According to the authors of this study, the global economy is passing through a period of profound change. They identify three global crises. The immediate concern is with the financial crisis, originating in the North. The South is affected via reduced demand and lower prices for their exports, reduced private financial flows and falling remittances. This is the first crisis. Simultaneously, climate change remains unchecked, with the growth in greenhouse gas emissions exceeding previous estimates. This is the second crisis. Finally, malnutrition and hunger are on the rise, propelled by the recent inflation in global food prices. This constitutes the third crisis. These three crises interact to undermine the prosperity of present and future generations. Each has implications for international aid and underlines the need for concerted action.
Resource allocation and health financing
This paper examined the influence of national, sub-national and global factors on priority setting for noncommunicable disease control in Uganda. A mixed methods design that used the Kapiriri Martin framework for evaluating priority setting in low income countries and the evaluation period was 2005–2015. Priority setting for noncommunicable diseases was not entirely fair nor successful. While there were explicit processes that incorporated relevant criteria, evidence and wide stakeholder involvement, these criteria were not used systematically or consistently in the contemplation of noncommunicable diseases. There were insufficient resources for noncommunicable diseases, despite being a priority area. There were weaknesses in the priority setting institutions, and insufficient mechanisms to ensure accountability for decision-making. Priority setting was influenced by the priorities of major stakeholders, such as development assistance partners, which were not always aligned with national priorities. There were major delays in the implementation of noncommunicable disease-related priorities and in many cases, a failure to implement. This evaluation revealed the challenges that low income countries are grappling with in prioritizing noncommunicable diseases in the context of a double disease burden with limited resources. The authors propose that strengthening local capacity for priority setting would help to support the development of sustainable and implementable noncommunicable disease-related priorities and that global support to low income countries for noncommunicable diseases must catch up to align with NCDs as a global health priority.
Joseph S. Coyne, DrPH, PhD, Health Policy and Administration Program, Washington State University, Spokane.
Peter Hilsenrath, Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth.
Comparative studies have been part of health services research literature for decades. The benefits of these analyses include documenting how the more successful practices can be adapted in another country. Such has been the case in France, where many US health care delivery practices have been adopted in market reforms.
The World Health Organization (WHO) studied the health systems of 191 countries for its World Health Report 2000. The study is provocative and has stimulated significant analysis of the structure and performance of health systems. We examine the variables and methodology used by the WHO to measure efficiency and performance of health systems.
Vicente Navarro, MD, PhD, DrPH
Director of the Public Policy Program jointly sponsored by the School of Public Health of The Johns Hopkins University
The major criticisms that can be made of the WHO report are conceptual and methodological in nature and can be made for each of the components (effectiveness, responsiveness, and fairness) of the single indicator of performance used in the report. Regarding effectiveness of health care, for example, the WHO report assumes erroneously that health care is the primary force responsible for the decline of mortality and morbidity in both developed and developing countries. That assumption is evident in statements such as "[If] Sweden enjoys better health than Uganda—life expectancy is almost exactly twice as long—it is in large part because it spends exactly 35 times as much in its health systems." Not surprisingly, the report concludes that what is needed to eradicate disease in less-developed countries is a greater investment in health care: "with investment in health care of $12 per person, one third of the disease burden in the world in 1990 would have been averted." Such statements reveal a medicalization of the concept of health that is worrisome and surprising, coming as it does from the major international health agency of the United Nations.
In this report, the World Health Organization maps out what countries can do to modify their financing systems so they can move more quickly towards the goal of universal health coverage and sustain the gains that have been achieved. The report builds on new research and lessons learnt from country experience. It provides an action agenda for countries at all stages of development and proposes ways that the international community can better support efforts in low income countries to achieve universal coverage and improve health outcomes. To ensure universal coverage, countries must raise sufficient funds, reduce the reliance on direct payments to finance services, and improve efficiency and equity. The report proposes three ways for governments to raise money: increase the efficiency of revenue collection, re-prioritise government budgets and put innovative financing mechanisms in place.
