Many low- and middle-income countries are seeking to reform their health financing systems to move towards universal coverage. This typically means that financing is based on people’s ability to pay while, for service use, bene-fits are based on the need for health care. Financing incidence analysis (FIA) and benefit incidence analysis (BIA) are two popular tools used to assess equity in health systems financing and service use. FIA studies examine who pays for the health sector and how these contributions are distributed according to socioeconomic status (SES). BIA determines who benefits from health care spending, with recipients ranked by their relative SES. In this article, the authors identify 10 resources to assist researchers and policy makers seeking to undertake or interpret findings from financing and benefit incidence analyses in the health sector. The article pays particular attention to the data requirements, computations, methodological challenges and country level experiences with these types of analyses.
Resource allocation and health financing
This paper looks at the potentially destructive polarisation between 'vertical' financing (aiming for disease-specific results) and 'horizontal' financing (aiming for improved health systems) of health services in developing countries. The authors propose 'diagonal' financing, which aims for disease-specific results through improved health systems to prevent certain diseases from receiving disproportionate resources within a chronically under-funded health system. Rather, specific interventions should drive improvements in the health system, tackling the wide-reaching problems of human resource development, financing, facility planning, drug supply, rational prescription and quality assurance. This would involve the transformation of the Global Fund to fight AIDS, Tuberculosis and Malaria into a Global Health Fund, which requires substantial donor increases and should happen gradually and carefully, accompanied by measures to safeguard its exceptional features.
The potentially destructive polarisation between 'vertical' financing (aiming for disease-specific results) and 'horizontal' financing (aiming for improved health systems) of health services in developing countries has found its way to the pages of Foreign Affairs and the Financial Times. The opportunity offered by 'diagonal' financing (aiming for disease-specific results through improved health systems) seems to be obscured in this polarisation.In April 2007, the board of the Global Fund to fight AIDS, Tuberculosis and Malaria agreed to consider comprehensive country health programmes for financing. The new International Health Partnership Plus, launched in September 2007, will help low-income countries to develop such programmes. The combination could lead the Global Fund to fight AIDS, Tuberculosis and Malaria to a much broader financing scope. This evolution might be critical for the future of AIDS treatment in low-income countries, yet it is proposed at a time when the Global Fund to fight AIDS, Tuberculosis and Malaria is starved for resources. It might be unable to meet the needs of much broader and more expensive proposals. Furthermore, it might lose some of its exceptional features in the process: its aim for international sustainability, rather than in-country sustainability, and its capacity to circumvent spending restrictions imposed by the International Monetary Fund. The authors believe that a transformation of the Global Fund to fight AIDS, Tuberculosis and Malaria into a Global Health Fund is feasible, but only if accompanied by a substantial increase of donor commitments to the Global Fund. The transformation of the Global Fund into a 'diagonal' and ultimately perhaps 'horizontal' financing approach should happen gradually and carefully, and be accompanied by measures to safeguard its exceptional features.
The focus of this report is on sub-Saharan Africa because this region appears to be particularly lagging behind in the sphere of the provision of social protection, being at the same time more vulnerable than other developing areas. More people live below the poverty line, more people die of HIV or malaria, income distribution is very unequal, more people depend on volatile agriculture, the climate changes threaten to bring about more dramatic natural disasters, state institutions are often unrecognised or illegitimate, economies are less diversified and violent conflict is rife. In the aftermath of the three crises (food, fuel and financial), which in a short time span have hit the world economy, sub-Saharan Africa has little resources to react. The European Union, together with other external funders, this paper argues, should pursue a development policy that reinforces social protection and, in particular, can help sub-Saharan African countries to build resilience through social protection, and break out of vicious circles and poverty traps. However, the paper cautions that any action can interfere with ownership; furthermore, overseas development assistance can itself become a source of vulnerability if the initial commitments in terms of amounts, targets and time horizon are not fulfilled.
The world has officially entered the final leg of its 15-year journey to halve extreme poverty and reduce child mortality by two-thirds, reverse the tide against HIV/AIDS and malaria, and ensure that more people have access to basic services, such as primary education and safe drinking water. Despite a challenging global economic environment, many low and middle-income countries are making dramatic progress towards the highly ambitious MDG targets. ONE’s 2013 DATA Report examines the recent progress of individual countries against eight MDG targets, focusing particular attention on sub-Saharan Africa, and compares that progress against African government and donor spending in three key poverty-reducing sectors: health, education, and agriculture.
