The author, working for the medical humanitarian organisation Médecins Sans Frontières (MSF), which uses the medical relief paradigm, has argued that the health development paradigm and its focus on sustainability – defined as the aim of replacing foreign assistance with domestic resources within a foreseeable future – is one of the main reasons we are not able to realise universal coverage. A new global health aid paradigm would aim for technical sustainability, as in the health development paradigm, but without aiming for financial sustainability. It would tolerate open-ended external financing, but without relying on external human resources for management and implementation. The Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund)distinguishes between technical and financial sustainability: it has abandoned financial sustainability, not technical or ‘programmatic’ sustainability. When countries use their Global Fund grants wisely and effectively, they can count on continued support from the Global Fund. In adopting this approach, the Global Fund is – implicitly – using a human rights based approach. Foreign assistance, aimed at the realisation of essential human rights, is not a matter of charity; it is a matter of fulfilling international legal obligations. There is no reason to assume that global health aid will disappear (which is the underlying assumption of the aim of financial in-country sustainability). On the contrary there are many reasons to insist that global health aid should continue and increase.
Resource allocation and health financing
According to this policy brief, European aid donors are taking steps to meet promises to deliver a higher share of development aid directly to governments in the form of budget support. The brief points to positive and negative consequences of budget support. While budget support is argued to enhance local accountability, it may not succeed unless government recipients are accountable to their populations for how the funds are used. A more self-serving reason is argued for donors to turn to budget support – it enables the donor to increase aid delivery, thus meeting disbursement rates, without requiring an enlargement of their own administrative operations, thereby keeping costs down. This motivation has more to do with donors’ institutional dynamics than with poverty reduction. The brief calls for a more nuanced political analysis to ensure that budget support enhances rather than undermines democratic accountability in developing countries.
There is no good reason why a country with an income of US$366 per capita cannot afford to increase its domestic health spending from US$20 to US$34. It is the value of forgone alternative benefits (as perceived through either collective decision making or unilateral decisions of political authority) that puts a limit on how much a society can spend on health, not some health expenditure-GDP ratio technical limit. Further, general lessons of experience from parts of east and south-east Asia and Latin America show that, as countries experience substantial broad-based economic and social progress, greater health funding becomes feasible. Such a situation requires time, but has been realised in these countries within about 20 to 40 years. The author believes it will take a long time to reduce the high dependency on donor aid, but Africa should aim to increase domestic resource mobilisation.
Using South Africa as a case study, this review examines whether private health systems are susceptible to regulation and therefore able to support an extension and deepening of coverage when complementing a pre-existing publicly funded and delivered health system. The study finds that the private health system in South Africa has played an important supplementary role in achieving universal coverage throughout its history, but more especially in the post-Apartheid period. However, the quality of this role has been erratic, influenced predominantly by policy vacillation. The objective of universal coverage can be seen in two dimensions, horizontal extension and vertical deepening. Private systems play an important role in deepening coverage by mobilising revenue from income earners for health services over-and-above the horizontal extension role of public systems and related subsidies. South Africa provides an example of how this natural deepening occurs whether regulated or unregulated. It also demonstrates how poor regulation of mature private systems can severely undermine this role and diminish achievements below attainable levels of social protection. When measures to enhance risk pooling are introduced, coverage is expanded and becomes increasingly fair and sustainable. When removed, however, the system becomes less stable and fair as costs rise and people with poor health status are systematically excluded from cover.
Dr. Roland Msiska, Project Director for UNOPS executed UNDP Regional Project on HIV and Development in sub-Saharan Africa-Pretoria, South Africa.
This paper attempts to contribute to potential ways of ensuring that the momentum that has been generated by UNGASS and the creation of the GFATM for an effective well coordinated response to HIV, especially in Africa, is increased and sustained for at least 20 years. In order to achieve this, I am suggesting that we respond to the following questions: (a). What is the current situation of HIV/AIDS and what are the implications for achieving the global millennium goals? (b). What are the key areas of focus for sustaining the momentum of UNGASS implementation at global, regional and national levels? (c). How can we ensure that the GFATM facilitates the implementation of UNGASS at global, regional and national levels? (d). How can we ensure that wealthy nations facilitate countries in the sub-Saharan Africa to meet UNGASS commitments?
