In with the good, out with the bad - Investment standards for external funding of health?

In recent decades, external financing of health systems in low- and middle-income countries has helped achieve remarkable improvements across the world. However, these successes have not come without problems. There are a growing number of areas where external assistance can cause harm and even undermine the development of national health systems. Recent decades have seen a surge of knowledge on investing in health systems. We propose the setting up of investment standards for external assistance that aim to incentivize a more efficient evidence-based investment in a country's health system, led by decision-makers in country. Using a more standardized process would lead to a better use of precious external assistance resources. The long-term goal would be fully functioning health systems with all the necessary essential public health functions in all countries.

Exploring the relationship between national governance indicators and speed of initial government response to COVID-19 in low- and middle-income countries.

Objectives: This study aimed to explore the relationship between national governance and country response to the COVID-19 pandemic in low- and middle-income countries, to support preparedness for the next pandemic. We conducted a statistical analysis of 116 countries, examining the relationship between speed of initial response and measures of national governance. Study design: Observational study, with individual countries as the unit of analysis. Methods: We used logistic regression to look for associations between quicker initial government response and four national governance indicators: Government Effectiveness, Political Stability and Absence of Violence/Terrorism, Voice and Accountability, and Corruption Perceptions Index. Results: A quicker initial government response was associated with countries with higher Government Effectiveness (OR 13.92 95% CI 3.69-52.48, p < 0.001) and lower Political Stability and Absence of Violence/Terrorism (OR 0.23, 95% CI 0.09-0.57, p = 0.002). There was no relationship observed between speed of initial government response and Voice and Accountability or Corruption Perceptions Index. Other factors associated with quicker initial response were small population size, experiencing first COVID-19 case after the pandemic declaration, not having previous experience with SARS-CoV1 or MERS and not being an island nation. Conclusions: This study shows that having higher state policy and implementation capacity, and lower political stability was associated with a quicker initial pandemic response. Limitations of this study include the use of crude national level indicators and broad categorisations of countries into quicker and slower responders. Deeper enquiry into the early decision-making processes taken at the national executive level within individual countries may help clarify the observed associations further.

Health sector governance: should we be investing more?

Governance is central to improving health sector performance and achieving Universal Health Coverage (UHC). However, the growing body of research on governance and health has not yet led to a global consensus on the need for more investment in governance interventions to improve health. This paper aims to summarise the latest evidence on the influence of governance on health, examines how we can assess governance interventions and considers what might constitute good investments in health sector governance in resource constrained settings. The paper concludes that agendas for improving governance need to be realistic and build on promising in-country innovation and the growing evidence base of what works in different settings. For UHC to be achieved, governance will require new partnerships and opportunities for dialogue, between state and non-state actors. Countries will require stronger platforms for effective intersectoral actions and more capacity for applied policy research and evaluation. Improved governance will also come from collective action across countries in research, norms and standards, and communicable disease control.

Public-private interactions on health in South Africa: opportunities for scaling up.

South Africa has long recognized partnerships between the public and private sectors as a policy objective in health, but experience is still limited and poorly documented. The objectives of this article are to understand the factors that increase the likelihood of success of public-private interactions in South Africa, and identify and discuss opportunities for them to be scaled up. There is a strong legislative framework and a number of guidelines and tools that have been developed by the Treasury for managing partnerships. The review of literature confirmed the need for the state to have effective regulations in order to oversee quality and standards and to provide stewardship and oversight. The public sector requires sufficient capacity not only to manage relationships with the private sector but also to enable innovation and experimentation. Evaluation is an integral part of all interactions not only to learn from successes but also to identify any perverse incentives that may lead to unintended consequences. Four case studies show that the private for-profit sector is already engaged in a number of projects that are closely aligned to current health system reform priorities. Factors that increase the likelihood of interactions being successful include: increasing the government's capacity to manage public-private relationships; choosing public-private interactions that are strategically important to national goals; building a knowledge base on what works, where and why; moving from pilots to large scale initiatives; harnessing the contracting expertise in private providers; and encouraging innovation and learning.

Innovative Financing for Health: What are the Options for South Africa?

The paper assesses the options for additional innovative financing that could be considered in South Africa; covering both raising new funds and linking funds to results. New funds could come from: i) the private sector; including the mining and mobile phone industry; ii) from voluntary sources; through charities and foundations; iii) and through further expanding health (sin) levies on products such as tobacco; alcohol and unhealthy food and drinks. As in other countries; South Africa could earmark some of these additional sources for investment in interventions and research to reduce unhealthy behaviors and influence the determinants of health. South Africa could also expand innovative linking of funds to improve overall performance of the health sector; including mitigating the risks for non-state investment and exploring different forms of financial incentives for providers and patients. All such innovations would require rigorous monitoring and evaluation to assess whether intended benefits are achieved and to look for unintended consequences

Financing of health systems to achieve the health Millennium Development Goals in low-income countries.

Concern that underfunded and weak health systems are impeding the achievement of the health Millennium Development Goals in low-income countries led to the creation of a High Level Taskforce on Innovative International Financing for Health Systems in September, 2008. This report summarises the key challenges faced by the Taskforce and its Working Groups. Working Group 1 examined the constraints to scaling up and costs. Challenges included: difficulty in generalisation because of scarce and context-specific health-systems knowledge; no consensus for optimum service-delivery approaches, leading to wide cost differences; no consensus for health benefits; difficulty in quantification of likely efficiency gains; and challenges in quantification of the financing gap owing to uncertainties about financial commitments for health. Working Group 2 reviewed the different innovative mechanisms for raising and channelling funds. Challenges included: variable definitions of innovative finance; small evidence base for many innovative finance mechanisms; insufficient experience in harmonisation of global health initiatives; and inadequate experience in use of international investments to improve maternal, newborn, and child health. The various mechanisms reviewed and finally recommended all had different characteristics, some focusing on specific problems and some on raising resources generally. Contentious issues included the potential role of the private sector, the rights-based approach to health, and the move to results-based aid. The challenges and disagreements that arose during the work of the Taskforce draw attention to the many issues facing decision makers in low-income countries. International donors and recipient governments should work together to improve the evidence base for strengthening health systems, increase long-term commitments, and improve accountability through transparent and inclusive national approaches.

Lumping and splitting: the health policy agenda in India.

India's health system was designed in a different era, when expectations of the public and private sectors were quite different. India's population is also undergoing transitions in the demographic, epidemiologic and social aspects of health. Disparities in life expectancy, disease, access to health care and protection from financial risks have increased. These factors are challenging the health system to respond in new ways. The old approach to national health policies and programmes is increasingly inappropriate. By analyzing inter- and intra-state differences in contexts and processes, we argue that the content of national health policy needs to be more diverse and accommodating to specific states and districts. More 'splitting' of India's health policy at the state level would better address their health problems, and would open the way to innovation and local accountability. States further along the health transition would be able to develop policies to deal with the emerging epidemic of non-communicable diseases and more appropriate health financing systems. States early in the transition would need to focus on improving the quality and access of essential public health services, and empowering communities to take more ownership. Better 'lumping' of policy issues at the central level is also needed, but not in ways that have been done in the past. The central government needs to focus on overcoming the large inequalities in health outcomes across India, tackle growing challenges to health such as the HIV epidemic, and provide the much needed leadership on systemic issues such as the development of systems for quality assurance and regulation of the private sector. It also needs to support and facilitate states and districts to develop critical capacities rather than directly manage programmes. As India develops a more diverse set of state health policies, there will be more opportunities to learn what works in different policy environments.