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Bulletin of the World Health Organization. 2014; 92:389.The World Health Organization (WHO) in 2012 set up a Consultative Group on Equity and Universal Health Coverage. The final report, entitled Making fair choices on the path to universal health coverage, was launched in London on 1 May 2014.5 The report addresses and clarifies the key issues of fairness and equity that arise on the path to univer¬sal coverage and recommends ways in which countries can manage them. (Excerpts)
The ghosts of user fees past: Exploring accountability for victims of a 30-year economic policy mistake.
Health and Human Rights. 2013 Jun; 15(1):175-185.Today, there is an unmistakable shift in international consensus away from private health financing, including the use of user fees toward public financing mechanisms (notably tax financing), to achieve universal health coverage (UHC). This is, however, much the same as an earlier consensus reached at the WHO's World Health Assembly at Alma-Ata in 1978. When considering the full circle journey from Alma-Ata in 1978 to today’s re-emerging support for UHC, it is worth taking stock and reflecting on how and why the international health community took this nearly three decade detour and how such misguided policies as user fees came to be so widely implemented during the intervening period. It is important for the international health community to ensure that steps are taken to compensate victims and determine accountability for those responsible. Victims of user fees suffered violations of their human right to health as enshrined in Universal Declaration, ICESCR, and a number of other human rights treaties, and yet still cannot avail themselves of remedies, such as those provided by international and regional human rights fora or the various United Nations treaty-monitoring bodies, and the responsible institutions and individuals have thus far remained unaccountable. This lack of accountability suggests a degree of impunity for international organizations and health economists dispensing with health policy advice. Such a lack of accountability should be noted with concern by the international health community as it increasingly relies on the advice and direction of health economists. Steps must be taken to provide survivors of user fees with compensation and hold those responsible to account.
Contraception. 2011 Oct; 84(4):339-41.This editorial focuses on a strategy to expand contraceptive coverage through the development of a numerical International Statistical Classifications of Diseases (ICD) code for "unwanted fertility." It explains how this strategy would work, how to make the strategy happen through a revision process, and defining unwanted fertility as a medical problem. Copyright © 2011 Elsevier Inc. All rights reserved.
Bulletin of the World Health Organization. 2011 Apr 1; 89(4):267-77.OBJECTIVE: To cross-validate the global cost of scaling up child survival interventions to achieve the fourth Millennium Development Goal (MDG4) as estimated by the World Health Organization (WHO) in 2007 by using the latest country-provided data and new assumptions. METHODS: After the main cost categories for each country were identified, validation questionnaires were sent to 32 countries with high child mortality. Publicly available estimates for disease incidence, intervention coverage, prices and resources for individual-level and programme-level activities were validated against local data. Nine updates to the 2007 WHO model were generated using revised assumptions. Finally, estimates were extrapolated to 75 countries and combined with cost estimates for immunization and malaria programmes and for programmes for the prevention of mother-to-child transmission of the human immunodeficiency virus (HIV). FINDINGS: Twenty-six countries responded. Adjustments were largest for system- and programme-level data and smallest for patient data. Country-level validation caused a 53% increase in original cost estimates (i.e. 9 billion 2004 United States dollars [US$]) for 26 countries owing to revised system and programme assumptions, especially surrounding community health worker costs. The additional effect of updated population figures was small; updated epidemiologic figures increased costs by US$ 4 billion (+15%). New unit prices in the 26 countries that provided data increased estimates by US$ 4.3 billion (+16%). Extrapolation to 75 countries increased the original price estimate by US$ 33 billion (+80%) for 2010-2015. CONCLUSION: Country-level validation had a significant effect on the cost estimate. Price adaptations and programme-related assumptions contributed substantially. An additional 74 billion US$ 2005 (representing a 12% increase in total health expenditure) would be needed between 2010 and 2015. Given resource constraints, countries will need to prioritize health activities within their national resource envelope.
Communities of practice: The missing link for knowledge management on implementation issues in low-income countries?
