Members of the Organization for Economic Co-operation and Development's (OECD) Development Assistance Committee (DAC) gave US$121.5 billion in bilateral aid in 2009, reaching a historic high, but the gap between commitments and promises made in 2005 is widening, according to this report. In 2005 DAC external funders collectively promised to commit 0.56% of gross national income to aid by 2010, but reached just 0.31% in 2009. Though aid commitments have continued to increase, the rate of increase has dropped off in the past few years, making external funders increasingly off-track. DAC external funders gave US$27 billion to Africa in 2009, an increase of 3% on 2008, but this is still less than half of the extra aid they promised at Gleneagles in 2005. Norway, France, the UK, Korea, Finland, Belgium and Switzerland all increased their aid commitments, while Japan, Greece, Ireland, Spain and Portugal, among others, reduced theirs. The largest external funders by volume were the USA, France, Germany, the UK and Japan, but just five countries met or exceeded the UN overseas development aid target of 0.7% of national income: Denmark, Luxembourg, the Netherlands, Norway and Sweden. External funders pledged to increase aid to US$130 billion by 2010; but the report predicts they will fall short by US$78 billion (both figures in 2004 US dollars).
Resource allocation and health financing
According to this brief, aid effectiveness refers to how effective aid is in achieving expected outputs and stated objectives of aid interventions. In contrast, the brief observes, aid actors are also interested in development effectiveness, a term which lacks clarity leaving it open to considerable scope for interpretation. The brief suggests four categories to help in understanding the term development effectiveness: as organisational effectiveness; as coherence or coordination; as the development outcomes from aid; and as overall development outcomes. The latter overlaps with other understandings of the term but is the most comprehensive approach of the four categories. Here, it is seen as a measure of the overall development process, and not just the outcomes from aid. The brief recommends that a successful agenda on development effectiveness should depend on concerted efforts between developing country governments and official aid funders basing on their willingness to reformulate the current effectiveness agenda, and that the creation of a development effectiveness agenda will require a level of agreement on the operational meaning of the term.
The Department for International Development’s (DFID) new White Paper presents a shift in the way the United Kingdom (UK) delivers development aid, refocusing resources onto fragile countries and for the first time treating security and justice as a basic service alongside health, education, water and sanitation. Fifty percent of new bilateral funding will be committed to fragile countries. Key announcements include a renewed commitment to 0.7% of the UK Gross National Income (GNI) for international development (totalling £9bn per year by 2013), measures to reduce maternal mortality rates to save the lives of six million mothers and babies by 2015 and doubling of funding to £1bn for African infrastructure, including transport, energy and trade in the region. Regarding growth and trade, DFID proposes a quadrupling of funding to promote fair and ethical trade and a new International Growth Centre to offer world-class economic expertise and practical advice to poor countries.
Direct facility funding (DFF) links facility funding levels to general indicators of facility size and workload rather than specific output targets. To reduce user fees, DFF was piloted in Coast Province, Kenya, with health facility committees (HFCs) responsible for managing the funds. This study evaluated the implementation and perceived impact 2.5 years after DFF introduction. Quantitative data collection at 30 public health centres and dispensaries included a structured interview with the staff member in-charge, record reviews and exit interviews. In-depth interviews were also conducted with the in-charge and HFC members at 12 facilities, and with district staff and other stakeholders. DFF procedures were well established and it made an important contribution to facility cash income, accounting for 47% in health centres and 62% in dispensaries. DFF was perceived to have a highly positive impact through funding support staff such as cleaners and patient attendants, outreach activities, renovations, patient referrals and increasing HFC activity. A number of problems were identified, such as inadequate HFC training, and lack of DFF documentation at facility level. Charging user fees above those specified in the national policy remained common, and understanding of DFF among the broader community was very limited. The study concludes that relatively small increases in funding may significantly affect facility performance when the funds are managed at the periphery. Kenya plans to scale up DFF nationwide and the authors indicate this is warranted, but should include improved training and documentation, greater emphasis on community engagement, and insistence on user fee adherence.
Health and education budgets are cut in times of financial crises despite the fact that the opposite should be happening, according to South African health department Director-General Precious Matsoso. Addressing the plenary at the 3rd People’s Health Assembly Matsoso said that while the country was supposed to be rolling out National Health Insurance (NHI), it had to do so with only R11-million per pilot district from Treasury. She argued that social services should not suffer when there is a crisis, the opposite should happen. Instead, she said, we see that when there is a financial crisis, there is a cut in social spending and health. Prior to this, Professor Di McIntyre, who is also a key NHI advisor to the health minister, reiterated that NHI was about the comprehensive reform of the health system. She said one of her key concerns while establishing NHI was the underfunding of the NHI pilot sites by Treasury and the “enormous pressure to protect the positions of the high income groups and private sector profits”.
In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, the authors consider inequalities in access to the DG for patients on ART and implications of DG access for on-going access to healthcare. Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. Grant recipients were comparatively worse off than non-recipients in terms of employment and wealth. The regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed. Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG. The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.
Maximising health as the guiding principle for resource allocation in health has been challenged by concerns about the distribution of health outcomes. There are few empirical studies that consider these potentially divergent objectives in settings of extreme resource scarcity. The aim of this study is to help fill this knowledge gap by exploring distributional preferences among health planners in Tanzania. Distribution of health outcomes, in terms of life-years, matters. Specifically, the lower the initial life expectancy of the target group, the more important the programme is considered. Such preferences are compatible, within the sphere of health, with what ethicists call “prioritarianism”.
This research aimed to identify the determinants of out of pocket (OOP) health expenditures in the Ivory Coast population in Abidjan, a rural and an urban area. The authors used data from the 2015 standard households living survey conducted by the National Institute of Statistics. About 13.3% of the participants experienced OOP expenditures on health with a mean expenditure of US$29. There were significant differences in the self-reported OOP between the three areas. People in Abidjan spent an average of 1.6 and 1.5 times more than those in the rural and urban areas respectively. Hospitalisation is the highest expenditure item in terms of money spent, while medicines are the most common item of expenditure in terms of frequency, regardless of the place of residence. Female gender, high social economic status and large household size increase OOP health expenditure significantly in all areas of residence while having insurance reduces it.
The highest per capita primary health care expenditure in the public sector by a district in South Africa during 2005/06 was R416 per person in Bophirima district in the North West province. This is in stark contrast to the lowest rate of R115 per person spent in Greater Sekhukhune, a relatively deprived district in Limpopo province.
In this paper, the author examines the impact of removing user fees from healthcare on the health status of poor children in South Africa. By comparing health development across similar children, the author found that free healthcare improved the health status of all children, but to a greater extent for boys than for girls. These results present several important policy implications for other developing countries contemplating the abolition of user fees. First, removing user fees is effective in improving child health status through increased access to and utilisation of health services in an environment where poor households face significant budget constraints. Second, increased access to health services is an important determinant of better health outcomes. Third, free health services are often challenged by a potential trade off between quantity and quality of services. The study supports the assertion that the quality of health services appears to have deteriorated, due to poor financial management, leading to lower health status among older children in the high treatment region. However, the net benefits were still positive and significant for children who received free healthcare.