This study analysed the relationship between the provision of general budget support (GBS) and Millennium Development Goal (MDG) performance, by disaggregating countries into 'high' and 'low' budget support recipients and assessing the extent to which selected MDGs have improved in each of these groups. It found that high GBS recipients have performed better, often significantly so, in all four MDGs assessed (covering primary enrolment, gender parity in education, child mortality, and access to water), as well as in terms of improvements in the Human Development Index (HDI), in the period 2002-2007. Correlation analysis also suggests that there is a positive relationship between budget support receipts and MDG performance (significant in the case of both education indicators and the HDI), but it is not always strong and other factors will also be important determinants of MDG performance. It also found that, even when quality of the policy environment, income level and aid dependency are controlled for, high GBS recipients have on average still performed better than other countries. The study cautions that it is an analysis of association, not causality. Nevertheless, the results overall do provide more comprehensive support for the view that countries receiving large amounts of budget support perform better than those receiving little or no budget support.
Resource allocation and health financing
More than 50 countries have engaged in Gender Budget Initiatives (GBI), but few of these initiatives articulate an explicit connection between budgets and the Convention on Elimination of All Forms of Discrimination Against Women (CEDAW). This booklet, produced by the United Nations Development Fund for Women, articulates what it means to take an explicitly rights-based approach to government budgets. It draws on the lessons of gender budgeting experiences from around the world. It poses three questions. How can the four main dimensions of budgets – revenue, expenditure, macro economics of the budgets and budget decision making processes – be linked to governments’ commitments under CEDAW? Using these links, how can gender budget analysis then assist in monitoring a government’s compliance with CEDAW? How can CEDAW be used to set equality-enhancing criteria in budget activities and guide GBIs and other initiatives towards achieving gender equality? The booklet is intended as an advocacy and action tool for key stakeholders in the area of government budgets and women’s human rights including policy and law makers at the country level and gender human rights advocates.
In this interview with Irene Agyepong, Regional Director of Health for Greater Accra, she attributes Ghana’s success in rolling out universal coverage to genuine political commitment as well as demand from society for change. She identifies three major challenges facing Ghana: poor capacity, loss of health workers who migrate overseas and lack of financing. She gives advice to other countries wishing to implement universal coverage. First, they should build a strong health system as well as technical and administrative capacity and make sure that they retain that capacity to support universal coverage. Second, governments and external funders must realise that leadership has to come from within the country – externally motivated change is unlikely to work. Third, context and history matter. Countries need to tailor their systems to fit their context and history. Overall, stakeholders should bear in mind that universal coverage is a long-term goal.
The 2005 Paris Declaration on Aid Effectiveness sets targets for increased use by external funders (donors) of recipient country systems for managing aid. This study investigates the degree to which external funders ' use of country systems is in fact positively related to their quality, using indicators explicitly endorsed for this purpose by the Paris Declaration and covering the 2005-2010 period. The author shows that external funders
appear to have modified their aid practices in ways that build rather than undermine administrative capacity and accountability in recipient country governments.
This study describes the impact of cash grants and parenting quality on 854 children aged 5–15 in South African and Malawi on educational outcomes including enrollment, regular attendance, correct class for age and school progress, controlling for cognitive performance. Consecutive attenders at randomly selected Community based organisations were recruited. The effects of cash plus good parenting, HIV status and gender were examined. Overall 73.1% received a grant – significantly less children with HIV (57.3% vs 75.6%). Controlling for cognitive ability, grant receipt was associated with higher odds of being in the correct grade, higher odds of attending school regularly, and much higher odds of having missed less than a week of school recently. Grant receipt was not associated with how well children performed in school compared to their classmates or with school enrollment. Grant receipt was associated with a significant reduction in educational risk for girls.
In the debate surrounding aid effectiveness in Africa, some have suggested that these countries ought to ‘wean themselves off’ aid dependency. This paper provides five strategies that African countries can employ to eliminate the need for donor funding for health. First, they can reduce economic inefficiencies. Second, they should institutionalise economic efficiency monitoring within national health management information systems with a view to implementing appropriate policy interventions to reduce wastage of scarce health systems inputs. Third, they can reprioritise public expenditures by, for example, cutting back on military spending and raising additional tax revenues by increasing the tax share to at least 15% of gross domestic product (GDP). Fourth, more private sector involvement in health development is required and, last, the fight against corruption needs to be stepped up.
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.
While countries such as the USA, South Africa and China debate health reforms to improve access to care while rationalising costs, Canada’s health care system has emerged as a notable option. According to this article, in the United States (US), meaningful discussion of the advantages and disadvantages of the Canadian system has been thwarted by ideological mudslinging on the part of large insurance companies seeking to preserve their ultra-profitable turf and backed by conservative political forces stirring up old fears of ‘socialised medicine’. These distractions have relegated the possibility of a ‘public option’ to the legislative dustbin, leaving tens of millions of people to face uninsurance, under-insurance, bankruptcy and unnecessary death and suffering, even after passage of the Obama health plan. While South Africa appears to experience similar legislative paralysis, there remains room for reasoned health reform debate to address issues of equity, access, and financing. This article contributes to the debate from a Canadian perspective by setting out the basic principles of Medicare (Canada’s health care system), reviewing its advantages and challenges, clarifying misunderstandings, and exploring its relevance to South Africa. It periodically refers to the US because of the similarities to the South African situation, including its health care system, which mirrors South Africa’s current position if left unchanged. The article concludes that, while Medicare is neither flawless nor a model worthy of wholesale imitation, an open discussion of Canada’s experience should be included in South Africa’s current policy and political efforts.
This research project investigates how governments can generate more of their own national resources for health and reduce their dependence on donor funding, which can be both unstable and unsustainable. Case studies in Nigeria, South Africa and Kenya, document country experiences of increasing the effectiveness of their tax collection services and investigate how this has contributed to increased health sector spending. Governments in Kenya, Lagos State (Nigeria) and South Africa have increased domestic tax revenue by expanding the tax base and improving the efficiency of tax collection systems. Specific efforts have been made to reach the informal sector by taxing businesses (in Kenya) and reaching informal trade associations (in Nigeria). Political support to tax policy reforms and the tax collection agencies led to additional funding for their operations and strengthened human resource capacity. Despite achievements in raising tax revenue, the share of government spending allocated to the health sector has not increased. A critical challenge for Ministries of Health is to make a better case for health during budget negotiations, and to demonstrate the social and economic benefits of health investments.
This report aims to call health leaders’ attention to the importance and feasibility of establishing the systems and institutions needed to pursue universal health coverage (UHC). It also seeks to quantify the transition costs associated with reforming a health system away from one that relies on out-of-pocket payments and towards one in which health expenditures are more evenly distributed and that can supply UHC. Although models for UHC vary by country, governments are re-organising national health systems to share health costs more equitably across the population and its life cycle, instead of concentrating the burden on the few who face catastrophic illness in any given year. Using examples from four countries that have made tremendous strides toward achieving universal coverage, including Rwanda, the report puts an approximate price tag on these investments. It concludes that relatively small early investments can set countries on the path toward UHC.