The dialogue found that countries challenges of high turnover of Health Ministers, shortage of human and financial resources for scaling up action, and weak health information systems. The dialogue recommended flooding health systems with low and middle level staff. The meeting called for resourcing of the Global Fund, which should also “open a window” for maternal, newborn and child health. Mobilization of more domestic resources, accountability, ownership and good coordination were reported as essential for “more money for more health”. The Assembly recommended the development and adoption of national policies, to ensure health is integrated in national development strategies and also costing of national development plans with appropriate economic and other expertise. It was concluded that national and district health accounts should be institutionalized, to track expenditures and ensure decentralization to reach to the communities. Harmonization of health initiatives by development partners was recommended to support and strengthen national plans and programmes, under national ownership and leadership.
Resource allocation and health financing
On 22 August, the Western Cape Interim Steering Committee of the Conference of the Democratic Left hosted a public meeting on South Africa’s proposed national heath insurance (NHI). More than 100 activists from a wide range of communities and organisations attended the meeting. The Conference made several important decisions to further their campaign to mobilise popular (community and worker), progressive and left voices on the NHI by releasing and circulating widely all available documents on the NHI policy discussions, building the campaign from existing community and worker struggles on health issues, and ensuring the campaign is driven by community organisations, trade unions and shop-stewards organised around local health facilities, as well as ordinary people who use the public health system – their experiences, energies, interests and aspirations. As part of the campaign, a People’s Conference on the NHI and the public health crisis is being planned.
A robust public financial management (PFM) system is vital to a country’s development efforts and to the effectiveness of the aid funds that support those efforts. Three years ago, the Paris Declaration on Aid Effectiveness gave new prominence to this idea, as partner countries committed to strengthen their PFM systems and donors committed to use those systems. Now, as the development community prepares for the Third High Level Forum on Aid Effectiveness, this report takes stock of these achievements. The report finds that there has been progress: many countries and donors have taken positive action toward strengthening and using country PFM systems, and the Public. Expenditure and Financial Accountability (PEFA) partnership has developed a performance measurement framework that can help countries determine where they need to concentrate their efforts. At the same time, the aggregate numbers on donors’ use of country systems have not changed much; it is clear that there is still much work to do. The report argues that many of the conditions on which that work must build are now in place, so there is good reason to expect that the Paris Declaration targets for 2010 can be achieved. The report makes important recommendations for this work: partner countries need to take an enhanced role, donors need to better equip themselves to carry out their commitments, external accountability bodies (such as parliaments and civil society organisations) need to increase their demand for implementation of the Paris Declaration, and planning, communication, dissemination and use of lessons learned are crucial.
Trudy Harpham, Emma Grant, South Bank University, London, UK and Elizabeth Thomas, Medical Research Council, Johannesburg, South Africa. Health Policy and Planning; 17(1): 106-111 Oxford University Press 2002. With growing recognition of the social determinants of health, social capital is an increasingly important concept in international health research. Although there is relatively little experience of measuring social capital, particularly in developing countries, there are now a number of studies that allow the identification of some key issues that need to be considered when measuring social capital.
'Resilience’ is topping the list of new buzzwords in international cooperation rhetoric lately and the European Commission (EU) has now issued a policy proposal addressing resilience. In this article, the author criticises the EU’s proposed new policy approach to foreign aid, arguing it has several fundamental weaknesses. First, it airs a highly “top-down” and “state-centric” approach to resilience that risks overlooking the existence of a multitude of local communities and groups that have their own sources of resilience. In situations where government structures are absent or not genuine in the partner country, the EU should try to discover, research and link up with these groups. Second, the EU proposal fails to incorporate and to refer to lessons learnt from its own work on capacity development. While it recognises the leading role of partner countries – fully in accordance with aid effectiveness principles – there is a risk that this will remain rhetoric as long as the EU does not lay out its approach on how it, as an outsider, can support, facilitate or stimulate change. Third, it is questionable whether the proposal is based on a solid understanding of policy coherence, as it aims to undertake a wide range of resilience-enhancing actions that link up diverse sectors, including agriculture, health, natural resource management, regional trade and national reconciliation. The fact that such actions are risky and can be at odds with each other is not sufficiently addressed.