Is the sector approach still relevant to development assistance and aid given the track record and the rapidly changing global context? Or is it time – again – to look for something new that might work better? This paper argues that the sector approach continues to be relevant, but that it needs to become a 'sector approach version 2.0'. This requires significant – and difficult - changes in how external funders work. The new approach has to make where connectivity, collaboration, communication and horizontal knowledge acquisition central to its aims. This entails addressing five closely linked challenges: accepting the complexity of the task; working proactively with the new global interconnectedness; paying more attention to knowledge, dialogue, quality and results; adapting the sector approach to the specific context and sector, particularly in fragile situations; and gaining leverage as 'brokers' of knowledge and agendas.
This document was prepared as a follow-up to the United Nations Summit on Non-communicable Diseases, held in September 2011. It proposes a micro-levy on tobacco products – the Solidarity Tobacco Contribution (STC) – that can be used to generate revenue for Health Ministries. The STC concept builds on and is additional to existing national taxes on tobacco products and broader World Health Organisation (WHO) recommendations for countries to raise their tobacco taxes for public health goals. It does not replace existing national tobacco excise taxes nor does it exclude the need to increase them to WHO‐recommended levels. It is intended to achieve three simultaneous benefits: public health benefits by reducing tobacco consumption and saving lives; a source of revenue to support health; and financial support for international health efforts in developing countries. WHO has conducted an economic feasibility study and has determined that potential revenue from the STC, if applied in 43 countries (G20+), could generate between US$5.5 billion and US$16 billion each year.
African States are on average far from meeting key health financing goals such as the Abuja Declaration target of allocating 15% of the government budget to health. Out-of-pocket expenditure is still higher than 40% of the total health expenditure in 20 of 45 African countries, and in 22 countries the total health expenditure does not reach even the minimal level of US$ 44 per capita defined by the High Level Task Force on Innovative International Financing for Health Systems (HLTF). Only three countries have attained the Abuja Declaration and HLTF targets. Many countries have limited capacity of raising public revenue mainly because the informal nature of their economies makes collection of tax and contributions difficult. This limits their opportunities for investing in health. The paper presents trends in health financing in African countries and calls for close collaboration between the ministries of finance and health and inter-ministerial dialogue to develop a health financing strategy that supports efforts to strengthen all the other health system dimensions to move towards universal health coverage.
This report warns that if urgent and strategic action is not taken to close the gaps in funding, research and global immunisation coverage, the world will see the re-introduction of old diseases and the emergence of new infections. The report was launched in Dakar, Senegal, at the 2nd Partners' Meeting of the Global Alliance for Vaccines and Immunisation (GAVI). Jointly produced by the World Health Organisation (WHO), UNICEF and the World Bank, the report highlights remarkable achievements in immunisation over the last decade and outlines the challenges for the future.
Since 2008 there has been much debate about where agencies, NGOs, programmes and countries might turn to for sustainable funding. One thing is very clear, says the author of this blog: Global Health, including HIV, no longer enjoys the same enthusiasm it once did. The relative ease of garnering financing for malaria bed nets or innovations in drug distribution that NGOs and agencies experienced in 2005 has yielded to tough slogging for basic financing in 2013. For ministries of health and country-based health programmes this shift ushers need to look to domestic sources for support. South Africa is the first significant aid recipient to set a goal for complete health self-reliance, and actually meet most of its targets en route. Combined with a package of new taxes on everything from cell phone use to plane flights, alcohol and tobacco levies could garner African countries an additional $15.5 billion. Two obstacles obviously stand in the way, according to the author: The political will for governments to implement what undoubtedly would be unpopular use taxes, and the monumental fights within government over allocation of those revenues. Just because a country gleans a fresh $1 billion from such taxes by no means assures the government will allocate most, or even any of it, to health programmes.