Making development assistance work for Africa: from aid-dependent disease control to the new public health order.

The Coronavirus disease (COVID-19) pandemic has revealed the fragility of pre-crisis African health systems, in which too little was invested over the past decades. Yet, development assistance for health (DAH) more than doubled between 2000 and 2020, raising questions about the role and effectiveness of DAH in triggering and sustaining health systems investments. This paper analyses the inter-regional variations and trends of DAH in Africa in relation to some key indicators of health system financing and service delivery performance, examining (1) the trends of DAH in the five regional economic communities of Africa since 2000; (2) the relationship between DAH spending and health system performance indicators and (3) the quantitative and qualitative dimensions of aid substitution for domestic financing, policy-making and accountability. Africa is diverse and the health financing picture has evolved differently in its subregions. DAH represents 10% of total spending in Africa in 2020, but DAH benefitted Southern Africa significantly more than other regions over the past two decades. Results in terms of progress towards universal health coverage (UHC) are slightly associated with DAH. Overall, DAH may also have substituted for public domestic funding and undermined the formation of sustainable UHC financing models. As the COVID-19 crisis hit, DAH did not increase at the country level. We conclude that the current architecture of official development assistance (ODA) is no longer fit for purpose. It requires urgent transformation to place countries at the centre of its use. Domestic financing of public health institutions should be at the core of African social contracts. We call for a deliberate reassessment of ODA modalities, repurposing DAH on what it could sustainably finance. Finally, we call for a new transparent framework to monitor DAH that captures its contribution to building institutions and systems.

From Universal Health Coverage services packages to budget appropriation: the long journey to implementation.

Essential packages of health services (EPHS) potentially contribute to universal health coverage (UHC) financing through several pathways. Generally, expectations on what an EPHS can achieve for health financing are high, yet stakeholders rarely spell out mechanisms to reach desired outcomes. This paper analyses how EPHS relate to the three health financing functions (revenue raising, risk pooling and purchasing) and to public financial management (PFM). Our review of country experiences found that using EPHS to directly leverage funds for health has rarely been effective. Indirectly, EPHS can translate into increased revenue through fiscal measures, including health taxes. Through improved dialogue with public finance authorities, health policy-makers can use EPHS or health benefit packages to communicate the value of additional public spending connected with UHC indicators. Overall, however, empirical evidence on EPHS contribution to resource mobilisation is still pending. EPHS development exercises have been more successful in advancing resource pooling across different schemes: EPHS can help comparing performance of coverage schemes, occasionally leading to harmonisation of UHC interventions and identifying gaps between health financing and service delivery. EPHS development and iterative revisions play an essential role in core strategic purchasing activities as countries develop their health technology assessment capacity. Ultimately, packages need to translate into adequate public financing appropriations through country health programme design, ensuring funding flows directly address obstacles to increased coverage.

Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance.

Despite limited evidence of successful development and implementation of contributory health insurance and low and middle income countries, many countries are in the process implementing such schemes. This commentary summarizes all available evidence on the limitations of contributory health insurance including the lack of good theoretical underpinning and the considerable evidence of inequity and fragmentation created by such schemes. Moreover, the initiation of a contributory health insurance scheme has not been found to increase revenues to the health sector or help health countries achieve universal health coverage. Low and middle income countries can improve equity and efficiency of the health sector by replacing out-of-pocket spending with pre-paid pooling mechanisms, but that is best done through budget transfers and not by contributory insurance that links payment to sub-population entitlements.

Using costing to facilitate policy making towards Universal Health Coverage: findings and recommendations from country-level experiences.

