The Global Fund's resource allocation decisions for HIV programmes: addressing those in need.

BACKGROUND: Between 2002 and 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria's investment in HIV increased substantially to reach US$12 billion. We assessed how the Global Fund's investments in HIV programmes were targeted to key populations in relation to disease burden and national income. METHODS: We conducted an assessment of the funding approved by the Global Fund Board for HIV programmes in Rounds 1-10 (2002-2010) in 145 countries. We used the UNAIDS National AIDS Spending Assessment framework to analyze the Global Fund investments in HIV programmes by HIV spending category and type of epidemic. We examined funding per capita and its likely predictors (HIV adult prevalence, HIV prevalence in most-at-risk populations and gross national income per capita) using stepwise backward regression analysis. RESULTS: About 52% ($6.1 billion) of the cumulative Global Fund HIV funding was targeted to low- and low-middle-income countries. Around 56% of the total ($6.6 billion) was channelled to countries in sub-Saharan Africa. The majority of funds were for HIV treatment (36%; $4.3 billion) and prevention (29%; $3.5 billion), followed by health systems and community systems strengthening and programme management (22%; $2.6 billion), enabling environment (7%; $0.9 billion) and other activities. The Global Fund investment by country was positively correlated with national adult HIV prevalence. About 10% ($0.4 billion) of the cumulative HIV resources for prevention targeted most-at-risk populations. CONCLUSIONS: There has been a sustained scale up of the Global Fund's HIV support. Funding has targeted the countries and populations with higher HIV burden and lower income. Prevention in most-at-risk populations is not adequately prioritized in most of the recipient countries. The Global Fund Board has recently modified eligibility and prioritization criteria to better target most-at-risk populations in Round 10 and beyond. More guidance is being provided for Round 11 to strategically focus demand for Global Fund financing in the present resource-constrained environment.

Slovenia: health system review

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policyinitiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and therole of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. Life expectancy in Slovenia has improved since 1993, reaching 78.5 years in 2007. This value is comparable to those of other European Union (EU) Member States (those belonging to the EU prior to 2004, plus those joining the EU on 1 May 2004 (EU25)), but slightly below the average of the EU MemberStates before the enlargement of May 2004 (EU15) and significantly above the respective average value of the countries that joined the EU in May 2004 and January 2007 (EU12). Health care services in Slovenia are financed mainly bycontributions to compulsory health insurance, premiums for voluntary health insurance (VHI) and through taxes. Although entitlement to health care services is universal in Slovenia, access to some health care services is limited due to lack of providers (for example, dental care) or long waiting times (for example, for certain operations). Health care services at the primary level are provided mainly by state-owned primary health care institutions as well as by independent general practitioners (GPs). Providers of primary health care act as gatekeepers for specialist services. Slovenia’s health care system has undergone major changes since the countryachieved independence in 1991. This momentum of constant change was retained during the period from 2002 to 2007 and was based on a white paper published by the Ministry of Health and on the World Bank project “A Management Model or Health Care”. Reform policy during this period included, inter alia, reform of health care financing (for example, payment for hospital services is now based on diagnosis-related groups (DRGs)); introduction of clinical guidelines by the Ministry of Health to increase quality of health care; cancellation of compulsory insurance (Health Insurance Institute of Slovenia (HIIS)) debts; and subsequent introduction of a convergence programme to limit HIIS expenditure. Furthermore, a risk-equalization scheme for VHI was introduced in 2005, which aims to reduce cream-skimming between voluntary health insurers and to equalize the variations in risk structure between private health insurance companies.

Latvia: health system review

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policyinitiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and therole of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The life expectancy in Latvia has improved over the last two decades and was 71.1 years in 2005. This value is comparable to those in other eastern Europeanand former Soviet Union countries but is the lowest among the Baltic and Nordic countries. Health care services in Latvia are financed mainly by taxation through the state budget as well as by out-of-pocket (OOP) payments, voluntary healthinsurance (VHI) and other direct payments. Although entitlement to health care services is universal in Latvia, equity in access to services is compromised due to high levels of OOP payments by consumers. Health care services at the primary level are provided mainly by general practitioners (GP) who work independently and act as gatekeeper for specialized services. Latvia’s health care system has undergone major changes since the country achieved independence in 1991. Reform policy since then has included amongst others: adoption of a Public Health Strategy in 2001 (which aims at developingan integrated approach of prevention and treatment at all levels of the health care system), reform of health care financing (e.g. payment for hospital services, introduction of a primary health care payment system based on capitation and fund holding, pooling and channelling of almost all funds for health care through the centralized State Compulsory Health Insurance Agency (SCHIA)), regulations of the pricing system for pharmaceuticals and introduction of a centralized health management information system. However, patients and health care consumers are concerned with regard to quality of the health careservices, long waiting lists and access to specialized care.

Bulgaria: health system review

The Health Systems in Transition (HiT) country profiles provide an analytical description of each health system and of policy initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This series is an ongoing initiative and material is updated at regular intervals.

Crosslinking of 4.5S RNA to the Escherichia coli ribosome in the presence or absence of the protein Ffh.

Radioactively labeled 4.5S RNA containing statistically distributed 4-thiouridine residues in place of normal uridine was prepared by T7 transcription. The ability of this modified 4.5S RNA to form a complex with the protein Ffh was demonstrated by a gel shift assay. The modified 4.5S RNA, with or without Ffh, was added to Escherichia coli ribosomes under various conditions, and crosslinking from the thiouridine residues was induced by irradiation at 350 nm. The crosslinked ribosomal components were analyzed by our standard procedures. Two clearly defined types of crosslinking were observed. The first was a crosslink to 23S rRNA, which was entirely dependent both on the presence of Ffh and a nascent protein chain in the 50S subunit. This crosslink was localized to nt approximately 2828-2837 of the 23S rRNA, from position 84 of the 4.5S molecule. The second type of crosslinking, to the 30S ribosomal subunit, was independent of the presence of Ffh, and was found both with vacant 70S ribosomes or isolated 30S subunits. Here the crosslink was localized to the 3'-terminal region of the 16S rRNA, from positions 29-50 of the 4.5S RNA. Cross-linking to ribosomal protein S1 was also observed. The known crystal structure of the protein Ffh/4.5S RNA fragment complex was extrapolated by computer modeling so as to include the whole 4.5S molecule, and this was docked onto the ribosome using the crosslinking data. The results are discussed in terms of multiple functions and binding sites of the 4.5S RNA.

Construction of the 'minimal' SRP that interacts with the translating ribosome but not with specific membrane receptors in Escherichia coli.

Escherichia coli signal recognition particle (SRP) consists of 4.5S RNA and Ffh protein. In contrast to eukaryotes, it remains unclear whether translation arrest takes place in prokaryotic cells. To study this problem we constructed a fusion of the M domain of Ffh protein with a cleavable affinity tag. This mutant Ffh, in a complex with 4.5S RNA, can bind signal peptide at the translating ribosome but is unable to bind the membrane. This SRP-ribosome complex should accumulate in the cell if translation is arrested. To test this, the complex was purified from the cells by ultracentrifugation and affinity chromatography. The composition of the complex was analyzed and found to consist of ribosomal RNAs and proteins, the Ffh M domain and 4.5S RNA. The accumulation of this complex in the cell in significant amounts indicated that SRP-mediated translation arrest did occur in bacterial cells.