Most low- and middle-income countries face financing pressures if they are to adequately address the recommendations of the Global Strategy for Women’s, Children’s and Adolescent’s Health. Negotiations between government ministries of health and finance are a key determinant of the level and effectiveness of public expenditure in the health sector. Yet ministries of health in low- and middle-income countries do not always have a good record in obtaining additional resources from key decision-making institutions. This is despite the strong evidence about the affordability and cost–effectiveness of many public health interventions and of the economic returns of investing in health. This article sets out 10 attributes of effective budget requests that can address the analytical needs and perspectives of ministries of finance and other financial decision-makers. The authors developed the list based on accepted economic principles, a literature review and a workshop in June 2015 involving government officials and other key stakeholders from low- and middle-income countries. The aim is to support ministries of health to present a more strategic and compelling plan for investments in the health of women, children and adolescents.
Resource allocation and health financing
Mark Pearson, 2001. HSRC Health Systems Research Center, Institute for Health Sector Development (IHSD), DFID's Health Population Department, London, UK
The way in which a country finances its health care can have a major bearing on the access to health services enjoyed by its poor. National health policies generally set out a strategic goal of ensuring equal access to essential health services for all, on the basis of need and irrespective of ability to pay or some variation on this theme. Health financing impacts on this goal in two ways: on the supply side by ensuring that essential services are adequately financed and delivered, and on the demand side by reducing financial barriers to access and by making sure that funds are raised and services delivered in ways which are affordable to all. In a typical low income country, where only $3 - $5 of public funds per head is available for the health sector, such an ambitious goal is probably unrealistic no matter how well resources are allocated and used. In practice, there will often be significant inefficiency and inequity in both allocation and use of resources. This clearly raises the question as to whether, and how, financing policies could be made more pro-poor.
About one-third of foreign aid from developed countries is now channelled through or directly to civil society in developing countries. There is a significant change in the way donors give support to civil society, including pooling donor support through national and regional intermediaries; multiple funding agencies and adoption of a variety of support models. Based on a detailed analysis of seven country case studies (Botswana, Lesotho, Malawi, Namibia, South Africa, Zambia and Zimbabwe), the findings challenge the conventional wisdom and advance the civil society agenda in certain key ways.
According to this article, the Forum on China-Africa Co-operation is the main mechanism whereby China’s Ministry of Foreign Affairs and its Ministry of Commerce are starting to align their respective responsibilities toward more effective co-ordination and implementation of a Chinese foreign policy and aid policy toward Africa. Figures on China’s aid disbursements to Africa remain vague, the authors note, in absence of a central Chinese aid agency to monitor funding flows to the continent. Part of China’s strategic industrial plan for Africa is to establish five preferential trade and industrial zones for Chinese business entry in Africa: Zambia, Mauritius, Egypt, Nigeria and possibly Tanzania. In 2007, The Chinese Development Bank was designated to manage the US$5 billion China-Africa Development Fund, but the authors cautions that, even though it is termed a ‘development fund’, it has been actually put in place to finance the market entry of Chinese firms into the African economy. In conclusion, the authors provide recommendations to relevant stakeholders that are engaged in the aid process. Recommendations for African countries include developing a better understanding of the Chinese approach to aid; facilitating regional co-ordination; avoiding poor co-ordination which may lead to Chinese aid fatigue; avoiding the division between traditional and emerging donors; strengthening the African voice; improving the reporting mechanisms within recipient countries; and improving debt reporting.
Drawing on a study conducted in five African countries, the authors of this paper explore different stakeholder perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and health and how different stakeholders perceive this. The countries were Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi. Key background documents were analysed and 258 semi-structured interviews and 45 focus group discussions were held. Although the researchers found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS.
