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Africa/Global: Public Health, Shared Responsibilities

AfricaFocus Bulletin
November 5, 2014 (141105)
(Reposted from sources cited below)

Editor's Note

The language is moderate, as one would expect from a prestigious mainstream institute such as Chatham House. But the message, which echoes the clear lessons of the Ebola epidemic, is very clear. Sustainable financing for public health, in every country and at a global level, is not only a moral imperative but also a pragmatic economic necessity.

The report, which comes from the Working Group on Health Financing in the Centre on Global Health Security at Chatham House and was released in May this year, represents a growing consensus among policy specialists about the enormous economic advantages of timely investment in public health. This comes in addition to the stress in global health institutions on the imperative to implement the universal right to health.

Although it is obvious that political realities have and will continue to be formidable obstacles to the implementation of such policies in practice, the Ebola epidemic continues to highlight the urgency of broadening political support to take meaningful action, based on both economic and moral imperatives.

The report stresses the need for financing at three levels, at national levels, at the level of global public health goods (GPHGs), and in adequate global support for national health in countries unable at this time to fund the minimal investment needed. Such financing, the authors note, brings shared benefits and requires shared responsibilities.

This AfricaFocus Bulletin contains the executive summary and a few additional excerpts from the Chatham House study. The full study is available at / direct URL:

For previous AfricaFocus Bulletins on health issues, visit

Ebola Perspectives

[AfricaFocus is regularly monitoring and posting links on Ebola on social media. A few are included here. For additional links, see]

New York Times, October 31, "Braving Ebola" -
Moving words and beautiful images of those in the front line against #Ebola.
Thanks to for this link.

Map resource, "Africa without Ebola"

Washington Post, October 31, "Good for you, Kaci Hickox
Best short article on Ebola quarantines in USA

Ebola Deeply, November 4, Interview with Lawrence Gostin Very clear statement on priorities on Ebola

++++++++++++++++++++++end editor's note+++++++++++++++++

Shared Responsibilities for Health: A Coherent Global Framework for Health Financing

Final Report of the Centre on Global Health Security Working Group on Health Financing

Chatham House: The Royal Institute of International Affairs

May 21 2014 / direct URL:

Executive Summary and Recommendations

Financing is at the centre of efforts to improve health and health systems. It is only when resources are adequately mobilized, pooled and spent that people can enjoy robust health systems and sustained progress towards universal health coverage - that is, all people receiving high-quality health services that meet their needs without exposing them to financial hardship in paying for the services.

This report, which presents the findings and recommendations of the Working Group on Health Financing in the Centre on Global Health Security at Chatham House, shows how common challenges put such progress at risk in countries across the world, and particularly in low- and middle-income countries. These challenges are common not only because they happen to be present throughout these countries, but also because globalization means the underlying causes and transitions know no borders. This calls for collective action on a global scale. Specifically, the report calls for an agreed coherent global framework for health financing capable of securing sufficient and sustainable funding and of both mobilizing and using these funds efficiently and equitably.

Progress towards such a framework can be made by revising the current approach to health financing in three areas: the domestic financing of national health systems, the joint financing of global public goods for health, and the external financing of national health systems where domestic capacity is inadequate. Progress in these areas can be achieved through a set of policy responses which can be encapsulated in 20 recommendations.

To strengthen domestic financing of national health systems, we conclude that:

1. Every government should meet its primary responsibility for securing the health of its own people. This involves a responsibility to oversee domestic financing for health and ensure that it is sufficient, efficient, equitable and sustainable.

2. Every government should commit to spend at least 5 per cent of gross domestic product (GDP) on health and move progressively towards this target, and every government should ensure government health expenditures per capita of at least $86 whenever possible. Most middle-income countries should be able to reach both targets without external support.

3. Every government should ensure that catastrophic and impoverishing OOPPs [out-of-pocket payments] are minimized. Specifically, governments should commit to the targets of OOPPs representing less than 20 per cent of total health expenditures (THE) and no OOPPs for priority services or for the poor.

