The countries worst hit by the worldwide TB epidemic, including South Africa and Zimbabwe, urgently need extra help if they are to meet ambitious global targets set for the year 2005, the World Health Organisation (WHO) says. Experts working with WHO estimate that the total cost for TB control worldwide is $1.2 billion every year. Three-quarters of that total is already covered by countries, donors and other sources. The remaining $300 million each year is urgently needed if the targets are to be met by 2005. WHO's World Health Assembly has set global targets of detecting 70% of TB patients and successfully curing 85% of these patients by 2005. "This is a race against time," said Dr. J.W. Lee, director of WHO's STOP TB Department in Geneva. "Poor control practices in many countries and the TB/HIV coepidemic mean that urgent action needs to be taken to control TB." "This funding gap is clearly identified and affordable," he added. "If we are to meet these targets, we must act now."
Resource allocation and health financing
User fees for health care, also referred to as cost sharing, cost recovery or co-payment, are widespread around the developing world, despite mounting opposition to them. Many studies have found them to be among the barriers to the use of health services, and have shown that they affect poor people more than others. Such concerns have led many researchers, advisers, and policy makers to question whether user fees should be applied, especially among poor and vulnerable groups. In particular, there is concern that user fees will hinder access to essential social services and so prevent the Millennium Development Goals from being met.
A recent study in the International Journal for Equity in Health states that user fees represent an unfair mechanism of financing for health services because they exclude the poor and the sick. To mitigate this effect, flat rates and lower fees for the most vulnerable users were introduced to replace the fee-for-service system in some hospitals after the survey. The results are encouraging: hospital use, especially for pregnancy, childbirth and childhood illness, increased immediately, with no detrimental effect on overall revenues. A more equitable user fees system is possible.
In Oxfam's press release after the 35th G8 summit, held in Italy from 8–10 July 2009, Jeremy Hobbs, its executive director, noted: ‘A stalemate persists because, in the past eight years, rich countries have used the talks to continue to push to open up new export markets. Developing countries have resisted, saying they were promised a deal that would give them space to protect their farmers and new industries, an end to rich country trade-distorting agricultural subsidies, and more access to rich markets for their farmers and industries. This summit has been a shambles, it did nothing for Africa, and the world is still being cooked. Canada 2010 is the end of the road for the G8 – all the promises they have made are due. They have 12 short months to avoid being remembered as the ones who let the poor and the planet die. Millions of children are out of school, millions more dying from curable diseases. This is shameful and the Canadians must move fast to fix it. There won’t be any second chances.’
The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E). A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme. The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time. The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.
This study looked at the monitoring and evaluation (M&E) methods used to measure the equity, efficiency and sustainability of the Tanzania National Voucher Scheme (TNVS), which is used to deliver subsidised insecticide-treated mosquito nets (ITNs) to pregnant women and infants in Tanzania. The M&E focused on five key domains: ITN ownership and use among target groups, provision and use of reproductive and child health services, “leakage” of vouchers (use of vouchers by people not meant to benefit from the programme or use of vouchers to buy other things), availability of nets in the commercial ITN market and cost and cost-effectiveness of the scheme. The authors identify several successful features of this approach, namely, independence, breadth of scope, timely reporting with regular feedback, and sustainability - monitoring outcomes over time helps to identify lasting change.
In a health budget that has received a R600-million boost, the Western Cape's drastic nursing shortage, HIV and Aids and tuberculosis are top of the list for the financial year, says Western Cape Health MEC Pierre Uys.
This study examined the experiences of poor people with health financing reforms that target them. The authors conducted a qualitative cross-sectional study in two purposively selected counties in Kenya, using focus group discussions and in-depth interviews with people in the lowest wealth quintile and health insurance subsidy programme beneficiaries. Health financing reforms reduced financial barriers and improved access to health services for poor people in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that health insurance subsidy programme beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among poor people.
In a statement ahead of the WHA meetings, APHRA coordinator Rotimi Sankore stated: “The World Health Assembly has in the past three years passed several resolutions on health financing and health worker shortages - yet there has been an overall increase in annual African deaths resulting from lack of sustainable health finance and health worker shortages. The worlds Health Ministers must now move from passing resolutions to effecting resolutions and emergency action to end the deaths of over 8 million Africans a year to preventable, treatable and manageable diseases, caused mainly by maternal mortality, child mortality, HIV/AIDS, TB and malaria.”
This article reviews trends and patterns of government spending in the East and Southern Africa region. It points out methodological challenges with interpreting data from the World Health Organization’s (WHO) Global Health Expenditure Database (GHED) and other sources. Government expenditure for health has increased for most countries, albeit at a slower rate than gross domestic product (GDP). In most countries there has been a prioritization away from health in government budgets, putting the onus on the private sector and external funders to fill the gap. Reliance on external funding is important in the region but argued to be inconsistent with countries’ stated ambitions of universal health coverage. A number of methodological challenges with estimating health expenditures are identified. Capturing health expenditures adequately across agencies and levels of decentralization can be challenging, and off-budget funds and arrears are evasive. Measurement error can be significant because actual expenditure information can be hard to come by and is often dated and unreliable. Furthermore, how external financing is captured will affect government health expenditure estimates. These factors have contributed to differences in expenditure estimates between WHO and country-specific public expenditure reviews and complicate interpretation. The article concludes that it is critical to strengthen national data capacity and international efforts to promote quality and consistency of data.