Are current debt relief initiatives an option for scaling up health financing in beneficiary countries?

One central goal of the enhanced Heavily Indebted Poor Countries (HIPC) Initiative and the more recent Multilateral Debt Relief Initiative (MDRI) is to free up additional resources for public spending on poverty reduction. The health sector was expected to benefit from a considerable share of these funds. The volume of released resources is important enough in certain countries to make a difference for priority programmes that have been underfunded so far. However, the relevance of these initiatives in terms of boosting health expenditure depends essentially, at the global level, on the compliance of donors with their aid commitments and, at the domestic level, on the success of health officials in advocating for an adequate share of the additional fiscal space. Advocacy efforts are often limited by a state of asymmetric information whereby some ministries are not well aware of the economic consequences of debt relief on public finances and of the management systems in place to deal with savings from debt relief. A thorough comprehension of these issues seems essential for health advocates to increase their bargaining power and for a wider public to readjust expectations of what debt relief can realistically achieve and of what can be measured. This paper intends to narrow the information gap by classifying debt relief savings management systems observed in practice. We illustrate some of the major advantages and stated drawbacks and outline the policy implications for health officials operating in the countries concerned. There should be careful monitoring of fungibility (i.e. where untraceable funds risk substitution) and additionality (i.e. the extent to which new inputs add to existing inputs at national and international level).

Guide d'analyse économique du circuit du médicament

this manual focuses on economic aspects of selection, procurement, distribution and prescribing. It is particularly aimed at those in national bodies responsible for defining and guiding health policies on drugs, and those responsible for drug procurement and management at national level. Document in pdf format; Acrobat Reader required.

Indigence and access to health care in sub-Saharan Africa.

Access to health care services for the poor and indigent is hampered by current policies of health care financing in sub-Saharan Africa. This paper reviews the issue as it is discussed in the international literature. No real strategies seem to exist for covering the health care of the indigent. Frequently, definitions of poverty and indigence are imprecise, the assessment of indigence is difficult for conceptual and technical reasons, and, therefore, the actual extent of indigence in Africa is not well known. Explicit policies rarely exist, and systematic evaluation of experiences is scarce. Results in terms of adequately identifying the indigent, and of mechanisms to improve indigents' access to health care, are rather deceiving. Policies to reduce poverty, and improve indigents' access to health care, seem to pursue strategies of depoliticizing the issue of social injustice and inequities. The problem is treated in a 'technical' manner, identifying and implementing 'operational' measures of social assistance. This approach, however, cannot resolve the problem of social exclusion, and, consequently, the problem of excluding large parts of African populations from modern health care. Therefore, this approach has to be integrated into a more 'political' approach which is interested in the process of impoverishment, and which addresses the macro-economic and social causes of poverty and inequity.

Affordability, cost-effectiveness and efficiency of primary health care: the Bamako Initiative experience in Benin and Guinea.

Since 1986 two West African countries, Benin and Guinea, have been actively reorganizing their peripheral health systems according to strategies subsequently called the "Bamako Initiative". Two preceding articles described the strategies implemented and the increased effectiveness of primary health care (PHC) witnessed over a period of six years. This article presents an analysis of cost and coverage data from biannual monitoring sessions between 1988 and 1993 in approximately 200 health centres in Benin and 214 in Guinea. In order to assess affordability, the total and per capita recurrent costs for operational health centres are analysed and then compared. The cost analysis reveals a mean total cost per health centre per year of slightly over US+11,000 in Benin and nearly US+9,000 in Guinea. The median cost per capita per year is approximately US+1.0 in Benin and between US+0.60 and US+0.80 in Guinea. Comparisons of these costs between regions, health centres and over time (as coverage levels evolved) show very little variation in either country. Cost-effectiveness is estimated by allocating these costs to immunization, antenatal and curative care and comparing them to the coverage achieved with these interventions. First, the cost-effectiveness of the Bamako Initiative (BI) system as a whole is analysed. The cost per fully vaccinated child is calculated at US+10.9 in Benin and US+8.8 in Guinea. The cost per woman receiving at least three antenatal visits is US+7 in Benin and US+4.7 in Guinea. For curative care, cost per full treatment is US+1.6 in Benin and half this amount in Guinea. Cost-effectiveness is variable between regions, health centres reveals that these differences in cost-effectiveness are mainly caused by the coverage levels achieved, since total costs are relatively stable. Finally the efficiency of drug management and prescriptions as well as of outreach for the expanded programme of immunizations (EPI) is estimated by relating specific drug and outreach activities costs to the number of beneficiaries. The average cost of drugs per treatment is around US+0.5 in Benin and around US+0.3 in Guinea. Cost analysis of outreach activities undertaken for EPI in Guinea revealed a similar average cost per child completely vaccinated for health centres with different intensities of outreach (approximately US+10) and an additional cost per child vaccinated attributable to outreach of US+1-2.

[Economics of health systems in developing countries: what is the contribution of work published in french?]. / Economie des systèmes de santé des pays en développement: quelle contribution des travaux publiés en français?

Health economics is poorly developed in the francophone community. There is little published work addressing developing francophone countries, and it is largely limited to the sub-Saharan Africa. Few specialist research workers from developing countries contribute. Universities only propose global analyses, and other groups involved (expert consultants) only conduct narrow studies, targeted at immediate action or decision making. The article analyses some of the reasons from this underdevelopment, and overviews what has been produced over the last 15 years. Three areas appear to be preferred: the analysis of costs and financing of vertical programs (vaccination programs in particular), the issue of supply and the price of essential drugs, and the effects and consequences of attempts to recover costs. Research work is mainly conducted by experts and consultants working for the financing bodies or international organizations. Their ideas, methods and conclusions often reflect the interests and working methods of those sponsoring the study. In many cases, pragmatism and short-termism dominate over intellectual and ethical rigor. A major issue is that of the roles of the State and the marker in the organization and financing of health systems and policies. Francophone economist differ from others on this issue, although, since the 1993 World Bank report entitled "Investing in Health" the opposition is less direct, and the "specificities" in the health sector, including those concerning economics, are now universally recognized.