The Economic Burden of Severe Acute Malnutrition with Complications: A Cost Analysis for Inpatient Children Aged 6 to 59 Months in Northern Senegal.

Severe acute malnutrition (SAM) is a high-fatality condition that affected 13.7 million children under five years of age worldwide in 2022, with complicated cases requiring extensive inpatient stay with an accompanying caregiver. Our objective was to assess the costs of inpatient treatment for complicated SAM in children aged 6 to 59 months in Northern Senegal and identify cost predictors. We performed a retrospective cost analysis, including 140 children hospitalized from January to December 2020 in five SAM inpatient treatment facilities. We adopted a societal perspective, including direct medical and non-medical costs and indirect costs. We extracted patients' sociodemographic and clinical data from medical records and conducted semi-structured interviews with healthcare staff to capture information on time allocation and care management. A multivariable generalized linear model with gamma family and a log link was used to investigate the factors associated with direct costs. Costs are expressed in 2020 international USD using purchasing power parity. Mean length of stay was 5.3 (SD = 3.2) days and diarrhoea was the cause of the admission in 55.7% of cases. Mean total cost was USD 431.9 (SD = 203.9), with personnel being the largest cost item (33% of the total). Households' out-of-pocket expenses represented 45.3% of total costs and amounted to USD 195.6 (SD = 103.6). Costs were significantly associated with gender (20.3% lower in boys), diarrhoea (27% increase), anaemia (49.4% increase), inpatient death (44.9% decrease), and type of facility (26% higher in hospitals vs. health centre). Our study highlights the financial burden of complicated SAM in Senegal in particular for families. This underscores the need for tailored prevention and social policies to protect families from the disease's financial burden and improve treatment adherence, both in Senegal and similar contexts.

Costs associated with informal health care pathway for patients with suspected Lyme borreliosis.

OBJECTIVES: To compare the direct and indirect medical costs for patients with suspected Lyme borreliosis according to whether or not they had used an informal care pathway. PATIENTS AND METHODS: We retraced the care pathways of participating patients by a prospective questionnaire survey and a retrospective analysis of care records. Direct and indirect costs were estimated using a micro-costing method from different perspectives. We compared the costs of patients who had consulted a "Lyme Doctor" (informal care pathway) with those who had only used the formal care pathway. Non-parametric tests were appraised the significance of the differences between the two groups of patients. RESULTS: Out of 103 eligible patients, 49 (including 12 having used an informal health care pathway) agreed to be investigated. Five expenditure items entirely borne by patients were significantly higher for patients following an informal care pathway: productivity loss (3041 ± 6580 vs 194 ± 1177 euros, p = 0.01), alternative therapies (3484 ± 7308 vs 369 ± 956 euros), biological tests sent abroad (571 ± 1415 vs 17 ± 92 euros, p < 0.01), self-medication (918 ± 1998 vs 133 ± 689, p = 0.02) and transport (3 094 ± 3456 vs 1 123 ± 1903p = 0.01). CONCLUSIONS: From the patient's standpoint, the informal care pathway involving consultation with a Lyme Doctor is far more expensive than the formal care pathway. More specifically, the patient has to bear the costs of alternative treatments and repeated, non-recommended examinations.

Efficiency of district hospitals in Zimbabwe: Assessment, drivers and policy implications.

The Government of Zimbabwe is committed to making progress towards universal health coverage. Unmet health needs are huge and the health system suffers from serious dysfunctions and weaknesses. The situation is further complicated by a weak governance. To address these challenging issues, many of which would require an increase in public health expenditures, the government faces severe macroeconomic constraints. In this context, improving the efficiency of public health expenditures is of paramount importance. This study focuses on the efficiency of district hospitals, whose role is crucial for the strengthening of the health care system and achieving significant results in implementing the universal health coverage. Based on a sample of 31 district hospitals observed from 2015 to 2017 we use the double bootstrap procedure developed by Simar and Wilson to (a) estimate bias-adjusted DEA efficiency scores and to (b) investigate the factors associated with the previously calculated scores using truncated regression. The average efficiency of district hospitals is low and stagnant over 2015-2017. The findings suggest the existence of a significant room for maneuver to get more results with the resources spent. The analysis of the efficiency drivers shows the importance of both supply and demand-side factors, leading to several policy-oriented considerations. The study also highlights important shortcomings in the routine collection of basic data that need to be addressed by the Ministry of Health and Child Care.