Tropical Medicine and International Health. 2011 Aug; 16(8):1007-1014. [The implementation of policies remains a huge challenge in many low-income countries. Several factors play a role in this, but improper management of existing knowledge is no doubt a major issue. In this article, we argue that new platforms should be created that gather all stakeholders who hold pieces of relevant knowledge for successful policies. To build our case, we capitalize on our experience in our domain of practice, health care financing in sub-Saharan Africa. We recently adopted a community of practice strategy in the region. More in general, we consider these platforms as the way forward for knowledge management of implementation issues.
Essential medicines for mothers and children: a key element of health systems. Access to medicines and public pharmaceutical policy.
Entre Nous. 2009; (68):14-15.Medicines, when used appropriately, are one of the most cost effective interventions in health care. European countries spend an important part of their health budget on medicines, from 12% on average for the EU countries to more than 30% for the Newly Independent States (NIS) countries. Whereas in EU countries the larger part of the medicines expenditures are publicly funded through taxes and/or social health insurance, in the NIS and in the south eastern European countries it is often the patients who have to pay directly for the drugs themselves. This means that many patients simply do not get the drugs they need because they cannot afford them, and also may force families to incur enormous expenses as they sell their belongings in order to pay for their drugs and their health care.
Lancet Infectious Diseases. 2008 Jan; 8(1):14.A report from the International Treatment Preparedness Coalition (ITPC) warns that meeting the "near universal access target" to AIDS drugs access by the 2010 deadline will require an enormous effort by governments, global agencies, and drug companies. According to the report, which looked at AIDS treatment access in 14 countries, "scale-up is working but high prices, patent and registration barriers, and ongoing stock-outs are core issues impeding AIDS drug delivery". "The issues highlighted in this report are real and widespread", said Nathan Ford of Médecins Sans Frontières (MSF; Johannesburg, South Africa). The HIV programmes run by MSF across the developing world are struggling against user fees, high drug costs, lack of human resources, and poor health infrastructure, he told TLID. The ITPC, a group of 1000 treatment activists from more than 125 countries, highlights that the high cost of antiretroviral drugs is a particular barrier in Argentina, China, and Belize. (excerpt)
The practice of charging user fees at the point of service delivery for HIV / AIDS treatment and care.
Geneva, Switzerland, WHO, 2005 Dec.  p. (WHO Discussion Paper; WHO/HIV/2005.11)The global movement to expand access to antiretroviral treatment for people living with HIV/AIDS as part of a comprehensive response to the HIV pandemic is grounded in both the human right to health and in evidence on public-health outcomes. However, for many individuals in poor communities, the cost of treatment remains an insurmountable obstacle. Even with sliding fee scales, cost recovery at the point of service delivery is likely to depress uptake of antiretroviral treatment and decrease adherence by those already receiving it. Therefore, countries are being advised to adopt a policy of free access at the point of service delivery to HIV care and treatment, including antiretroviral therapy. This recommendation is based on the best available evidence and experience in countries. It is warranted as an element of the exceptional response needed to turn back the AIDS epidemic. With the endorsement by G8 leaders in July 2005 and UN Member States in September 2005 of efforts to move towards universal access to HIV treatment and care by 2010, health sector financing strategies must now move to the top of the international agenda. Rapid scale-up of programmes within the framework of the "3 by 5" target has underscored the challenge of equity, particularly for marginalized and rural populations. It is apparent that user charges at the point of service delivery "institutionalize exclusion" and undermine efforts towards universal access to health services. Abolishing them, however, requires prompt, sustained attention to long-term health system financing strategies, at both national and international levels. (excerpt)
Washington, D.C., World Bank, Global HIV / AIDS Program, 2005 Dec. 5 p.Many countries are working to expand access to antiretroviral (ARV) drugs for millions of people with HIV/AIDS. Uninterrupted and timely supplies of safe, effective and affordable ARV drugs are needed. They must be dispensed correctly by health workers, and consistently taken by patients. A partnership between the World Bank and World Health Organization (WHO), in collaboration with the Global Fund for AIDS, TB and Malaria (GFATM), UNICEF, UNAIDS, and the American and French Governments is helping countries build capacity to procure and manage HIV/AIDS drugs and related supplies. This effort has helped support an increase in the number of people on ARV treatment in low- and middle income countries, from 400,000 at the end of 2003, to about one million in June 2005. (author's)