4. Every government should improve revenue generation and achieve reduction of OOPPs through effective, equitable and sustainable ways of increasing mandatory prepaid pooled funds for health services. Individual contributions to the pool(s) should primarily be based on capacity to pay and be progressive with respect to income.

5. Every government should consider improved and innovative taxation as a means to raise funds for health. Promising policies include the introduction or strengthening of excise taxes related to tobacco, alcohol, sugar and carbon emissions, and these should be combined with measures to increase tax compliance, reduce illicit flows and curb tax competition among countries. Other sources of government revenue, particularly in countries rich in natural resources, should also be explored.

6. Every government should ensure that mandatory prepaid pooled funds are used with the aim of making progress towards UHC - that is, affordable access for everyone. Specifically, every government should seek to ensure a universal health system with full population coverage of comprehensive primary health care, high-priority specialized care and public health measures, and should not prioritize expanding coverage of a more comprehensive set of services for only some privileged groups in society

7. Every government, in collaboration with civil society, should formalize systematic and transparent processes for priority-setting and for defining a comprehensive set of entitlements based on clear, well-founded criteria. Potential criteria include those related to cost-effectiveness, severity and financial risk protection. The processes can build on the methods of health technology assessment and multicriteria decision analysis, which can help translate evidence and explicit values into policy decisions.

8. Every government and other actor involved in the financing or provision of health care must continuously strive to improve efficiency. In particular, this will require action on corruption and strategic purchasing, with continuous assessment and active management of which services are purchased and what providers and payment mechanisms are used.

To strengthen joint financing of global public goods for health (GPGHs), we conclude that:

9. Every government should meet its key responsibility for the co-financing of GPGHs and take the necessary steps to correct the current undersupply of such goods. Among key GPGHs are health information and surveillance systems, and research and development for new technologies that specifically meet the needs of the poor. Public funding for the latter purpose should be at least doubled compared with the current level.

10. Every government should increase its support for new and existing institutions charged with the financing or provision of GPGHs. In particular, the World Health Organization's capacity to provide GPGHs should be enhanced and adequate funds provided on a sustainable basis for that purpose.

11. Every government, international organization, corporation and other key actor should promote a global environment that enables all countries to pursue government-revenue policies that can sufficiently finance their social sectors, including health, education and welfare. This requires action on illicit financial flows, tax havens, harmful tax competition and overexploitation of natural resources.

To strengthen external financing for national health systems, we conclude that:

12. Every country with sufficient capacity should contribute with external financing for health. Determination of capacity should partly depend on GDP per capita. Net contributing countries should include all high-income countries and most uppermiddle -income countries and not only member countries of the OECD's Development Assistance Committee (OECD-DAC).

13. High-income countries should commit to provide external financing for health equivalent to at least 0.15 per cent of GDP. Most upper-middle-income countries should commit to progress towards the same contribution rate.

14. Every provider of external financing for health, including contributing countries and international organizations, should establish clear, well-founded and publicly available criteria to guide the allocation of resources. These should be the outcome of broad, deliberative processes with input from key stakeholders, including civil society in contributing and recipient countries.

15. Every provider of external financing for health should align its support with recipient-country government priorities to the greatest extent possible. This calls for strong adherence to the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. In particular, providers of external financing for health should encourage and comply with national plans and strategies, improve transparency and monitoring of disbursements and results, and help to build domestic governance and institutional capacity.

16. All providers of external financing for health should strive to strengthen coordination among themselves and with each recipient country, in order to improve efficiency as well as equity. In particular, they should encourage and comply with country-led division of labour, harmonize procedures, increase the use of joint and shared arrangements, and improve information sharing.

17. Every government should actively assess the existing mechanisms for pooling of external funds for health - including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, and the World Bank's health trust funds - and consider the feasibility of broader mandates, mergers and increased global pooling with the aim of improving efficiency and equity.

Strong accountability mechanisms and global agreement on responsibilities, targets and strategies will facilitate the implementation of the needed policy responses and a coherent global framework. We conclude that:

18. Every government and other actor involved in domestic or external financing or in the provision of health services should seek to strengthen accountability at global, national and local levels. This should be done by improving transparency about decisions, resource use and results, by improving monitoring and data collection and by ensuring critical evaluation of information with effective feedback into policy-making. Accountability should also be strengthened through active monitoring by civil society and by ensuring the broad participation of stakeholders throughout the policy process.