Health care for all does not always mean increased health expenditure. This article looks at various strategies that may be employed to save costs and maximise resources. Health policy reforms alone have not been successful in containing health care cost. While lack of money is often a governing constraint, it does not mean that progress is not possible without the injection of money into the system. It is necessary to identify areas of wastage, inappropriate spending and strategies to contain health care cost while improving quality of health care provision. It makes sense to start by spending money on cost-effective interventions that save a lot of lives. A recent experiment in Tanzania illustrates the impact of rational spending. Researchers were sent to the rural districts of Morogoro and Rufiji. They carried out a door-to-door survey asking whether anyone had died or been laid low recently, and if so, with what symptoms. They found that the amount of money local authorities spent on each disease had no relation whatsoever to the harm it inflicted on local people.
This UNAIDS report summarises the most recent data available on spending from all sources of AIDS programmes in low- and middle-income countries. Its purpose is to identify the magnitude of global resources available relative to the estimated resource needs. The report also reviews and compares the methodological approaches used to track HIV/AIDS expenditure at global and national levels, and identify gaps in HIV/AIDS financial information and present ways they can be addressed.
Harvey Whiteford, M. Teeson, R. Scheurer, Dean Jamison. CMH Working Paper No. WG1 : 12, July 2001 Commission on Macroeconomics and Health, WHO
Mental Disorders are found in all cultures, are prevalent, cause considerable disability and rank high on the league table of world disease burden. By extension, they constitute a significant economic burden in all countries. Better understanding the extent of this economic burden and the development of frameworks to deliver cost effective interventions will provide a basis for programs which not only reduce the disability associated with these disorders but also promote human development and economic productivity. International agencies such as the World Health Organisation are intensifying their focus on mental illness with the World Health Report 2001 dedicated to mental health. The World Bank has identified neuropsychiatric disorders as an important emerging public health problem for developing market economies.
This response to Kirigia and Diarra-Nama’s paper points out that they do not propose alternative strategies to enable African countries to mobilise the funds without depending solely on donor funding. Kirigia and Diarra-Nama argue that eight countries whose current military spending is above the regional average of US$ 16 per person may have scope for savings. Thirteen countries whose tax share of GDP is less than 15% have scope for raising additional revenue by improving efficiency of their tax administration systems. The amounts, however small, are not insignificant in these countries where more than 60% of the population live below the international poverty line of US$1 per person per day. The effectiveness of international aid should also be judged on the extent to which it helps recipient countries to ‘wean themselves off’ external donor funding.
Results-based financing for health programmes are being piloted in many low- and middle-income countries. While the term results-based financing refers to demand- and supply-side incentives to increase output – that is, improved access to and quality of health care – this editorial focuses on the incentives that target service providers, also referred to as performance-based financing or pay-for-performance. A study in Zambia concluded that the pay-for-performance intervention was cost–effective. However, cost–effectiveness is not the most interesting point of this study, as four policy relevant lessons emerge. First, any output-based provider payment method requires some method of verification. In Zambia, setting up verification mechanisms required new investments, as before the pilot, providers were paid based on inputs. The estimates of the costs of the programme in Zambia, although annualized, are based on only 2.3 years of experience. Given that it is a new programme, one would expect that pay-for-performance verification costs would decline over time. Second, approaching pay-for-performance as an either-or choice of financing is no longer the only frame of reference. The substantive question is how to integrate elements of performance into the mixed provider payment system. Third, as described in the overall evaluation of the project, the direct disbursement of funds to facility bank accounts in the pay-for-performance group was a key ingredient for ensuring better service delivery. Fourth, facility financial autonomy supported by pay-for-performance was found to be key for ensuring progress towards strategic purchasing in Zambia. If balanced with clear accountability for both good results and the use of funds, it should be promoted. In shifting towards mixed provider payment methods with timely disbursement of funds and greater financial autonomy by front-line providers, the budgeting processes need to be considered. In countries such as Zambia, where budgets are mainly formulated, approved and executed based on detailed input lines, the authors argue that shifting to payments based on performance could be challenging.