The impact of the obstetrical risk insurance scheme in Mauritania on maternal healthcare utilization: a propensity score matching analysis.

In Mauritania, obstetrical risk insurance (ORI) has been progressively implemented at the health district level since 2002 and was available in 25% of public healthcare facilities in 2015. The ORI scheme is based on pre-payment scheme principles and focuses on increasing the quality of and access to both maternal and perinatal healthcare. Compared with many community-based health insurance schemes, the ORI scheme is original because it is not based on risk pooling. For a pre-payment of 16-18 USD, women are covered during their pregnancy for antenatal care, skilled delivery, emergency obstetrical care [including caesarean section (C-section) and transfer] and a postnatal visit. The objective of this study is to evaluate the impact of ORI enrolment on maternal and child health services using data from the Multiple Indicator Cluster Survey (MICS) conducted in 2015. A total of 4172 women who delivered within the last 2 years before the interview were analysed. The effect of ORI enrolment on the outcomes was estimated using a propensity score matching estimation method. Fifty-eight per cent of the studied women were aware of ORI, and among these women, more than two-thirds were enrolled. ORI had a beneficial effect among the enrolled women by increasing the probability of having at least one prenatal visit by 13%, the probability of having four or more visits by 11% and the probability of giving birth at a healthcare facility by 15%. However, we found no effect on postnatal care (PNC), C-section rates or neonatal mortality. This study provides evidence that a voluntary pre-payment scheme focusing on pregnant women improves healthcare services utilization during pregnancy and delivery. However, no effect was found on PNC or neonatal mortality. Some efforts should be exerted to improve communication and accessibility to ORI.

Cost-effectiveness of diagnostic algorithms including lateral-flow urine lipoarabinomannan for HIV-positive patients with symptoms of tuberculosis.

BACKGROUND: Tuberculosis (TB) is the leading cause of death among HIV-positive patients. We assessed the cost-effectiveness of including lateral-flow urine lipoarabinomannan (LF-LAM) in TB diagnostic algorithms for severely ill or immunosuppressed HIV-positive patients with symptoms of TB in Kenya. METHODS: From a decision-analysis tree, ten diagnostic algorithms were elaborated and compared. All algorithms included clinical exam. The costs of each algorithm were calculated using a 'micro-costing' method. The efficacy was estimated through a prospective study that included severely ill or immunosuppressed (CD4<200cells/µL) HIV-positive adults with symptoms of TB. The cost-effectiveness analysis was performed using the disability-adjusted life year (DALY) averted as effectiveness outcome. A 4% discount rate was applied. RESULTS: The algorithm that added LF-LAM alone to the clinical exam lead to the least average cost per TB case detected (€47) and was the most cost-effective with a cost/DALY averted of €4.6. The algorithms including LF-LAM, microscopy and X-ray, and LF-LAM and Xpert in sputum, detected a high number of TB cases with a cost/DALY averted of €6.1 for each of them. In the comparisons of the algorithms two by two, using LF-LAM instead of microscopy (clinic&LAM vs clinicµscopy) and using LF-LAM along with GeneXpert in sputum instead of GeneXpert in urine along with GeneXpert in sputum, (clinic&LAM&Xpert_sputum vs clinic&Xpert_sputum&Xpert_urine) led to the highest increase in the cost-effectiveness ratios (ICERs): €-7.2 and €-12.6 respectively. In these two comparisons, using LF-LAM increased the number of TB patients detected while reducing costs. Adding LF-LAM to smear microscopy alone or to smear microscopy and Xray led to the highest increase in the additional number of TB cases detected (31 and 25 respectively) with an incremental efficiency estimated at 134 and 344 DALYs respectively. The ICERs were €22.0 and €8.6 respectively. CONCLUSION: Including LF-LAM in TB diagnostic algorithms is cost-effective for severely ill or immunosuppressed HIV-positive patients.