As countries progress towards universal health coverage (UHC), they frequently develop explicit packages of health services compatible with UHC goals. As part of the Disease Control Initiative 3 Country Translation project, a systematic survey instrument was developed and used to review the experience of five low-income and lower-middle-income countries-Afghanistan, Ethiopia, Pakistan, Somalia and Sudan-in estimating the cost of their proposed packages. The paper highlights the main results of the survey, providing information about how costing exercises were conducted and used and what country teams perceived to be the main challenges. Key messages are identified to facilitate similar exercises and improve their usefulness. Critical challenges to be addressed include inconsistent application of costing methods, measurement errors and data reliability issues, the lack of adequate capacity building, and the lack of integration between costing and budgeting. The paper formulates four recommendations to address these challenges: (1) developing more systematic guidance and standard ways to implement costing methodologies, particularly regarding the treatment of health systems-related common costs, (2) acknowledging ranges of uncertainty of costing results and integrating sensitivity analysis, (3) building long-term capacity at the local level and institutionalising the costing process in order to improve both reliability and policy relevance, and (4) closely linking costing exercises to public budgeting.

The role of the private sector in delivering essential packages of health services: lessons from country experiences.

Many countries are adopting essential packages of health services (EPHS) to implement universal health coverage (UHC), which are mostly financed and delivered by the public sector, while the potential role of the private health sector (PHS) remains untapped. Currently, many low-income and lower middle-income countries (LLMICs) have devised EPHS; however, guidance on translating these packages into quality, accessible and affordable services is limited. This paper explores the role of PHS in achieving UHC, identifies key concerns and presents the experience of the Diseases Control Priorities 3 Country Translation project in Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar. There are key challenges to engagement of the PHS, which include the complexity and heterogeneity of private providers, their operation in isolation of the health system, limitations of population coverage and equity when left to PHS's own choices, and higher overall cost of care for privately delivered services. Irrespective of the strategies employed to involve the PHS in delivering EPHS, it is necessary to identify private providers in terms of their characteristics and contribution, and their response to regulatory tools and incentives. Strategies for regulating private providers include better statutory control to prevent unlicensed practice, self-regulation by professional bodies to maintain standards of practice and accreditation of large private hospitals and chains. Potentially, purchasing delivery of essential services by engaging private providers can be an effective 'regulatory approach' to modify provider behaviour. Despite existing experience, more research is needed to better explore and operationalise the role of PHS in implementing EPHS in LLMICs.

Governance Roles and Capacities of Ministries of Health: A Multidimensional Framework.

The lack of capacity for governance of Ministries of Health (MoHs) is frequently advanced as an explanation for health systems failures in low- and middle-income countries (LMICs). But do we understand what governance capacities MoHs should have? Existing frameworks have not fully captured the dynamic and contextually determined role of MoHs, and there are few frameworks that specifically define capacities for governance. We propose a multidimensional framework of capacities for governance by MoHs that encompasses both the "hard" (de jure, explicit and functional) and "soft" (de facto, tacit, and relational) dimensions of governance, and reflects the diversification of their mandates in the context of the Sustainable Development Goals (SDGs). Four case studies illustrate different aspects of the framework. We hope that the framework will have multiple potential benefits including benchmarking MoH governance capacities, identifying and helping analyze capacity gaps, and guiding strategies to strengthen capacity.

Projected health-care resource needs for an effective response to COVID-19 in 73 low-income and middle-income countries: a modelling study.

BACKGROUND: Since WHO declared the COVID-19 pandemic a Public Health Emergency of International Concern, more than 20 million cases have been reported, as of Aug 24, 2020. This study aimed to identify what the additional health-care costs of a strategic preparedness and response plan (SPRP) would be if current transmission levels are maintained in a status quo scenario, or under scenarios where transmission is increased or decreased by 50%. METHODS: The number of COVID-19 cases was projected for 73 low-income and middle-income countries for each of the three scenarios for both 4-week and 12-week timeframes, starting from June 26, 2020. An input-based approach was used to estimate the additional health-care costs associated with human resources, commodities, and capital inputs that would be accrued in implementing the SPRP. FINDINGS: The total cost estimate for the COVID-19 response in the status quo scenario was US$52·45 billion over 4 weeks, at $8·60 per capita. For the decreased or increased transmission scenarios, the totals were $33·08 billion and $61·92 billion, respectively. Costs would triple under the status quo and increased transmission scenarios at 12 weeks. The costs of the decreased transmission scenario over 12 weeks was equivalent to the cost of the status quo scenario at 4 weeks. By percentage of the overall cost, case management (54%), maintaining essential services (21%), rapid response and case investigation (14%), and infection prevention and control (9%) were the main cost drivers. INTERPRETATION: The sizeable costs of a COVID-19 response in the health sector will escalate, particularly if transmission increases. Instituting early and comprehensive measures to limit the further spread of the virus will conserve resources and sustain the response. FUNDING: WHO, and UK Foreign Commonwealth and Development Office.