Community-based health insurance expansion has been proposed as a financing solution for the sizable informal sector in low-income settings. However, there is limited evidence of the administrative costs of such schemes. We assessed annual facility and district-level costs of running the Community Health Fund (CHF), a voluntary health insurance scheme for the informal sector in a rural and an urban district from the same region in Tanzania. Information on resource use, CHF membership and revenue was obtained from district managers and health workers from two facilities in each district. The administrative cost per CHF member household and the cost to revenue ratio were estimated. Revenue collection was the most costly activity at facility level (78% of total costs), followed by stewardship and management (13%) and pooling of funds (10%). Stewardship and management was the main activity at district level. The administration cost per CHF member household ranged from USD 3.33 to USD 12.12 per year. The cost to revenue ratio ranged from 50% to 364%. The cost of administering the CHF was high relative to revenue generated. Similar studies from other settings should be encouraged.
There are over a million older persons in Uganda, many of whom lack food, money, clean water and medical support and have lost their children to war and AIDS. This paper, based on a survey of older persons and a follow-up conference, which analysed the results, collates the major issues facing many older persons in Uganda, the policy response so far and outlines priorities for action in the future. Despite the fact that in the Ministry of Gender, Labour and Social Development, there is a Minister of State for Elderly and Disability, there is in 2008 still no policy for older persons. Lack of a formal policy on ageing is harming the elderly in Uganda. The government needs to introduce specific programmes to support older persons who care for their orphaned grandchildren, start HIV and AIDS education and testing programmes for older persons, initiate geriatric medicine at hospitals and health centres and establish a National Council on Ageing.
This study focuses on two main areas, namely aid agency effectiveness (cost effectiveness of agencies) and aid policy effectiveness (the cost of parallel development policy making). Whereas other areas of the Paris agenda are equally important (like ownership, mutual accountability, and a focus on results), this study explored the costs, and put a price-tag on not implementing the Paris agenda. The study reviewed the aid effectiveness literature to date, most of which point to benefits of coordination. The European Commission found direct savings for the European Union (EU) through lower administrative costs from harmonising, from reducing the number of partner countries, changing the aid modality towards Budget Support (general or sectoral), untying aid and eliminating aid volatility. The total efficiency gains were estimated at € 5 billion per year.
Following the ARV roll out in South Africa, people living with HIV (PLHIV) experienced improved health that, in turn, affected their grant eligibility. The aim of this paper was to explore whether PLHIV reduced or stopped treatment to remain eligible for the disability grant from the perspectives of both PLHIV and their doctors. Researchers conducted interviews with 29 PLHIV and eight medical doctors working in the public sector, as well as three focus group discussions with programme managers, stakeholders and community workers, and a panel survey of 216 PLHIV receiving anti-retrovirals (ARVs). They found that unemployment and poverty were the primary concerns for PLHIV and the disability grant was viewed as a temporary way out of this vicious cycle. Although loss of the disability grant significantly affected the well-being of PLHIV, they did not discontinue ARVs. However, in a number of subtle ways, PLHIV "tipped the scales" to lower the CD4 count without stopping ARVs completely. Grant criteria were deemed ad hoc, and doctors struggled to balance economic and physical welfare when assessing eligibility. The researchers call on government to ensure that it provides sustainable economic support in conjunction with ARVs in order to make "positive living" a reality for PLHIV. A chronic illness grant, a basic income grant or an unemployment grant could provide viable alternatives when the PLHIV are no longer eligible for a disability grant.
Despite progress in the fight against AIDS over the past few years, this report warns that the gains that the world has made are in danger of being lost. There is not yet shared global responsibility for achieving the goal of ending AIDS, nor have stakeholders mapped out a collective plan for how to achieve the goal with specific responsibilities or time-bound milestones. ONE argues that there must be a renewed effort to examine, improve and scale up the financial, political and programmatic efforts needed to turn vision into action. In this report, ONE monitors progress on improving access to treatment and reducing new HIV infections; provides an assessment of the G7 countries’ and the European Commission’s past and current efforts in the fight against HIV and AIDS globally; and sets a baseline for monitoring future progress towards the beginning of the end of AIDS. The organisation calls on external funders from the West to work in closer partnership with each other and with African governments, emerging economy governments, the private sector and civil society groups to leverage unique skill-sets and resources, all aimed towards the achievement of common targets. While funding remains one of the largest hurdles in making progress towards this vision, additional efforts to address the AIDS pandemic cannot come at the expense of financing for other global health and development initiatives.