This report is the first ever to track what developing countries are spending on the Millennium Development Goals (MDGs), finding that recent spending increases explain the rapid progress on the MDGs. But the vast majority of countries are spending much less than they have promised, or than is needed. Aid cuts, low implementation rates and low recurrent spending all threaten to reverse existing progress. This Government Spending Watch report suggests that developing countries need to make data on MDG spending more accessible to their citizens; to strengthen policies for revenue mobilisation (notably combating tax avoidance and tax havens), debt and aid management; and to spend more on agriculture, water, sanitation and hygiene, and social protection. External funders need to report and repatriate illicit outflows; end laws and investment treaties which reduce poor countries’ revenues; increase innovative financing such as financial transaction and carbon taxes; put more aid through developing country budgets; maximise budget and sector support to make spending more accountable; and report planned disbursements to developing countries. The International Monetary Fund also needs to sharply increase space for sustainable spending in its programmes.
Resource allocation and health financing
This study describe how quality of care is incorporated into performance-based financing (PBF) programmes, what quality indicators are being used, and how these indicators are measured and verified. An exploratory scoping methodology was used to characterise the full range of quality components in 32 PBF programmes, initiated between 2008 and 2015 in 28 low- and middle-income countries, totalling 68 quality tools and 8,490 quality indicators. The programmes were identified through a review of the peer-reviewed and grey literature as well as through expert consultation with key funder representatives. Most of the PBF programmes were implemented in sub-Saharan Africa and most were funded primarily by the World Bank. On average, PBF quality tools contained 125 indicators predominately assessing maternal, newborn, and child health and facility management and infrastructure. Indicators were primarily measured via checklists which largely (over 90%) measured structural aspects of quality, such as equipment, beds, and infrastructure. Of the most common indicators across checklists, 74% measured structural aspects and 24% measured processes of clinical care. The quality portion of the payment formulas were in the form of bonuses (59%), penalties (27%), or both (hybrid) (14%). The median percentage (of a performance payment) allocated to health facilities was 60%, ranging from 10% to 100%, while the median percentage allocated to health care providers was 55%, ranging from 20% to 80%. Nearly all of the programmes included in the analysis (91%) verified quality scores quarterly (every 3 months), typically by regional government teams. PBF is argued by the authors to be a potentially appealing instrument to link verified performance measurement with strategic incentives and could ultimately help meet policy priorities. They also raise substantial variation and complexity in how PBF programmes incorporate quality of care considerations suggesting a need to further examine whether differences in design are associated with differential programme impacts.
Dependency on aid (external funding) among 54 of the world’s poorest countries has declined by a third over the last decade, according to this new report from ActionAid. The number of low income countries (LICs) receiving external funding equivalent to 30% of government expenditure or more has reduced from 42 to 30 in the past decade. In Zambia, for instance, external funding has fallen from 84% of government expenditure to just 44%. ActionAid notes the apparent paradox that while external funding has increased globally, dependence on the funding has reduced because of strong economic growth. Allied to growth is a new-found determination among poor countries to end 30 or more years of dependence on funding that has seldom delivered the kind of development for which they had hoped. Some of the poorest countries in the world, including Ghana, Rwanda, and Uganda, have set reducing this type of dependence as a key medium-term goal in their national development or aid-management policies. Reliance on external funding in Ghana has reduced from 46% to 27%, Mozambique from 74% to 58% and Rwanda from 86% to 45%.
Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. This study documents the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy three years after its implementation. Data was collected in two districts, Kwale and Makueni, and focus group discussions and patient exit interviews were conducted. Adherence to the policy was poor in both districts, and drug shortages, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy. In conclusion, reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. Caution must be taken when deciding on how to reduce or abolish user fees and all potential consequences should be carefully considered.
Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. EnrolLing all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.