Analyzing the Financial Sustainability of User Fee Removal Policies: A Rapid First Assessment Methodology with a Practical Application for Burkina Faso.

The purpose of this paper is to briefly present a methodological framework that does not require cumbersome investigations for a first assessment of the financial sustainability of policies aiming to remove or reduce healthcare user fees (the so-called free healthcare policy [FHCP]). This paper is organized in two main sections. The first analyzes the various possibilities available to finance an FHCP. Using several scenarios, it includes a special focus devoted to the calculus of what to consider when assessing the sustainability of expanding fiscal space for financing the FHCP. The second section relies on the current FHCP being implemented in Burkina Faso to illustrate a selection of specific issues raised in the methodological framework. The results suggest that sustainable FHCP financing is not outside the range of the government but does represent a significant challenge, as it will require, both currently and in the future, complex and delicate budget trade-offs at the highest governmental levels, regardless of other policy options to be considered.

Do free caesarean section policies increase inequalities in Benin and Mali?

BACKGROUND: Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced. METHODS: We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries. RESULTS: We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present. CONCLUSIONS: Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa.

INTRODUCTION: Mali and Benin introduced a user fee exemption policy focused on caesarean sections in 2005 and 2009, respectively. The objective of this study is to assess the impact of this policy on service utilisation and neonatal outcomes. We focus specifically on whether the policy differentially impacts women by education level, zone of residence and wealth quintile of the household. METHODS: We use a difference-in-differences approach using two other western African countries with no fee exemption policies as the comparison group (Cameroon and Nigeria). Data were extracted from Demographic and Health Surveys over four periods between the early 1990s and the early 2000s. We assess the impact of the policy on three outcomes: caesarean delivery, facility-based delivery and neonatal mortality. RESULTS: We analyse 99 800 childbirths. The free caesarean policy had a positive impact on caesarean section rates (adjusted OR=1.36 (95% CI 1.11 to 1.66; P≤0.01), particularly in non-educated women (adjusted OR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those living in rural areas (adjusted OR=2.02; 95% CI 1.48 to 2.76; P≤0.001) and women in the middle-class wealth index (adjusted OR=3.88; 95% CI 1.77 to 4.72; P≤0.001). The policy contributes to the increase in the proportion of facility-based delivery (adjusted OR=1.68; 95% CI 1.48 to 1.89; P≤0.001) and may also contribute to the decrease of neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to 0.85; P≤0.001). CONCLUSION: This study is the first to evaluate the impact of a user fee exemption policy focused on caesarean sections on maternal and child health outcomes with robust methods. It provides evidence that eliminating fees for caesareans benefits both women and neonates in sub-Saharan countries.

Cost-effectiveness analysis and mortality impact estimation of scaling-up pregnancy test kits in Madagascar, Ethiopia and Malawi.

Cost-effective, innovative approaches are needed to accelerate progress towards ending preventable infant, child and maternal mortality. To inform policy decisions, we conducted a cost-effectiveness analysis of adding urine pregnancy test kits to the maternal and reproductive services package offered at the community level in Madagascar, Ethiopia and Malawi. We used a decision tree model to compare the intervention with the status quo for each country. We also completed single factor sensitivity analyses and Monte Carlo simulations with 10 000 iterations to generate the probability distribution of the estimates and uncertainty limits. Among a hypothetical cohort of 100 000 women of reproductive age, we estimate that over a 1-year period, the intervention would save 26, 35 and 48 lives in Madagascar, Ethiopia, and Malawi, respectively. The Incremental Cost Effectiveness Ratio (ICER) for the cost per life saved varies by country: $2311 [95% Uncertainty Interval (UI): $1699; $3454] in Madagascar; $2969 [UI: $2260; $5041] in Ethiopia and $1228 [UI: $918; $1777] in Malawi. This equates to an average cost per Disability Adjusted Life Year (DALY) averted of $36.28, $47.95 and $21.92, respectively. Based on WHO criteria and a comparison with other maternal, newborn, and child health interventions, we conclude that the addition of urine pregnancy tests to an existing community health worker maternal and reproductive services package is highly cost-effective in all three countries. To optimize uptake of family planning and antenatal care services and, in turn, accelerate the reduction of mortality and DALYs, decision makers and program planners should consider adding urine pregnancy tests to the community-level package of services.