The Case Against Labor-Tax-Financed Social Health Insurance For Low- And Low-Middle-Income Countries.

An increasing interest in initiating and expanding social health insurance through labor taxes in low- and low-middle-income countries goes against available empirical evidence. This article builds on existing recommendations by leading health financing experts and summarizes recent research that makes the case against labor-tax financing of health care in low- and low-middle-income countries. We found very little evidence to justify the pursuit of labor-tax financing for health care in these countries and persistent evidence that such policies could lead to increased inequality and fragmentation of the health system. We recommend that countries considering such policies heed the evidence on labor-tax financing and seek alternative approaches to health financing: primarily using general taxes or, depending on the context, general taxes combined with adequately regulated insurance premiums.

Effective coverage measurement in maternal, newborn, child, and adolescent health and nutrition: progress, future prospects, and implications for quality health systems.

Intervention coverage-the proportion of the population with a health-care need who receive care-does not account for intervention quality and potentially overestimates health benefits of services provided to populations. Effective coverage introduces the dimension of quality of care to the measurement of intervention coverage. Many definitions and methodological approaches to measuring effective coverage have been developed, resulting in confusion over definition, calculation, interpretation, and monitoring of these measures. To develop a consensus on the definition and measurement of effective coverage for maternal, newborn, child, and adolescent health and nutrition (MNCAHN), WHO and UNICEF convened a group of experts, the Effective Coverage Think Tank Group, to make recommendations for standardising the definition of effective coverage, measurement approaches for effective coverage, indicators of effective coverage in MNCAHN, and to develop future effective coverage research priorities. Via a series of consultations, the group recommended that effective coverage be defined as the proportion of a population in need of a service that resulted in a positive health outcome from the service. The proposed effective coverage measures and care cascade steps can be applied to further develop effective coverage measures across a broad range of MNCAHN services. Furthermore, advances in measurement of effective coverage could improve monitoring efforts towards the achievement of universal health coverage.

Financing Global Common Goods for Health: When the World is a Country.

"Global functions" of health cooperation refer to those activities that go beyond the boundaries of individual nations to address transnational issues. This paper begins by presenting a taxonomy of global functions and laying out the key value propositions of investing in such functions. Next, it examines the current funding flows to global functions and the estimated price tag, which is large. Given that existing financing mechanisms have not closed the gap, it then proposes a suite of options for directing additional funding to global functions and discusses the governance of this additional funding. These options are organized into resource mobilization mechanisms, pooling approaches, and strategic purchasing of global functions. Given its legitimacy, convening power, and role in setting global norms and standards, the World Health Organization (WHO) is uniquely placed among global health organizations to provide the overarching governance of global functions. Therefore, the paper includes an assessment of WHO's financial situation. Finally, the paper concludes with reflections on the future of aid for health and its role in supporting global functions. The concluding section also summarizes a set of key priorities in financing global functions for health.

The Case for Public Financing of Environmental Common Goods for Health.