[Washington, D.C.], Population Council, Frontiers in Reproductive Health, 2006 Jun.  p. (USAID Cooperative Agreement No. HRN-A-00-98-00012-00)The Government of Ghana has adopted the WHO focused antenatal care (ANC) package in a move to improve access, quality and continuity of ANC services to pregnant women. As part of these efforts, the Government has exempted fees for ANC clients. The main objective of this study, undertaken by Noguchi Memorial Institute for Medical Research in collaboration with the Ghana Health Service (GHS), FRONTIERS, and with USAID funding, was to examine the extent to which adaptation of the package influenced quality of care received by pregnant women and its acceptability to both providers and clients. The study used a policy analysis and a situation analysis in ten intervention clinics in which the package had been introduced and four comparison clinics. Data were collected through key informant interviews, focused group discussions, client exit interviews, client card reviews, observations of provider-client interactions and review of facility records. (excerpt)
The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings.
Lancet. 2006 Aug 5; 368(9534):505-510.WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the "four Ss"--when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop--enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system. (author's)
Boston Globe. 2003 Jul 30; A10.The World Health Organization announced yesterday that it will create a new model to buy antiretroviral AIDS drugs in hopes of dramatically speeding distribution and reducing the cost of the life-saving medication. The plan comes from a collaboration among tuberculosis experts, foremost among them the new WHO director general, Jong-wook Lee. That program, called the TB Drug Facility, purchases drugs in bulk on behalf of countries and then oversees the distribution. (excerpt)
Fees-for-services, cost recovery, and equity in a district of Burkina Faso operating the Bamako Initiative. [Prestation de services, couverture des coûts et équité dans une région au Burkina-Faso exploitant l'Initiative de Bamako]
Bulletin of the World Health Organization. 2003 Jul; 81(7):532-538.Objective: To gauge the effects of operating the Bamako Initiative in Kongoussi district, Burkina Faso. Methods: Qualitative and quasi-experimental quantitative methodologies were used. Findings: Following the introduction of fees-for-services in July 1997, the number of consultations for curative care fell over a period of three years by an average of 15.4% at ‘‘case’’ health centres but increased by 30.5% at ‘‘control’’ health centres. Moreover, although the operational results for essential drugs depots were not known, expenditure increased on average 2.7 times more than income and did not keep pace with the decline in the utilization of services. Persons in charge of the management committees had difficulties in releasing funds to ensure access to care for the poor. Conclusion: The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the community is able to identify such people. Incentivesmust be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay. (author's)
In: Family planning programme sustainability: a review of cost recovery approaches. Papers presented at the Seminar on Programme Sustainability through Cost Recovery, Kuala Lumpur, Malaysia, 21-25 October 1991, edited by Lori S. Ashford, Med Bouzidi. London, England, International Planned Parenthood Federation [IPPF], 1992 Mar. 3-6.The International Planned Parenthood Federation (IPPF) organized a seminar on program sustainability through cost recovery October 21-25, 1991, in Kuala Lumpur, Malaysia. The seminar was attended by representatives from family planning associations (FPA) from many parts of the world, including Malaysia, Indonesia, Japan, Korea, India, Sri Lanka, Kenya, the Gambia, Switzerland, Colombia, and Suriname. IPPF Secretariat and International Office staff were also in attendance, as well as representatives from the World Bank, UNFPA, the Futures Group, Management Sciences for Health, Innovative Development Research, and the Indonesian Government family planning agency, BKKBN. The seminar reviewed issues related to program sustainability, including the rationale for and the prerequisites of financial and program sustainability. Participants exchanged field experiences on a wide variety of approaches to cost recovery and resource development. The participants also worked to develop strategies and practical guidelines for FPAs either embarking upon cost recovery schemes for the first time or searching for new strategies. The authors discuss defining what is meant by cost recovery and arguments for and against cost recovery.