Use of health care among febrile children from urban poor households in Senegal: does the neighbourhood have an impact?

Urban malaria is considered a major public health problem in Africa. The malaria vector is well adapted in urban settings and autochthonous malaria has increased. Antimalarial treatments prescribed presumptively or after rapid diagnostic tests are also highly used in urban settings. Furthermore, health care strategies for urban malaria must comply with heterogeneous neighbourhood ecosystems where health-related risks and opportunities are spatially varied. This article aims to assess the capacity of the urban living environment to mitigate or increase individual or household vulnerabilities that influence the use of health services. The data are drawn from a survey on urban malaria conducted between 2008 and 2009. The study sample was selected using a two-stage randomized sampling. The questionnaire survey covered 2952 households that reported a case of fever episode in children below 10 years during the month before the survey.Self-medication is a widespread practice for children, particularly among the poorest households in Dakar. For rich households, self-medication for children is more a transitional practice enabling families to avoid opportunity costs related to visits to health facilities. For the poorest, it is a forced choice and often the only treatment option. However, the poor that live in well-equipped neighbourhoods inhabited by wealthy residents tend to behave as their rich neighbours. They grasp the opportunities provided by the area and adjust their behaviours accordingly. Though health care for children is strongly influenced by household socio-economic characteristics, neighbourhood resources (facilities and social networks) will promote health care among the poorest and reduce access inequalities. Without being a key factor, the neighbourhood of residence-when it provides resources-may be of some help to overcome the financial hurdle. Findings suggest that the neighbourhood (local setting) is a relevant scale for health programmes in African cities.

Socioeconomic status and stroke prevalence in Morocco: results from the Rabat-Casablanca study.

BACKGROUND: Stroke is a growing public health concern in low- and middle- income countries. Improved knowledge about the association between socioeconomic status and stroke in these countries would enable the development of effective stroke prevention and management strategies. This study presents the association between socioeconomic status and the prevalence of stroke in Morocco, a lower middle-income country. METHODS: Data on the prevalence of stroke and stroke-related risk factors were collected during a large population-based survey. The diagnosis of stroke in surviving patients was confirmed by neurologists while health, demographic, and socioeconomic characteristics of households were collected using structured questionnaires. We used Multiple Correspondence Analysis to develop a wealth index based on characteristics of the household dwelling as well as ownership of selected assets. We used logistic regressions controlling for multiple variables to assess the statistical association between socioeconomic status and stroke. FINDINGS: Our results showed a significant association between household socioeconomic status and the prevalence of stroke. This relationship was non-linear, with individuals from both the poorest (mainly rural) and richest (mainly urban) households having a lower prevalence of stroke as compared to individuals with medium wealth level. The latter belonged mainly to urban households with a lower socioeconomic status. When taking into account the urban population only, we observed that a third of poorest households experienced a significantly higher prevalence of stroke compared to the richest third (OR = 2.06; CI 95%: 1.09; 3.89). CONCLUSION: We conclude that individuals from the most deprived urban households bear a higher risk of stroke than the rest of the population in Morocco. This result can be explained to a certain extent by the higher presence of behavioral risk factors in this specific category of the population, which leads in turn to metabolic and physiological risk factors of stroke, such as obesity, diabetes, and hypertension.

Public sector services for the prevention of mother-to-child transmission of HIV infection: a micro-costing survey in Namibia and Rwanda.

OBJECTIVE: To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries. METHODS: In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$). FINDINGS: The estimated costs to the providers of PMTCT, for each mother-infant pair, were US$202.75-1029.55 in Namibia and US$94.14-342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$3.15 million in Namibia and US$7.04 million in Rwanda (or < US$0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries. CONCLUSION: The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.