IRIN News has compiled this summary of aid successes and shortfalls among major external funders (donors) in 2010. European Union (EU) member states made pledges to provide 0.56% of gross national income (GNI) as official development aid by 2010, with a view to increasing to 0.7% by 2015. Together, they missed this target by US$21 billion; delivering just under four fifths of the commitment. The UK met the 0.56% goal, putting US$8.5 billion towards development aid in 2010; Germany gave 0.38% at $7.8 billion; and the US $18.5 billion - or 0.21% of GNI. The worst EU aid performers in terms of the proportion of GNI are Italy, Greece, Portugal, Austria and Germany. Best-performing are Sweden, Denmark, Luxembourg, Netherlands and Belgium. G8 and EU aid to sub-Saharan Africa was the highest on record in 2010 at US$18.2 billion; but lower than commitments pledged by G8 leaders in 2005. Assistance to sub-Saharan Africa has increased to $19.6 billion since 2000 - $15.6 billion of it coming from G7 countries (France, Germany, Italy, Japan, UK, USA and Canada). The G7 delivered 60% of the increase they promised to sub-Saharan Africa in 2005 - largely because the USA, Japan and Canada surpassed their targets, and the UK delivered 86% of its commitment, with an increase of $2.55 billion. Italy, Germany and France are mainly responsible for the shortfall. Italy's aid to sub-Saharan Africa has declined by $78million since 2004.
An effective referral system is a key element of health services based on primary healthcare (PHC). If referral steps are bypassed, treatment costs are greater than necessary. Higher level hospitals become overloaded while lower level facilities are underused. Why do referral systems fail and how can they be improved?
In the Democratic Republic of Congo, recognising the need for reliable health workforce information, the government has worked to implement iHRIS, an open source human resources information system that facilitates health workforce management. In Kasaï Central and Kasaï Provinces, health workers brought relevant documentation to data collection points, where trained teams interviewed them and entered contact information, identification, photo, current job, and employment and education history into iHRIS on laptops. After uploading the data, the Ministry of Public Health used the database of over 11 500 verified health worker records to analyse health worker characteristics, density, compensation, and payroll. Both provinces had less than one physician per 10 000 population and a higher urban versus rural health worker density. Most iHRIS-registered health workers (57% in Kasaï Central and 73% in Kasaï) reported receiving no regular government pay of any kind (salaries or risk allowances). Payroll analysis showed that 27% of the health workers listed as salary recipients in the electronic payroll system were ghost workers, as were 42% of risk allowance recipients. As a result, the Ministries of Public Health, Public Service, and Finance reallocated funds away from ghost workers to cover salaries and risk allowances for thousands of health workers who were previously under- or uncompensated due to lack of funds. The reallocation prioritised previously under- or uncompensated mid-level health workers, with 49% of those receiving salaries and 68% of those receiving risk allowances representing cadres such as nurses, laboratory technicians, and midwifery cadres. The authors observe that assembling accurate health worker records can help governments understand health workforce characteristics and use data to direct scarce domestic resources to where they are most needed.
The question of how developing countries can improve domestic resource mobilisation (DRM) was one of the main topics under discussion at the latest International Tax Compact (ITC) meeting held from 12 to 14 September 2011 in Bonn, Switzerland. The communiqué identifies five main issues facing developing countries looking to improve DRM: taxation and public financial management; taxation and state-building; taxation for economic growth; extractive resource taxation; and international taxation. Although each of these has been the focus of research, the most interesting questions and issues appear to lie at the intersection of each of these, such as how to align public financial management reforms relating to tax with the objectives of promoting economic growth and state capacity. Many of the issues were touched upon during the ITC meeting, and the discussions highlighted the important research being conducted on both the nature of the challenges developing countries must overcome and the technical and governance aspects of tax reforms. Enhancing tax revenues is not an end in itself, participants emphasised, as taxation is at the centre of resilient state-society relations and must therefore be linked with governance efforts and public service delivery and should be undertaken ‘with an overarching view to make tax systems more pro-poor’.
As aid diminishes in importance, the authors argue that governments need to improve the quality of their public spending. This paper suggests three organisational tools - independent ratings of spending systems, independent public service agencies, and sovereign development funds- as a means of assessing public spending.