HEALTH POLICY AND PLANNING. 1990 Jun; 5(2):186-9.WHO and UNICEF joined forces to support the Bamako Initiative agreed upon by African ministers of health at a 1987 meeting. Primary health care (PHC) should be advanced by identifying and introducing self-financing mechanisms at the district level (specifically, revenue from drug sales), securing a constant supply of drugs, and promoting social mobilization. UNICEF has produced several policy papers on recurrent costs and the sales of drugs. The 1988 UNICEF policy paper Problems and Priorities Regarding Current Costs reviews UNICEF practices of financing programs and proposes recommendations. For example, about 40% of program expenditure goes to recurrent costs, especially the financing of drugs and vaccines. Another 1988 UNICEF working paper is Community Financing Experiences for Local Health Services in Africa, which reviews 3 case studies on community financing. Today, however, UNICEF no longer considers drug cost recovery as essential to the Bamako Initiative. In July 1989, the WHO Regional Office for Africa published Guidelines for the Implementation of the Bamako Initiative. Charging for Drugs in Africa: UNICEF's 'Bamako Initiative' (1989) critiques UNICEF's policy in the context of the IMF and the World Bank adjustment programs. Availability of Pharmaceuticals in sub-Saharan Africa: Roles of Public, Private and Church Mission Sectors (1989) highlights the success of cost recovery in church mission health care and the efficiency of distribution through the commercial sector. Its authors consider the Bamako Initiative to be unrealistic. One of the first shots at reviewing community financing experiences is the 1982 article, Community Financing of PHC. Other works are Financing PHC Programmes (Christian Medical Commission), Financing PHC: Experiences in Pharmaceutical Cost Recovery (PRITECH), WHO's Financing Essential Drugs, and A Price to Pay: The Impact of User Charges in Ashanti-Akim District, Ghana.
HEALTH ACTION. 1994 Jun-Aug; (9):7.The Bamako Initiative, a health reform package initiated by the World Health Organization and UNICEF at a 1987 meeting of African Ministers of Health, has reached thousands of local health centers in 30 countries with its community participation program. A central goal is to generate funds for expansions in local health services through the introduction of user fees, prepayment schemes, and revolving drug funds. The concept of community co-financing is based on local involvement in selecting target health reforms, generating income, and managing programs rather than a top-down approach where programs and user fees are imposed on a community. Health management committees at all health facilities are responsible for implementing the reforms and being accountable to the community. To compensate for the limited management skills at the grass-roots level, UNICEF's Health Systems Development Unit has developed training modules for use by these committees. It is the intention that the community participation inherent in this approach will reverse the trend toward urban, hospital-based care and vertical programs.
Arlington, Virginia, John Snow [JSI], Resources for Child Health [REACH], 1988 Sep. , 99,  p. (USAID Contract No. DPE-5927-C-00-5068-00)Building upon smallpox and measles immunization campaigns originally supported by USAID, the Centers for Disease Control, and the World Health Organization, the African region Combatting Childhood Communicable Diseases (CCCD) Project began providing immunizations, oral rehydration therapy for children with diarrhea, and malaria prophylaxis services in 1982. The project was approved in September, 1981, for spending of $47 million through fiscal 1988, and was designed to be implemented through existing publicly operated health service delivery systems with recipient CCCD project countries helping to finance recurrent costs and providing human resources for project implementation. Accordingly, almost all country project agreements were written to ensure that country governments would provide financial support for activities through direct budget allocations, user fees, or some combination of the 2. Regular analyses of service provision were also agreed upon. The development and implementation of user fees have taken place, but the overall theoretical financial strategy has yet to be met in any country project. This document discusses financing achievements and what more is needed to ensure longer term project financial sustainability. Sections review country-specific agreements to spell out original USAID/country terms on financing components; consider the capacity of CCCD project governments to finance recurrent costs in their respective macroeconomic contexts; present highlights of a review of CCCD project financing activities; summarize an evaluation of alternative health financing options; give conclusions of analyses on the financial sustainability of CCCD project activity; and make recommendations for future USAID CCCD project support with respect to financing and economics.