19. Every government and other key actor should seek to ensure that health and universal health coverage are central goals and yardsticks in the post-2015 development agenda. These actors should also seek to ensure that the responsibilities, targets and strategies of a coherent global framework for health financing are integrated to the fullest extent possible. Moreover, the agenda should make clear that health is important both for its own sake and for the sake of other goals, including poverty eradication, economic growth, better education and sustainability.

20. All stakeholders should enter into a process of seeking global agreement on key responsibilities, targets and strategies for health financing - including on the mechanisms for monitoring and enforcement in order to expedite the implementation of a coherent global financing framework. In the short term, consultation on the post-2015 development agenda is one useful arena for building consensus, and the agenda itself can be a valuable commitment device. In the longer term, a more specific process should be devised in one or more relevant forums, such as the UN General Assembly, the World Health Assembly, World Bank/International Monetary Fund, or a high-level stand-alone meeting.

With successful agreements, the great potential of health system strengthening and proven high-impact interventions can eventually be unleashed.

The Case for Action

Unprecedented transitions, and new and persisting challenges call for a new global approach to health financing. These transitions include profound changes in the global economy, changes in health and risk factors for disease, and transformation of the institutional landscape in the global health arena. Significant challenges include poor health outcomes, poor access to health services, and financial risks to patients stemming from out-of-pocket health service payments. They are compounded by profound inequalities in these three dimensions both between and within countries and by the uneven distribution of recent improvements.

Economic growth has been accompanied by accentuation of inequalities, in terms of both income and health, and between and within many countries. A result of these processes is the new phenomenon that more than 75 per cent of the
world's poor now live in middle-income countries.

Health financing is central to meeting these challenges and for improving health and health systems. We believe that the current approach to health financing needs to be revised with respect to the domestic financing of national health systems, the joint financing of global public goods for health (GPGHs) and the external financing of national health systems where domestic capacity is inadequate. Only through concerted efforts in these three areas can the world move towards a global framework that is capable of securing sufficient and sustainable funding and of both mobilizing and using it efficiently and equitably. This is essential for building and sustaining momentum to reduce premature death, achieve universal health coverage (UHC) and reach the ultimate goal of a fairer and healthier global society.

This is also a particularly appropriate time to seek a coherent global framework. Led by the UN, the world is currently debating the shape of the post-2015 development agenda - i.e. the agenda to succeed the Millennium Development Goals (MDGs) when these expire in 2015. The role and content of health goals, and how to reach them, are a particular focus. The broad debate and the numerous processes informing it provide a platform for shaping the future we want, including for health financing.

Underlying transitions

Underlying the challenges in health financing, as well as the broader challenges to global health, are ongoing transitions in three areas: in the economic sphere, in health and in global health institutions. These are aspects of the broader processes of globalization which have made the world increasingly complex, interconnected and interdependent (Frenk et al. 2014). This new level of integration has created both opportunities and challenges.

The economic transition

There have been monumental economic changes over the last two decades. Economic growth rates have been impressive, not only in emerging economies (WB 2013). Many countries have moved from low-income to middleincome status, and 70 per cent of the world's population now live in middle-income countries (MICs). As a result, many countries are increasingly able to finance their own health needs without external support, and several MICs are also becoming significant contributors of external financing themselves (GHSi 2012; AidData 2013; IHME 2014). However, economic growth has been accompanied by accentuation of inequalities, in terms of both income and health, and between and within many countries (WCSDG 2004; Ortiz and Cummins 2011; UNDP 2013a). A result of these processes is the new phenomenon that more than 75 per cent of the world's poor now live in MICs (Sumner 2012; Alkire et al. 2013), and MICs account for a major share of the world's unmet health needs.