Inland valley rice production systems and malaria infection and disease in the forest region of western Côte d'Ivoire.

BACKGROUND: This study aimed to determine the epidemiological impact of rice cultivation in inland valleys on malaria in the forest region of western Côte d'Ivoire. The importance of malaria was compared in terms of prevalence and parasite density of infections and also in terms of clinical malaria incidence between three agro-ecosystems: (i) uncultivated inland valleys, (R0), (ii) inland valleys with one annual rice cultivation in the rainy season, (R1) and (iii) developed inland valleys with two annual rice cultivation cycles, (R2). METHODS: Between May 1998 and March 1999, seven villages of each agro-ecosystem (R0, R1 and R2) were randomly selected among villages pooled by farming system. In these 21 villages, a total of 1,900 people of all age groups were randomly selected and clinically monitored during one year. Clinical and parasitological information was obtained by active case detection of malaria episodes carried out during eight periods of five consecutive days scheduled at six weekly intervals and by cross-sectional surveys. RESULTS: Plasmodium falciparum was the principal parasite observed in the three agro-ecosystems. A level of holoendemicity of malaria was observed in the three agro-ecosystems with more than 75% of children less than 12 months old infected. Geometric mean parasite density in asymptomatic persons varied between 180 and 206 P. falciparum asexual forms per µL of blood and was associated with season and with age, but not with farming system. The mean annual malaria incidence rate reached 0.7 (95% IC 0.5-0.9) malaria episodes per person in R0, 0.7 (95% IC 0.6-0.9) in R1 and 0.6 (95% IC 0.5-0.7) in R2. The burden of malaria was the highest among children under two years of age, with at least four attacks by person-year. Then malaria incidence decreased by half in the two to four-year age group. From the age of five years, the incidence was lower than one attack by person-year. Malaria incidence varied with season with more cases in the rainy season than in the dry season but not with farming system. CONCLUSION: In the forest area of western Côte d'Ivoire, inland valley rice cultivation was not significantly associated with malaria burden.

To what extent could performance-based schemes help increase the effectiveness of prevention of mother-to-child transmission of HIV (PMTCT) programs in resource-limited settings? A summary of the published evidence.

BACKGROUND: In resource-limited settings, HIV/AIDS remains a serious threat to the social and physical well-being of women of childbearing age, pregnant women, mothers and infants. DISCUSSION: In sub-Saharan African countries with high prevalence rates, pediatric HIV/AIDS acquired through mother-to-child transmission (MTCT) can in largely be prevented by using well-established biomedical interventions. Logistical and socio-cultural barriers continue, however, to undermine the successful prevention of MTCT (PMTCT). In this paper, we review reports on maternal, neonatal and child health, as well as HIV care and treatment services that look at program incentives. SUMMARY: These studies suggest that comprehensive PMTCT strategies aiming to maximize health-worker motivation in developing countries must involve a mix of both financial and non-financial incentives. The establishment of robust ethical and regulatory standards in public-sector HIV care centers could reduce barriers to PMTCT service provision in sub-Saharan Africa and help them in achieving universal PMTCT targets.

[Hazards, tactics and constraints of evaluation of health care in low income countries]. / Enjeux, approches et contraintes de l'évaluation dans les pays à faible revenu.

Unless a large, new, financial contribution comes from the international community, health indicators are far from good in low income countries. However, even if health financing is still insufficient, better health care in these countries could be produced with their present resources. It requires an improvement in the health system performance, as well as efficacy and efficiency of health programs. As a tool, evaluation allows one firstly to check this performance and efficiency, and then to assess the impact of different programs. This article is organising in three sections. The first presents the different (economic, ethical and social) stakes of an evaluation system. The second section describes its methods and the third analyses its constraints.

Analysis of hospital costs as a basis for pricing services in Mali.