London, England, International Planned Parenthood Federation [IPPF], 1992 Mar. iv, 81 p.Participants at the October 1991 IPPF seminar on Program Sustainability through Cost Recovery addressed the challenge of continuing to provide even more family planning (FP) services to the poorer segments of society while at the same time ensuring program survival. Field reports indicated a variety of funding sources, including user fees, social marketing programs, income generating schemes unrelated to FP, service agreements with the public sector, and private sources. Fees comprise the most common means of recovering FP program costs, but there is substantial diversity based on the income of the user, location of the service, and type of service provided. In view of field reports presented at the workshop, 6 broad recommendations were developed: 1) any approach to program sustainability must place the needs of the clients first; 2) sustainability should be an integral part of the organization's longterm strategic plan; 3) cost-effectiveness is a requirement; 4) periodic analyses of service costs, overhead costs, and costs per unit of output should be undertaken to monitor cost-effectiveness; 5) greater inter-IPPF cooperation and sharing of experiences should be encouraged; and 6) a business plan is essential for cost recovery. In countries where family planning acceptance is low and donor funds are available, FP associations are urged to focus on resource development rather than cost recovery from users. FP associations that provide health education services are encouraged to derive income from the sales of IEC materials or seminar fees. In some cases, higher fees can be charged for specialized services such as infertility counseling, but care must be taken to avoid diverting the program's emphasis from the primary task of managing the family planning program. The cost recovery schemes selected--fees, sales, insurance, or community fundraising--should always be consistent with the association's role in the national population program.
Population Reports. Series J: Family Planning Programs. 1991 Nov; (39):1-31.This report discusses the challenges and costs involved in meeting the future needs for family planning in developing countries. Estimates of current expenditures for family planning go as high as $4.5 billion. According to a UNFPA report, developing country governments contribute 75% of the payments for family planning, with donor agencies contributing 15%, and users paying for 10%. Although current expenditures cover the needs of about 315 million couples of reproductive age in developing countries, this number of couples accounts for only 44% of all married women of reproductive age. Meeting all current contraceptive needs would require an additional $1 to $1.4 billion. By the year 2000, as many as 600 million couples could require family planning, costing as much as $11 billion a year. While the brunt of the responsibility for covering these costs will remain in the hand of governments and donor agencies (governments spend only 0.4% of their total budget on family planning and only 1% of all development assistance goes towards family planning), a wide array of approaches can be utilized to help meet costs. The report provides detailed discussions on the following approaches: 1) retail sales and fee-for-services providers, which involves an expanded role for the commercial sector and an increased emphasis on marketing; 2) 3rd-party coverage, which means paying for family planning service through social security institutions, insurance plans, etc.; 3) public-private collaboration (social marketing, employment-based services, etc.); 4) cost recovery, such as instituting fees in public and private nonprofit family planning clinics; and 5) improvements in efficiency.
Report of the Seminar on Programme Sustainability through Cost Recovery, Kuala Lumpur, Malaysia, 21-25 October, 1991.
London, England, IPPF, 1991. 15,  p.In the face of widespread user acceptance, rapidly growing demand, and developing country financial constraints, family planning associations must learn how to operate more efficiently and mobilize new resources with a view to ensuring greater long-term sustainability. Cost recovery was therefore identified as a means of maximizing the use of limited resources, improving program quality, strengthening management, and making service providers more accountable to clients. This document reports results from seminar participants organized to share the benefits of cost recovery with the international community, and to review policy and management issues. Reviewed in the seminar were country experiences with cost recovery, working group discussions on the definition of sustainability, the cost framework of family planning, determining user fees and clients' willingness to pay, preconditions for setting user fees, prerequisites for social marketing, models for cost sharing with the government and private sector, and country case studies from the Gambia, India, and Kenya. Those programs attaining highest self-sufficiency were aided by strong government commitment to either support family planning or to not impede program progress. Also helpful were a businesslike approach to service provision, a strong promotional campaign, organizational structure conductive to effective resource management, and resolve to try diverse approaches. In concluding, the importance of placing the customer first, cost-effectiveness, cost analysis, strategic planning, inter-FPA cooperation, and business plans are mentioned.
