Paying for Health in poor countries

In too many countries access to basic health services is severely limited. Commitments for assistance from the international community are variable and provided for finite periods. Financial support of this kind doesn’t allow for the long-term investments needed to build a comprehensive health care system, such as infrastructure and training the necessary personnel.

In the latest IBP brief, Gorik Ooms of the Institute of Tropical Medicine proposes the creation of a Global Health Fund that could provide constant long-term support to poor countries. He argues that-as the creation of the Global Fund did in the fight against AIDS-a Global Health Fund could provide an international foundation on which national social health protection could be built.

He argues further that such a fund is affordable and sustainable if one looks at total global health expenditure rather than at the revenue of individual poor countries. If we assume that the global economy can afford to spend the equivalent of 4 % of their GDP on health – which is far less than what most countries are currently spending on health – then a health expenditure level of US$ 300 per person per year would become affordable and sustainable.

Ooms also argues that in the last analysis, the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights also puts a legal obligation on rich countries to support poor countries in this way.
What do you think? Will sustainable long term funding help poor countries create the health systems they need? And do you think that they creation of such a fund is sustainable?

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Global Health: What would Barack do?

As the American Presidential campaign heats up, it is good to see that candidates’ views on the US’s global health agenda is also getting some column space.

Unsurprisingly global health is nowhere near as prominent in the McCain campaign as it is for Obama. Apart from supporting PEPFAR, McCain has been vague on other global health issues.

In a recent CGD Policy Brief, health economist Ruth Levine sets out a systematic to-do list for Obama. Some of her key points are:

• Work more closely with UN and other multilateral partners
• Live up to your funding commitments, also smaller ones like those for malaria and child health
• Make decisions based on scientific evidence, not political or narrow moral preferences
• Find  a balance between AIDS and non-AIDS health spending (click here for more on this debate)
• Establish exchange programs for training and research.

Obama’s campaign documents have made extensive commitments around expanding PEPFAR; taking on drug and insurance companies and supporting the Global fund and the MDGs. He has also made promises about adressing health infrastructure and the migration of health workers.

True to form, though, these campaign promises don’t explain how all these promises will be paid for or how  the strong interests that litter the health sector in the US and the rest of the world will be navigated. While Obama may attach more importance to questions of global  health, it only merits one paragraph in his 64 page ‘Blueprint for Change‘. It seems fairly clear therefore that he would only be able to move as far and as quickly on global health as his domestic constituency will let him.

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Paying for Safe Sex in Tanzania

An innovative research proposal by the Center for Global Development to the Tanzanian government proposes to offer payments to women who repeatedly test negative for curable sexually transmitted infections, such as gonorrhea and syphilis.

They hope that reductions in unsafe sexual contacts will protect the women not only from the curable STIs but also from contracting or spreading HIV, and the research project will measure whether this happens.

To help them achieve these objectives and also to contribute to the womens’ success in other dimensions of their lives, the intervention will include substantial gender and life-skills counseling.

They offer the following arguments in support of the proposal:

• First, so-called “conditional cash transfers” have previously been shown to be successful in changing health-related behaviors and improving health. For example, in Mexico’s Progresa program cash grants conditional on a poor family’s preventive health visits are reportedly associated with improved health of the family, adults and children alike.
• Second, transfers which are conditional on remaining free of the curable STIs reward safe behavior among those who are already HIV-positive as as well as those who are not. This is in contrast to conventional HIV testing and counseling programs, which urge safe sex by appealing to the self-interest of those who test negative, but can only appeal to the altruism of those who are already infected.

The obvious concern about the program is that that it would effectively punished people who would need support, that is people who test positive. Another risk is that this program will encourage social exclusion of those who test positive. Further the program assumes that women have control over their sexual behaviour and does not seem to take sufficient account of the effects of gender inequality.

What do you think? Could this program work? How would it work in your country?

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Proof that democracy works? Health Services and Community-Based Monitoring in Uganda

Recent research by Martina Bjorkman and Jakob Svensson for the Centre for Economic Policy Research investigatez the impact of community based monitoring on the quality and quantity of health services in Uganda.

As communities began to monitor local health service providers, both the quality and quantity of health servicesimproved. One year into the program, Bjorkman and Svensson found large increases in utilization, significant weight-for-age gains of infants, and markedly lower deaths among children.

A Citizen Report Card methodology was used to record the experiences and preferences of communities and fed back to service providers. Communities also monitored whether their recommendations and desires were implemented. This mechanism created the incentives for improved health service delivery.

The results suggest that community monitoring can play an important role in improving service delivery when traditional top-down supervision is ineffective.

This project was designed by staff from Stockholm University and the World Bank, and implemented in cooperation with a number of Ugandan practitioners and 18 community-based organizations. The 50 project facilities (all in rural areas) were drawn from nine districts in Uganda and reached approximately 55,000 households. Thus the project has already shown that it can be brought to scale.

Macro-level research by political scientists has underlined the importance of the so-called ‘democratic dividend’. While the link between democracy and concrete benefits to citizens can seem tenuous on a large scale, this project demonstrates that the links are much clearer at a local level.

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Are we spending too much money on AIDS?

Roger England argues in a recent BMJ article that we spend more money on HIV/AIDS programs than the contribution of AIDS to the global burden of disease can justify. Predictably there have been some vehement and high profile responses to his article.

In short England argues that too much is spent on HIV relative to other needs and that this is damaging health systems. Although HIV causes 3.7% of global mortality, he argues, it receives 25% of international health care aid and a big chunk of domestic expenditure.

England argues further that Aids does not correlate with poverty as closely as expected. If this is true, it would mean that more people with AIDS can contribute to their own health care needs than we think.

Some of the key responses to England have been:

Underfunding of other diseases is the result of global underspending on Health, not the result of prioritizing AIDS

AIDS has its most devastating effects in poor communities that lack access to health services

In regions like Southern Africa, the burden of disease associated with AIDS does justify what is spent on it

The spread of AIDS is silent and the long incubation period means the virus has infected many people before illnesses manifest and the threat is apparent. As a result we don’t know at what level incidence will peak.

Donor conditionalities do not allow poor countries to prioritize health spending based on their own burden of disease.

This debate raises some key points. It seems clear that:

• This question should not just be asked of ‘global health spending’, but also of the health spending in each country
• Most poor countries do not spend enough money on health
• Donor conditionalities sometimes do distort health spending in recipient countries
• We have no way of knowing what the potential contribution of HIV/AIDS to the global burden of disease is.

You must have an opinion on this issue! Let us know what you think by clicking on ‘comments’ below.

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