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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.
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.
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)
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)
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, London School of Hygiene and Tropical Medicine, Evaluation and Planning Centre for Health Care, 1988 Spring. 75 p. (EPC Publication No. 15)In response to the resource shortages of government health systems in developing countries, the World Bank has called for charges to be introduced for some types of government health care. While this call may seem to be a pragmatic response to the sector's financing problems, it is also tied closely to the current political emphasis on greater efficiency. Equity considerations are of 2ndary importance. This paper challenges the World Bank's support for health care fees on 2 grounds. 1rstly, the limited importance given to equity within its proposals. 2ndly, the failure to address the problems of implementing its fee strategy. To support this challenge, the different political perceptions of social justice and the importance of equity as a policy goal are explored. The World Bank's position can be characterized as liberal tending towards libertarian and it is argued that the Bank is predisposed towards change in health financing systems by its support for the market-based allocation of care. This predisposition leads the Bank to overlook the difficulties of implementing a fee system that benefits the poor: inability to pay fees, unwillingness to use government care, the difficulty of making payment exemptions and the barriers to retaining fee revenue and using it effectively within government health systems. Starting instead from a collectivist emphasis on equity, alternative options for addressing the problems of resource shortages are also suggested. Improving the performance of government health systems within the available resources is the top priority and the feasibility of implementing other financing options is linked to such an improvement. Policy change should be promoted because it will improve the current situation and not for its own sake.
In: Wood C, Rue Y, ed. Health policies in developing countries. London, England, The Royal Society of Medicine, 1980. 11-7. (Royal Society of Medicine. International Congress and Symposium Series; No. 24)In developing countries systems of "bare-foot doctor" health care are being used. The goal is to provide a health service that is within the reach of each individual and family in the community, is acceptable to participants, that entails their full participation at a cost suitable to the individual and the nation. As opposed to hospital oriented Western medicine, there is usually a health officer from the local community, trained and provided with a dispensary, who returns to the home community. 2 projects in progress which were having negative results, 1 in Zaire and 1 in Senegal, were evaluated. The principles which redirected the programs are discussed. Problems such as mobile centers versus fixed sites for health centers, single aim projects and self-administration of the centers are explored. The acceptance of responsibility by the local public by using funding and resources of its own was judged to run the least risk of failing in the long term. In Senegal a new law on administrative reform was passed which allowed district health committees dealing with about 100,000 people to be set up. With a system of self-financing, more than 500,000 people were treated in 3 years. The fees were modest and 65% of the income from fees was used to keep drug supplies up to date. 3 dangers were identified and overcome: risk of embezzlement by district treasurers, overconsumption of drugs, and stocking excessively expensive products. The basic conditions necessary to provide an efficient network of health services in a rural environment (Zaire) and an urban environment (Senegal) are joint financing of activities through contractual financial participation, local administration, improved medical personnel, standardized medical procedure, and continuous supervision in collaboration with non-professional health workers.