The health transition

Health outcomes have continued to improve over the last two decades. The global under-five mortality rate nearly halved, from 90 to 48 per 1,000 live births, between 1990 and 2012 (UNICEF 2013a), and the world average for female healthy life expectancy at birth increased from 58.7 healthy life years in 1990 to 63.2 years in 2010 (Salomon et al. 2012). However, there are vast inequalities between and within countries. For example, in 2010 female healthy life expectancy at birth ranged between 41.7 years in the Central African Republic to 75.5 years in Japan (Salomon et al. 2012). At the same time, many countries have significant inequalities in health outcome measures across gender, socioeconomic status and place of residence, and in many countries these inequalities are increasing (CSDH 2008; UNDP 2013a; WHO 2013c).

There have also been marked changes in disease patterns. Many countries have seen a major increase in the burden of non-communicable diseases (NCDs) such as cardiovascular disease, cancer, chronic respiratory disease and diabetes. As a result, NCDs are now the major cause of premature death and disability in the world, having increased from a share of 43 per cent in 1990 to 54 per cent in 2010 (Murray et al. 2012).

However, the shifts in disease pattern and associated risk factors have only been partial in many low-income countries (LICs) and MICs. As a result, many countries are now faced with a triple burden of disease: the unfinished agenda of infections, undernutrition and reproductive health problems; a rising burden of NCDs and their associated risk factors, such as smoking and obesity; and the burdens and risks more directly linked to globalization itself, such as the threat of pandemics, the spread of pathogens resistant to antimicrobials, and the health effects of climate change and trade policies (Frenk et al. 2011; Frenk and Moon 2013).

The institutional transition in global health

The priority accorded to global health issues has increased substantially over the past two decades. External financing for health almost doubled from $5.8 billion in 1990 to $11.2 billion in 2001, and nearly tripled to $31.3 billion (expressed in 2011 US dollar terms) by 2013 (IHME 2014). In parallel, there has been a proliferation of new institutions in global health that now play prominent roles (Szlezak et al. 2010; Frenk and Moon 2013). These include philanthropic organizations, such as the Bill & Melinda Gates Foundation, and public-private partnerships or hybrids, such as the GAVI Alliance (GAVI) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). These have supplemented and challenged the traditional roles of national bilateral aid agencies, the UN, including the World Health Organization (WHO), and multilateral development banks, such as the World Bank. In addition, civil society organizations, private firms, professional associations, and academic institutions have come to play a much more influential role in the global health arena. Moreover, the impact on health of other institutions outside the health sector, such as the World Trade Organization (WTO), has been increasingly recognized (Frenk and Moon 2013; Ottersen, O. et al. 2014).

At the same time, the financial crisis of 2008 and its ongoing ramifications pose a threat to external financing for health, and the annual increase in such financing over the last few years fell short of that seen between 1990 and 2010 (IHME 2014).

In parallel with major changes at the global level, there are global trends in the institutional reforms taking place within countries, often in the context of pursuing universal health coverage (UHC). In particular, a 'health financing transition' is under way in numerous countries (Fan and Savedoff 2014).


The call for a coherent global framework

A new, broad and coherent approach to health financing is required. Specifically, the world needs an agreed framework to secure sufficient, efficient, equitable and sustainable financing to achieve health goals, including UHC. To move towards such a framework, the challenges in the three financing areas must be effectively addressed through a range of policy responses, guided by the importance of health and the ultimate objective of achieving UHC. To promote sustained progress, agreement on clear targets and shared responsibilities should be sought on the basis of justice, solidarity and human rights. The policy responses should be anchored in the post-2015 agenda by firmly positioning health and key responsibilities, targets and strategies of the health financing framework in that agenda.

The shaping of a global framework for health financing should build on the legacy of the Commission on Macroeconomics and Health (CMH) (CMH 2001), the (high-level) Taskforce on Innovative International Financing for Health Systems (HLTF) (HLTF 2009b), the World Health Report 2010 (WHO 2010) and several more recent reports, including those of the Lancet Commission on Investing in Health and the Lancet-University of Oslo Commission on Global Governance for Health (Jamison et al. 2013a; Ottersen, O. et al. 2014). However, there is a need to go beyond this to acknowledge ongoing changes and transitions, integrate recent experience and insights on health and development financing, and build a comprehensive normative framework with shared, yet clear responsibilities and goals.

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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