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.

Funders: The missing link in equitable global health research?

Global health research is mired by inequities, some of which are linked to current approaches to research funding. The role of funders and donors in achieving greater equity in global health research needs to be clearly defined. Imbalances of power and resources between high income countries (HICs) and low- and middle-income countries (LMICs) is such that many funding approaches do not centre the role of LMIC researchers in shaping global health research priorities and agenda. Relative to need, there is also disparity in financial investment by LMIC governments in health research. These imbalances put at a disadvantage LMIC health professionals and researchers who are at forefront of global health practice. Whilst many LMICs do not have the means (due to geopolitical, historical, and economic reasons) for direct investment, if those with means were to invest more of their own funds in health research, it may help LMICs become more self-sufficient and shift some of the power imbalances. Funders and donors in HICs should address inequities in their approach to research funding and proactively identify mechanisms that assure greater equity-including via direct funding to LMIC researchers and direct funding to build local LMIC-based, led, and run knowledge infrastructures. To collectively shape a new approach to global health research funding, it is essential that funders and donors are part of the conversation. This article provides a way to bring funders and donors into the conversation on equity in global health research.

Health financing reforms for Universal Health Coverage in five emerging economies.

BACKGROUND: Many countries have committed to achieving Universal Health Coverage. This paper summarizes selected health financing themes from five middle-income country case studies with incomplete progress towards UHC. METHODS: The paper focuses on key flagship UHC programs in these countries, which exist along other publicly financed health delivery systems, reviewed through the lens of key health financing functions such as revenue raising, pooling and purchasing as well as governance and institutional arrangements. RESULTS: There is variable progress across countries. Indonesia's Jaminan Kesehatan Nasional (JKN) reforms have made substantial progress in health services coverage and health financing indicators though challenges remain in its implementation. In contrast, Ghana has seen reduced funding levels for health and achieved less than 50% in the UHC service coverage index. In India, despite Ayushman Bharat (PM-JAY) reforms having provided important innovations in purchasing and public-private mix, out of pocket spending remains high and the public health financing level low. Kenya still has a challenge to use public financing to enhance coverage for the informal sector, while South Africa has made little progress in strategic purchasing. CONCLUSIONS: Despite variations across countries, therefore, important challenges include inadequate financing, sub-optimal pooling, and unmet expectations in strategic purchasing. While complex federal systems may complicate the path forward for most of these countries, evidence of strong political commitment in some of these countries bodes well for further progress.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

The Economic Transition of Health in Africa: A Call for Progressive Pragmatism to Shape the Future of Health Financing.

Abstract-The new financing landscape for the Sustainable Development Goals has a larger emphasis on domestic resource mobilization. But, given the significant role of donor assistance for health, the fungibility of government health spending, and the downward revision of global growth, this article looks at what is possible with regard to a country's own ability to finance priority health services. Using cross-sectional and longitudinal economic and health spending data, we employ a global multilevel model with regional and country random effects to develop gross domestic product (GDP) projections that inform a dynamic panel data model to forecast health spending. We then assess sub-Saharan African countries' abilities to afford to finance their own essential health needs and find that there are countries that will still rely on high out-of-pocket or donor spending to finance an essential package of health services. To address this, we discuss policy opportunities for each set of countries over the next 15 years. This longer-term view of the economic transition of health in Africa stresses the imperative of engaging policy now to prioritize customized strategies and institutional arrangements to increase domestic financing, improve value for money, and ensure fairer and sustainable health financing. We address the need for rhetoric on UHC to incorporate "progressive pragmatism," a proactive joint approach by developing country governments and their development partners to ensure that policies designed to achieve universal health coverage align with the economic reality of available domestic and donor financing.

Health Care Expenditures Associated With Pollution: Exploratory Methods and Findings.

BACKGROUND: The research done for this paper is part of the background analysis undertaken to support the work of the Global Commission on Pollution, Health and Development, an initiative of The Lancet, the Global Alliance on Health and Pollution, and the Icahn School of Medicine at Mount Sinai. The paper expands on areas where the current literature has gaps in knowledge related to the health care cost of pollution. OBJECTIVES: This study aims to generate an initial estimate of total tangible health care expenditure attributable to man-made pollution affecting air, soil and water. METHODS: We use two methodologies to establish an upper and lower bounds for pollution related health expenditure. Key data points in both models include (a) burden-of-disease (BoD) at the national level in different countries attributable to pollution; and (b) the total cost of health care at the national level in different countries using standard national health accounts expenditure data. FINDINGS: Depending on which determinist model we apply, annual expenditures range from US$630 billion (upper bound) to US$240 billion (lower bound) or approximately three to nine percent of global spending on health care in 2013 (the reference year for the analysis). Although only 14 percent of global total for pollution related health care spending is in lower- and middle-income countries (LMICs) in our primary (lower bound) model, the relative share of spending for pollution related illness is substantial, especially in very low-income countries. Cancer, chronic respiratory and cardio/cerebrovascular illnesses account for the largest health care spending items linked to pollution even in LMICs. CONCLUSIONS: These conditions have historically received less attention by national governments, international public health organizations and development/financial agencies than infectious disease and maternal/child health sectors. Other studies posit that intangible costs associated with environmental pollution include lower productivity and reduced income - components which our models do not attempt to capture. The financial and health impacts are substantial even when we exclude intangible costs, yet it is likely that in many LMICs poor households simply forgo medical treatment and lose household income as a result of man-made environmental degradation. RECOMMENDATIONS: When evaluating the value of public health or environmental programs which prevent or limit pollution-related illness, policy makers should consider the health benefits, the tangible cost offsets (estimated in our models) and the opportunity costs.