Safeguarding the continued existence of humanity requires building societies that cause minimal disruptions of the essential planetary systems that support life. While major successes have been achieved in improving health in recent decades, threats from the environment may undermine these gains, particularly among vulnerable populations and communities. In this article, we review the rationale for governments to invest in environmental Common Goods for Health (CGH) and identify functions that qualify as such, including interventions to improve air quality, develop sustainable food systems, preserve biodiversity, reduce greenhouse gas emissions, and encourage carbon sinks. Exploratory empirical analyses reveal that public spending on environmental goods does not crowd out public spending on health. Additionally, we find that improved governance is associated with better performance in environmental health outcomes, while the degrees of people's participation in the political system together with voice and accountability are positively associated with performance in ambient air quality and biodiversity/habitat. We provide a list of functions that should be prioritized by governments across different sectors, and present preliminary costing of environmental CGH. As shown by the costing estimates presented here, these actions need not be especially expensive. Indeed, they are potentially cost-saving. The paper concludes with case examples of national governments that have successfully prioritized and financed environmental CGH. Because societal preferences may vary across time, government leaders seeking to protect the health of future generations must look beyond electoral cycles to enact policies that protect the environment and finance environmental CGH.

When Do Governments Support Common Goods for Health? Four Cases on Surveillance, Traffic Congestion, Road Safety, and Air Pollution.

Common goods such as air, water, climate, and other resources shared by all humanity are under increasing pressure from growing population and advancing globalization of the world economy. Safeguarding these resources is generally considered a government responsibility, as common goods are vulnerable to market failure. However, governments do not always fulfill this role, and face many challenges in doing so. This observation-that governments only sometimes address common goods problems-informs the central question of this paper: when do governments act in support of common goods? We structure our inquiry using a framework derived from three theories of agenda setting, emphasizing problem perception, the role of actors and collective action patterns, strategies and policies, and catalyzing circumstances. We used a poll of experts to identify important common goods for health: disease surveillance, environmental protection, and accountability. We then chose four historical cases for analysis: the establishment of the Epidemic Intelligence Service in the US, transport planning in London, road safety in Argentina, and air quality control in urban India. Our analysis of the collective evidence of these cases suggests that decisions to advance government action on common goods require a concisely articulated problem, a well-defined strategy for addressing the problem, and leadership backed by at least a few important groups willing to cooperate. Our cases reveal a variety of collective action patterns, suggesting that there are many routes to success. We consider that the timing of an intervention in support of common goods depends on favorable circumstances, which can include a catalyzing event but does not necessarily require one.

When Both Markets and Governments Fail Health.

This paper presents the rationale and motivation for countries and the global development community to tackle a critical set of functions in the health sector that appear to be under-prioritized and underfunded. The recent eruptions of Ebola outbreaks in Africa and other communicable diseases like Zika and SARS elsewhere led scientific and medical commissions to call for global action. The calls for action motivated the World Health Organization (WHO) to respond by defining a new construct within the health sector: Common Good for Health (CGH). While the starting point for developing the CGH construct was the re-emergence of communicable diseases, it extends to additional outcomes resulting from failures to act and finance within and outside the health sector. This paper summarizes global evidence on failures to address CGHs effectively, identifies potential reasons for the public and private sectors' failures to respond, and lays out the first phase of the WHO program as represented by the papers in this special issue of Health Systems & Reform.

Common Goods for Health: Economic Rationale and Tools for Prioritization.

This paper presents the economic rationale for treating Common Goods for Health (CGH) as priorities for public intervention. We use the concept of market failure as a central argument for identifying CGH and apply cost-effectiveness analysis (CEA) as a normative tool to prioritize CGH interventions in public finance decisions. We show that CGH are consistent with traditional lists of public health core functions but cannot be identified separately from non-CGH activities in such lists. We propose a public finance decision tree, adapted from existing health economics tools, to identify CGH activities within the set of cost-effective interventions for the health sector. We test the framework by applying it to the 2018 Disease Control Priority (DCP) list of interventions recommended for public funding and find that less than 10% of cost-effective interventions unconditionally qualify as CGH, while another two-thirds may or may not qualify depending on context and form. We conclude that while CEA can be used as a tool to prioritize CGH, the scarcity of such analyses for CGH interventions may be partly responsible for the lack of priority given to them. We encourage further research to address methodological and resource challenges to assessing the cost-effectiveness of CGH intervention packages, in particular those involving large investments and long-term benefits.