Zachariah R, Van Engelgem I, Massaquoi M, Kocholla L, Manzi M, Suleh A, Philips M, Borgdorff M: Transactions of the Royal Society of Tropical Medicine and Hygiene 102(3):288-93, March 2008
This retrospective analysis of routine programme data from Mbagathi District Hospital, Nairobi, Kenya shows the difference in rates of loss to follow-up between a cohort that paid 500 shillings/month (approximately US$7) for antiretroviral drugs (ART) and one that received medication free of charge. A total of 435 individuals (mean age 31.5 years, 65% female) was followed-up for 146 person-years: 265 were in the 'payment' cohort and 170 in the 'free' cohort. The incidence rate for loss to follow-up per 100 person-years was 47.2 and 20.5, respectively (adjusted hazard ratio 2.27, 95% CI 1.21-4.24, P=0.01). Overall risk reduction attributed to offering ART free of charge was 56.6% (95% CI 20.0-76.5). Five patients diluted their ART regimen to one tablet (instead of two tablets) twice daily in order to reduce the monthly cost of medication by half. All these patients were from the payment cohort. Payment for ART is associated with a significantly higher rate of loss to follow-up, as some patients might be unable to sustain payment over time. In resource-limited settings, ART should be offered free of charge in order to promote treatment compliance and prevent the emergence of drug resistance.
Performance-based financing: Just a donor fad or a catalyst towards comprehensive health-care reform?
Meessen B, Soucat A and Sekabaraga C: Bulletin of the World Health Organisation (89): 153-156, February 2011
Critics of performance-based financing suggest that it may be a fad of external funders, with limited potential to improve service delivery. Most critics view it solely as a provider payment mechanism. The authors of this article argue that performance-based financing can catalyse comprehensive reforms and help address structural problems of public health services, such as low responsiveness, inefficiency and inequity. The emergence of performance-based financing in Africa may profoundly transform the public sectors of the low-income countries in the region. However, the authors caution on the limits to performance-based financing, particularly as some dimensions of performance are difficult to measure and, therefore, to remunerate. More classical support and mechanisms will remain crucial for strengthening health systems in low-income countries.
Performance-based financing: the need for more research
Basinga P, Mayaka S and Condo J: Bulletin of the World Health Organisation 89(9): 698-699, September 2011
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.
Performance-based Incentives in Mozambique: A Situational Analysis
Connor, C, Cumbi A, Borem P, Beith A, Eichler R, Charles J: Abt Associates Bethesda, MD: Health, 2011
This report presents the findings of USAID’s Health Systems 20/20 Project assessment of local interest in and capacity to implement PBIs. PBIs are reported to be legally and culturally feasible. Given the low level of health spending, limited population coverage, and estimates of unmet need in
Mozambique, the authors argue that PBIs should be designed to improve system efficiency but not be expected to reduce spending in absolute terms. Local stakeholders are repirted to be open to the PBI concept, citing CDC, USAID, and World Bank being ready to support introducing PBIs in Mozambique; however, some authorities and health worker staff express concerns about sustainability and equity of paying for performance.
Performance-based Incentives to Improve Health Status of Mothers and Newborns: What Does the Evidence Show?
Rena Eichler, Koki Agarwal, Askew I, Iriarte E, Morgan L, Watson J: Journal of Health, Population and Nutrition; 31:4: December 2013
Performance-based incentives (PBIs) aim to counteract weak providers’ performance in health systems of many developing countries by providing rewards that are directly linked to better health outcomes for mothers and their newborns. Translating funding into better health requires many actions by a large number of people. The actions span from community to the national level. While different forms of PBIs are being implemented in a number of countries to improve health outcomes, there has not been a systematic review of the evidence of their impact on the health of mothers and newborns. This paper analyzes and synthesizes the available evidence from published studies on the impact of supply-side PBIs on the quantity and quality of health services for mothers and newborns. This paper reviews evidence from published and grey literature that spans PBI for public-sector facilities, PBI in social insurance reforms, and PBI in NGO contracting. Some initiatives focus on safe deliveries, and others reward a broader package of results that include deliveries. The Evidence Review Team that focused on supply-side incentives for the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives, reviewed published research reports and papers and added studies from additional grey literature that were deemed relevant. After collecting and reviewing 17 documents, nine studies were included in this review, three of which used before-after designs; four included comparison or control groups; one applied econometric methods to a five-year time series; and one reported results from a large-scale impact evaluation with randomly-assigned intervention and control facilities. The available evidence suggests that incentives that reward providers for institutional deliveries result in an increase in the number of institutional deliveries. There is some evidence that the content of antenatal care can improve with PBI. We found no direct evidence on the impact of PBI on neonatal health services or on mortality of mothers and newborns, although intention of the study was not to document impact on mortality. A number of studies describe approaches to rewarding quality as well as increases in the quantities of services provided, although how quality is defined and monitored is not always clear. Because incentives exist in all health systems, considering how to align the incentives of the many health workers and their supervisors so that they focus efforts on achieving health goals for mothers and newborns is critical if the health system is to perform more effectively and efficiently. A wide range of PBI models is being developed and tested, and there is still much to learn about what works best. Future studies should include a larger focus on rewarding quality and measuring its impact. Finally, more qualitative research to better understand PBI implementation and how various incentive models function in different settings is needed to help practitioners refine and improve their programmes.
Pluralism and Marketisation in the Health Sector:
Meeting Health Needs in Contexts of Social Change in Low and Middle Income Countries
Gerald Bloom and Hilary Standing. ISBN 1 85864 361 9 - IDS Working Papers - 136, Institute of Development Studies, University of Sussex, 2001
This paper is part of a broader attempt to identify the key producers of social goods and how social policy interventions can support them. This paper is focused on the health sector. It
examines the changing roles of health care providers and the management of health expertise in the context of pluralism and increasing marketisation of health goods and services; explores how pluralism of provisioning and increasing markets for health goods have affected the ways households meet their health needs; stimulates a reassessment of what governments should or could do to enable delivery of competent health care under conditions of pluralism and marketisation.
Further details: /newsletter/id/28849