FAMILY PLANNING WORLD. 1991 Nov-Dec; 1(2):13.Despite its seemingly conflicting goals, the Family Health Management Service (FHMS) has become an important middleman agency for contraceptives. A for-profit subsidiary of the International Planned Parenthood Federation (IPPF), FHMS has established itself by helping fill the funding gap left by large international donor agencies. FHMS acts as consulting and procurement firm of contraceptives for smaller family planning programs around the world. These organizations, whether government or private, are generally too small to qualify extensive assistance from major donor groups. Although FHMS is a for-profit organization, its leadership stresses that its main goal is to make family planning knowledge and skills available to everyone. FHMS makes a determination whether the organization seeking contraceptives is a charitable or commercial enterprise. If the organization is charitable, FHMS charges only a handling fee. If the organization is commercial, FHMS adds a percentage to make the cost of the contraceptive reflect the market value. Since it begun operating in 1988, FHMS has assisted hundreds of customers. When Action Aid needed 6000 contraceptive products (a figure too small to attract funding from large donor organizations but too large to buy in the open market) for its rural development program in sierra Leone, FHMS procured them at an affordable cost. Last year, the organization spent about $1 million in procuring, shipping, and managing contraceptive sales, and netted a profit of about $45,000. All profits are channeled back to IPPF's altruistic programs.
[Unpublished] 1991. Presented at the Demographic and Health Surveys World Conference, Washington, D.C., August 5-7, 1991. 22 p.A supply-demand approach is used to estimate total and unmet demand for family planning in Indonesia over the last decade. The 1976 Indonesia Fertility Survey, the 1983 Contraceptive Prevalence Survey, and the 1987 National Contraceptive Prevalence Survey form the database used in the study. Women under consideration have been married once, are aged 35-44, have husbands who are still alive, have had at least 2 live births, and had no births before marrying. High demand was found for family planning services, with the proportion of current users and women with unmet demand accounting for over 85% of the population. Marked improvement in contraceptive practice may be achieved by targeting programs to these 2 groups. Attention to unmotivated women is not of immediate concern. Women in need of these services are largely rural and uneducated. Programs will, therefore, require subsidization. The government should gradually and selectively further introduce self-sufficient family planning programs. User fees and private employer service provision to employees are program options to consider. Reducing the contraceptive use drop-out rate from its level of 47% is yet another approach to increase contraceptive prevalence in Indonesia. 33% drop out due to pregnancy, 26% from health problems, 10% because of method failure, 10% from inconveniences and access, and 21% from other causes. Improving service quality could dramatically reduce the degree of drop-outs.
INTEGRATION. 1991 Sep; (29):4-5.The work of the Soviet Family Health Association (SFHA) is described. Created in January, 1989, the organization boasts 25 state-paid workers, and as of June 1991, membership of 15,000 corporate and individual members. Individual annual membership fee is 5 rubles, and entitles members to counseling and family planning (FP) services. The SFHA works in cooperation with the Commission on Family Planning Problems of the USSR's Academy of Sciences, and has been a member of the International Planned Parenthood Federation (IPPF) since 1990. Association activities include lectures for students, newly-weds, adolescents, and working women on modern contraceptive methods; research on attitude regarding sex, sex behaviors, and the perceived need for effective contraception; clinical trials of contraceptive suitability for women; and the training of doctors in FP and contraceptives. Problems central to the SFHA's operations include insufficient service and examination equipment, a shortage of hard currency, and the small number of FP specialists in the country. Solutions to these obstacles are sought through collaboration with the government, non-governmental organizations in the Soviet Union, and international groups. The SFHA has a series of activities planned for 1991 designed to foster wider acceptance of FP. Increased FP services at industrial enterprises, establishing more FP centers throughout the Soviet Union, and studying FP programs in other countries are among Association targets for the year. Research on and promotion of contraceptives has been virtually stagnant since abortion was declared illegal in 1936. Catching up on these lost decades and remaining self-reliant are challenges to the SPHA.
JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 1989 Aug; 92(4):229-41.This general discussion on health economics provides an historical overview as well as a discussion of some of the developments and deficiencies in health economics in developing countries, broadly focused on expenditure and financing studies, cost benefit and cost effectiveness, local costing studies and health planning. In 1963, it was found that as GDP rose so did health expenditures, that countries with similar per capita income spent different percentages of GDp on health services, that the private sector involvement was greater than the public, and that hospitals received most of the money. Countries were encouraged to conduct further studies. The World Bank has successfully stimulated discussion. However, lacking the expenditure studies, cost benefits are hampered by the availability of epidemiological data and poor cost information, and geared toward studies on how to cut costs for immediate goals, or specific diseases, rather than on practical advice to governments. 1 such study helped identify that most cost effective allocation of resources. The limited local cost studies are particular to understanding specific costs of immunization versus antenatal visits; however, the usefulness of such preliminary information reveals wide variability between countries. The Health for All initiatives and the limited resources in developing countries have placed health planning in a central position with Ministries of Health. Due to prior mistakes in planning an excess number of trained medical staff are underutilized and present needs have been defined as developing local PHC support staff. The WHO expectation of 5% of GNP for health service was unfulfilled because larger donor aid and local resources have not been sufficient even with strong posturing, and over ambitious plans were made unrealistically. Since 1987, WHO has provided economic strategies but the economic crises changed the needs. Many questions remain and consultants are too few, improperly trained, or unavailable for the appropriate time period: unacceptable solutions, coupled with a confusing World bank prospectus for action when more research is needed. Intersectorial collaboration has not provided answers to priorities or addressed the interactions among nutrition and agricultural policy, education and lifestyle, water and sanitation and the economy. The research agenda should include: the identification of the determinants of health, key elements of primary health care (PHC), cost of delivering PHC, hospital efficiency, health manpower mix, adequate procurement and distribution, appropriate technology, user charges for financing, health insurance, and community financing.
In: Cost recovery in the health care sector: selected country studies in West Africa, by Ronald J. Vogel. Washington, D.C., The World Bank, 1988. 126-58. (World Bank Technical Paper No. 82)This chapter is a case analysis of Ghana's health care sector based on a 2-week mission that included site visits to the Christian Hospital Association, which coordinates 35 mission hospitals and 34 mission clinics with the USAID mission and UNICEF in Accra; interviews and analysis of the cost recovery questionnaire given to key planners and health personnel in Accra; site visits to the Government's Industrial Holding Company (GIHOC); and to the Ridge and Korle Bu Hospitals in Accra. Ghana faced severe economic hardship during the 1980's affecting the ability of the health sector to function effectively. Between 1978- 83 per capital health expenditures declined from US 63.6 cents to US 8.3 cents while raising again in 1985 to US 23.0 cents and between 1981-84 physician emigration went from 1700 to 800 because of low morale and the low government pay scale. Under the auspices of the World Bank and the International Monetary Fund, cost recovery for health care was instituted in 1983 and is becoming more comprehensive in coverage. Ghana's cost recovery ratio went from 7.9% in 1986 to 12.1% in 1987. In 1983 the Government revised its 1983 cost recovery law mandating "cost recovery for all government health-care institutions, and creating a uniform collecting and reporting system. It also insisted on full-cost pricing for drugs and pharmaceuticals." The major policy questions addressed in this chapter are: 1) the structure of health care prices and the amounts of revenue collected; 2) patient reaction to cost recovery; 3) equity aspects; and 4) administrative problems and collection costs.