In a move to achieve a better equity in the funding of access to health care, particularly for the poor, a better efficiency of hospital functioning and a better financial balance, the analysis of hospital costs in Mali brings several key elements to improve the pricing of medical services. The method utilized is the classical step-down process which takes into consideration the entire set of direct and indirect costs borne by the hospital. Although this approach does not allow to estimate the economic cost of consultations, it is a useful contribution to assess the financial activity of the hospital and improve its performance, financially speaking, through a more relevant user fees policy. The study shows that there are possibilities of cross-subsidies within the hospital or within services which improve the recovery of some of the current costs. It also leads to several proposals of pricing care while taking into account the constraints, the level of the hospital its specific conditions and equity.

Social and health determinants of the efficiency of cotton farmers in Northern Côte d'Ivoire.

This article assesses the role of malaria and some social determinants on the agricultural development and more precisely on efficiency in the context of cotton crop in the Korhogo region in the North of Côte d'Ivoire. Data envelopment analyses (DEA) was first applied for the purpose of calculating relative efficiencies in production. A Tobit regression model was then used to explain the variation in the DEA scores and check the hypotheses that the efficiency deviations between farmers can be explained by the disparity of malaria morbidity rate among the farmers and their family, by social cohesiveness and cultural behaviour. Field data were collected by the authors between March 1997 and February 1998 on 700 rural households living in three rice production systems differently exposed to the malaria risk. Two malaria indicators were used for the active (11-55 years old) family members of the farm: Plasmodium falciparum infection rate and high parasite density infection rate. The DEA model was applied on the sub-sample of cotton growers (about one third of the households of the full sample). Results of the different DEA and Tobit models (depending of the production process hypothesis) show that high parasite density infection has a direct and indirect negative effect on efficiency in the cotton crop. They also show that more cotton growers in the village improve efficiency, although villages where cotton is growing more widespread have weaker social cohesion.

[Evolution and new perspectives of health care financing in developing countries]. / Evolutions et nouvelles orientations pour le financement de la santé dans les pays en développement à faible revenu.

Over the last twenty five years, the perspective of health care financing has dramatically changed in developing countries. In this context, it is worth reviewing the literature and the experiences in order to understand the major shifts on this topic. During the sixties, health care policies focused on fighting major epidemics. Programs were dedicated to reduce the threat to population health. Financing related to the mobilization of resources for these programs and most of them were not managed within national administrations. The success of these policies was not sustainable. After Alma Ata, primary health care became a priority but it took some years before the management of the health care district was introduced as a major topic. In the eighties, with the district policy and the Bamako Initiative, the economic approach became a major part of all health care policies. At that time, most of health care financing was related to cost recovery strategies. All the attention was then drawn on how it worked: Fee policies, distribution of revenues, efficient use of resources and so on. In the second half of the nineties, cost recovery was relegated to the back scene, health care financing policy then becoming a major front scene matter. Two major reasons may explain this change in perspective: HIV which causes a major burden on the whole health system, and fighting poverty in relation with debts reduction. In most developing countries, with high HIV prevalence, access to care is no longer possible within the framework of the ongoing heath care financing scheme. Health plays a major role in poverty reduction strategies but health care officials must take into account every aspect of public financing. New facts also have to be taken into account: Decentralization/autonomy policies, the growing role of third party payment and the rising number of qualified health care professionals. All these facts, along with a broader emphasis given to the market, introduce a need for a better management of resources through financing mechanisms. Some major reports from WHO and the World Bank are the landmarks of the evolution on how to approach health care financing: The 1993 World Bank report on investing in health, the 2000 WHO report on health in the world and the WHO report on macroeconomics and health. In this early millenium, there is a general agreement on some major aspects of health care financing such as: Lack of resources for financing health care; cost recovery as a part of any sustainable health care system; health as a public good needing some extended subsidies; protecting people from the burden of disease as a part of financing schemes; equity in relation with the public private mix at the center of many debates; financing as a key mechanism for the regulation of the whole health care system and not only as a resource mobilization; HIV in bringing up new problems clearly shows how all these matters are related. Health care financing is at the heart of ongoing questions on health care reforms. Although developing countries have low insurance coverage and weak modern medical care, they share the same questions as developed countries: How to promote technical and allocative efficiency? What place for incentives? What role for the public sector? How can market and contracting bring results? What progress through stewardship and better governance?