Resource allocation and health financing

Health policies have the potential to be important instruments in achieving equity in health. A framework – EquiFrame - for assessing the extent to which health policies promote equity was used to perform an equity audit of the health policies of three international aid organizations, to assess the extent to which social inclusion and human rights feature in the health policies of DFID (UK), Irish Aid, and NORAD (Norway). EquiFrame was used as a tool for analysing equity and quality of health policies with regards to social inclusion and human rights. Each health policy was analyzed with regards to the frequency and content of a predefined set of Vulnerable Groups and Core Concepts. The three policies varied but were all relatively weak with regards to social inclusion and human rights issues as defined in EquiFrame. The needs and rights of vulnerable groups for adequate health services were largely not addressed. In order to enhance a social inclusion and human rights perspective that will promote equity in health through more equitable health policies, it is suggested that EquiFrame can be used to guide the revision and development of the health policies of international organizations, aid agencies and bilateral donors in the future.

With user fees now seen as a major hindrance to universal health coverage, many countries have introduced fee reduction or elimination policies, but there is growing evidence that adherence to reduced fees is often highly imperfect. In 2004, Kenya adopted a reduced and uniform user fee policy providing fee exemptions to many groups. The authors present data on user fee implementation, revenue and expenditure from a nationally representative survey of 248 Kenyan public health centres and dispensaries in 2010. No facilities adhered fully to the user fee policy across eight tracer conditions, with adherence ranging from 62.2% for an adult with tuberculosis to 4.2% for an adult with malaria. Three quarters of exit interviewees had paid some fees and a quarter of interviewees were required to purchase additional medical supplies at a later stage from a private drug retailer. No consistent pattern of association was identified between facility characteristics and policy adherence. User fee revenues accounted for almost all facility cash income, with average revenue of USD 683 per facility per year. Fee revenue was mainly used to cover support staff, non-drug supplies and travel allowances. Adherence to user fee policy was very low, leading to concerns about the impact on access and the financial burden on households. However, the potential to ensure adherence was constrained by the facilities’ need for revenue to cover basic operating costs, highlighting the need for alternative funding strategies for peripheral health facilities.

Principal Recipients (PRs) receive money from the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) to manage and implement programs. However, little research has gone into understanding their opinions and experiences. This survey set out to describe these, thereby providing a baseline against which changes in PR opinions and experiences can be assessed as the recently introduced new funding model is rolled out. An internet based questionnaire was administered to 315 PRs. A total of 115 responded from 69 countries in Africa, Asia, Eastern Europe and Latin America. The study was conducted between September and December 2012. Three quarters of PRs thought the progress update and disbursement request (PU/DR) system was a useful method of reporting grant progress. However, most felt that the grant negotiation processes were complicated, and that the grant rating system did not reflect performance. While nearly all PRs were happy with the work being done by sub-Recipients (92%) and Fund Portfolio Managers (86%), fewer were happy with the Office of the Inspector General (OIG). Non-government PRs were generally less happy with the OIG’s work compared to government PRs. Most PRs thought the Global Fund’s Voluntary Pooled Procurement system made procurement easier. However, only 29% said the system should be made compulsory. When asked which aspects of the Global Fund’s operations needed improvement, most PRs said that the Fund should re-define and clarify the roles of different actors, minimize staff turnover at its Secretariat, and shorten the grant application and approval processes. All these are currently being addressed, either directly or indirectly, under a new funding model. Vigorous assessments should nonetheless follow the roll-out of the new model to ensure the areas that are most likely to affect PR performance realize sustained improvement. Opinions and experiences with the Global Fund were varied, with PRs having good communication with Fund Portfolio Managers and sub-Recipients, but being unhappy with the grant negotiation and grant rating systems. Recommendations included simplifying grant processes, finding performance assessment methods that look beyond numbers, and employing Local Fund Agents who understand public health aspects of programs.

This paper tackles the paper by Kirigia and Diarra-Nama from the WHO Regional Office for Africa, which claims that countries in the WHO Africa Region need to ‘wean themselves off’ donor funding for health in order to meet the annual WHO target of US$40 per person required to provide universal coverage. The paper evaluated the five strategies that the Kirigia and Diarra-Nama paper proposed and dismissed all of them. It predicted their impact on eight countries and noted a reduction in military expenditure would not make a difference either, as expenditure in these countries is low. Six countries still face a huge gap between current total health expenditure and the revised target made by the Commission on Macroeconomics and Health and need more aid urgently. They can be helped through sustained international health aid, with health recognised as a human right.