This article examines how HIV policies and the funding priorities of global institutions affect practices in prenatal clinics and the quality of healthcare women receive. Data consist of observations at health centres in Lilongwe, Malawi and 37 interviews with providers. The author argues that a neoliberal ideology structuring global health produces a fragmented healthcare system on the ground. He found two kinds of healthcare practices within the same clinic: firstly externally funded non government organisations (NGOs) took on HIV services while government providers focused on prenatal care. NGO practices were defined by surveillance, where providers targeted a limited number of pregnant HIV positive women and intensively monitored their adherence to drug treatment. In contrast, state-led practices were defined by inclusion and rationing. Government providers worked with all pregnant women, but with staff and resource shortages, they limited time and services for each patient in order to serve everyone. The author concludes that global health priorities produce different conditions, practices and outcomes between externally funded NGO and state-led care.
While the worldwide AIDS community bemoans the global economic crisis and its impact on funding streams for the HIV and AIDS response, several speakers at the Fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention, which took place in Cape Town, South Africa, from 19–22 July, called on implementers to start doing more with less. Dr Stefano Bertozzi of the National Institute for Public Health in Mexico said choosing interventions more strategically would help, he said, citing abstinence programmes as one example of an approach that lacked evidence to support it. Focused, well-managed programmes targeted at populations with the greatest need were the most cost-effective, as were programmes integrated with services for related health issues, such as tuberculosis. Programmes that worked towards long-term goals, such as training new doctors and nurses, empowering women, and changing social norms, were more efficient than those with short-term targets, which looked good on annual reports but did little to change the course of the epidemic.
Donor support for the HIV response has increased dramatically in recent years. In parallel, the debate continues between those who argue that the money is still too little, and those who say there is too much emphasis on HIV. Often there is little relation between a country’s total funding for HIV and the actual HIV burden. This is not necessarily a problem, and in fact the same is true for other diseases. Burden of disease is not the only basis for allocating resources; other criteria used to justify donor support include cost-effectiveness, aligning funding with stated country priorities, or equity. However, there is little to suggest that current donor practices on HIV funding can be justified on any of these grounds. The HLSP Institute’s analysis also suggests that donor spending on HIV has, to some extent, crowded out other expenditure on health and population. Put simply, funding for health would have increased more rapidly had it not been for the large increase in support for HIV. If such programmes were to continue to expand (as they probably will) sustainability challenges would be even greater, and the potential for further misalignment of health sector funding would be likely to increase.
Every year the Ugandan government spends at least Shs377 billion (about US$150 million) on medical procedures for mostly top government officials abroad, according to the Ugandan newspaper, Sunday Monitor. This amount is similar to the total amount of foreign funding flowing into the country’s health sector. Ministry of Health permanent secretary Asuman Lukwago agreed that the amount should be reduced and that the money would be better spent on ongoing efforts to rejuvenate health facilities, including upgrading all referral hospitals. The secretary added that Uganda had the capacity to perform most procedures, arguing that there was minimal need for government officials to travel abroad to get treatment.
As high out-of-pocket payment dominates Nigeria’s healthcare spending and with low priority accorded to health by state and local governments, Nigeria’s quest to attain universal health coverage by 2015 is argued in this article to be bleak. The absence of financial protection has led most Nigerians to depend on out-of-pocket payment for healthcare financing with insurance penetration, which is a measure of the relationship between premiums earned and the nation’s Gross Domestic Product, put at less than 6 percent, according to industry experts. Experts explain that achieving universal health coverage would be hard to attain without expanding the fiscal space (through increasing domestic tax revenues, expanding tax base, developing social health insurance, and getting debt relief. Analysts believe that there is need to expand contributions from large profitable companies and tax mobile phone operators to fund healthcare.
Other innovations include tobacco and alcohol exercise tax, excise tax on foods that contribute to an unhealthy diet, and additional levy on top of existing VAT rate as is in the case with countries like Chile.
Some issues to consider in evaluating each innovative method include administrative costs, magnitude of the potential revenue, political acceptability and whether such funds should go into Consolidated Government Revenues or be earmarked.