This series of briefs provides a regional synthesis of findings of both the 12 thematic studies and the 20 individual case studies of social transfer schemes undertaken under the Regional Evidence Building Agenda (REBA). The themes explored in these briefs are the six addressed in the original REBA design: vulnerability, targeting, coordination and coverage, cost-effectiveness, markets, and asset protection and building. Each of these themes was covered by respective thematic studies in two of RHVP’s six priority countries, and was illustrated in each of the 20 case studies. Also included in the series are briefs on two additional themes that have emerged during the implementation of the REBA work as being of particular interest and policy relevance: delivery mechanisms and social pensions.
David M. Dror, International Labour Organization (ILO) Bulletin of the World Health Organization, July 2001, 79: 672–678.
Deficient financing of health services in low-income countries and the absence of universal insurance coverage leaves most of the informal sector in medical indigence, because people cannot assume the financial consequences of illness. The role of communities in solving this problem has been recognized, and many initiatives are under way. However, community financing is rarely structured as health insurance. Communities that pool risks (or offer insurance) have been described as micro-insurance units. The sources of their financial instability and the options for stabilization are explained. Field data from Uganda and the Philippines, as well as simulated situations, are used to examine the arguments. The article focuses on risk transfer from micro-insurance units to reinsurance. The main insight of the study is that when the financial results of micro-insurance units can be estimated, they can enter reinsurance treaties and be stabilized from the first year. The second insight is that the reinsurance pool may require several years of operation before reaching cost neutrality.
The last decade has seen widespread retreat from user fees with the intention to reduce financial constraints to users in accessing health care and in particular improving access to reproductive, maternal and newborn health services. This has had important benefits in reducing financial barriers to access in a number of settings. If the policies work as intended, service utilization rates increase. However this increases workloads for health staff and at the same time, the loss of user fee revenues can imply that health workers lose bonuses or allowances, or that it becomes more difficult to ensure uninterrupted supplies of health care inputs. This research aimed to assess how policies reducing demand-side barriers to access to health care have affected service delivery with a particular focus on human resources for health. The authors undertook case studies in five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe). In each the authors reviewed financing and HRH policies, considered the impact financing policy change had made on health service utilization rates, analysed the distribution of health staff and their actual and potential workloads, and compared remuneration terms in the public sectors. The authors question a number of common assumptions about the financing and human resource inter-relationships. The impact of fee removal on utilization levels is mostly not sustained or supported by all the evidence. Shortages of human resources for health at the national level are not universal; maldistribution within countries is the greater problem. Low salaries are not universal; most of the countries pay health workers well by national benchmarks. The interconnectedness between user fee policy and HRH situations proves difficult to assess. Many policies have been changing over the relevant period, some clearly and others possibly in response to problems identified associated with financing policy change. Other relevant variables have also changed. However, as is now well-recognised in the user fee literature, co-ordination of health financing and human resource policies is essential. This appears less well recognised in the human resources literature. This coordination involves considering user charges, resource availability at health facility level, health worker pay, terms and conditions, and recruitment in tandem. All these policies need to be effectively monitored in their processes as well as outcomes, but sufficient data are not collected for this purpose.
From 9 to 13 July 2011, members of the Future Health Systems consortium gathered in Toronto, Canada, to participate in the 8th World Congress on Health Economics (iHEA 2011). Following a keynote address that considered the risks of a polarised debate between private or public health care, a presentation considered the future of working with health markets. The focus of the Congress was how to deliver quality health services. Participants argued that ensuring quality in inequitable contexts requires the skillful combination of commodities with knowledge. With this in mind, two panels were convened to look at how both supply side and demand side factors can be altered to improve quality of health care, in terms of both ethics and economics.
The executive director of a $7 billion fund to fight deadly diseases in the world's poorest countries has made extensive use of a little-known private bank account, spending hundreds of thousands of dollars on limousines, expensive meals, boat cruises, and other expenses, according to an internal investigation. While not disputing 37 specific limousine charges in cities across Europe and the United States, dozens of entertainment and meals expenses, among other expenditures the inspector general deemed excessive, the Global Fund spokesman disputed the context, tone, and several facts in the inspector general's report. A separate investigation, overseen by the World Health Organization, also raised concerns about the use of the private bank account.