Markets, development assistance, and access to medicines in Africa: lessons from the Affordable Medicines Facility for malaria (AMFm).

Access to essential medicines in low-and middle-income countries is affected by market failures and government failures. This paper review the design and lessons learned from the multi-country Phase I of the Affordable Medicines for Malaria (AMFm), and the political economy of decision making around findings from its independent evaluation. It concludes with reflections on lessons learned, the potential applicability of the private-public approach to other health commodities and countries, and the implications of this experience for evidence-based decisions in global health and development assistance.

Integration of priority population, health and nutrition interventions into health systems: systematic review.

BACKGROUND: Objective of the study was to assess the effects of strategies to integrate targeted priority population, health and nutrition interventions into health systems on patient health outcomes and health system effectiveness and thus to compare integrated and non-integrated health programmes. METHODS: Systematic review using Cochrane methodology of analysing randomised trials, controlled before-and-after and interrupted time series studies. We defined specific strategies to search PubMed, CENTRAL and the Cochrane Effective Practice and Organisation of Care Group register, considered studies published from January 1998 until September 2008, and tracked references and citations. Two reviewers independently agreed on eligibility, with an additional arbiter as needed, and extracted information on outcomes: primary (improved health, financial protection, and user satisfaction) and secondary (improved population coverage, access to health services, efficiency, and quality) using standardised, pre-piloted forms. Two reviewers in the final stage of selection jointly assessed quality of all selected studies using the GRADE criteria. RESULTS: Of 8,274 citations identified 12 studies met inclusion criteria. Four studies compared the benefits of Integrated Management of Childhood Illnesses in Tanzania and Bangladesh, showing improved care management and higher utilisation of health facilities at no additional cost. Eight studies focused on integrated delivery of mental health and substance abuse services in the United Kingdom and United States of America. Integrated service delivery resulted in better clinical outcomes and greater reduction of substance abuse in specific sub-groups of patients, with no significant difference found overall. Quality of care, patient satisfaction, and treatment engagement were higher in integrated delivery models. CONCLUSIONS: Targeted priority population health interventions we identified led to improved health outcomes, quality of care, patient satisfaction and access to care. Limited evidence with inconsistent findings across varied interventions in different settings means no general conclusions can be drawn on the benefits or disadvantages of integrated service delivery.

The quest for universal access to effective malaria treatment: how can the AMFm contribute?

Access to quality assured artemisinin-based combination therapy (ACT) has remained very low in most malaria endemic countries. A number of reasons, including unaffordable prices, have contributed to the low accessibility to these life-saving medicines. The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT. The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives: replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin.Access to medicines frameworks paint a broad picture of dimensions of access to medicines and juxtapose components that enhance or hinder access to medicines. Access requires various activities--funding, institutions, interventions, and thinking--from public and private actors at global, national, and local levels. This paper examines, within access to medicines frameworks, the role of the AMFm across and within each dimension and discusses how the AMFm can help to solve access bottlenecks.

Integration of targeted health interventions into health systems: a conceptual framework for analysis.

The benefits of integrating programmes that emphasize specific interventions into health systems to improve health outcomes have been widely debated. This debate has been driven by narrow binary considerations of integrated (horizontal) versus non-integrated (vertical) programmes, and characterized by polarization of views with protagonists for and against integration arguing the relative merits of each approach. The presence of both integrated and non-integrated programmes in many countries suggests benefits to each approach. While the terms 'vertical' and 'integrated' are widely used, they each describe a range of phenomena. In practice the dichotomy between vertical and horizontal is not rigid and the extent of verticality or integration varies between programmes. However, systematic analysis of the relative merits of integration in various contexts and for different interventions is complicated as there is no commonly accepted definition of 'integration'-a term loosely used to describe a variety of organizational arrangements for a range of programmes in different settings. We present an analytical framework which enables deconstruction of the term integration into multiple facets, each corresponding to a critical health system function. Our conceptual framework builds on theoretical propositions and empirical research in innovation studies, and in particular adoption and diffusion of innovations within health systems, and builds on our own earlier empirical research. It brings together the critical elements that affect adoption, diffusion and assimilation of a health intervention, and in doing so enables systematic and holistic exploration of the extent to which different interventions are integrated in varied settings and the reasons for the variation. The conceptual framework and the analytical approach we propose are intended to facilitate analysis in evaluative and formative studies of-and policies on-integration, for use in systematically comparing and contrasting health interventions in a country or in different settings to generate meaningful evidence to inform policy.

A systematic review of the evidence on integration of targeted health interventions into health systems.

A longstanding debate on health systems organization relates to benefits of integrating health programmes that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration arguing the relative merits of each approach. However, all too frequently these arguments have not been based on hard evidence. The presence of both integrated and non-integrated programmes in many countries suggests there may be benefits to either approach, but the relative merits of integration in various contexts and for different interventions have not been systematically analysed and documented. In this paper we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of the integration of targeted health programmes that emphasize specific interventions into critical health systems functions, (ii) how the integration or non-integration of health programmes into critical health systems functions in different contexts has influenced programme success, (iii) how contextual factors have affected the extent to which these programmes were integrated into critical health systems functions. Our analysis shows few instances where there is full integration of a health intervention or where an intervention is completely non-integrated. Instead, there exists a highly heterogeneous picture both for the nature and also for the extent of integration. Health systems combine both non-integrated and integrated interventions, but the balance of these interventions varies considerably.