Lukman Ademola Adepoju, Oyetunji Oyewale, Odekunle Bola Odegbemi, Ifeoluwa Abraham Adeagbo · 5 authors
Over 40 years after the identification of human immunodeficiency virus (HIV), Nigeria remain one of the highest burdens of HIV infections in the world, accounting for almost 10% of new infections in sub-Saharan Africa. Despite significant investments and technical supports from different foreign donors including the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, and bilateral partners. The persistent structural, financial, and programmatic gaps continue to hamper the country’s HIV response. This assessment of HIV-related interventions in Nigeria examines what has been achieved, what still need to be done, and how to establish a sustainable and domestically owned HIV care. The review summarizes evidence from peer-reviewed literature (2018–2025) and major institutional reports (UNAIDS, NACA, WHO, PEPFAR) to assess five key domains: coverage and access, funding and sustainability, health system strengthening, monitoring and evaluation, and sociocultural barriers. Evidence shows that while substantial progress has been achieved in testing, antiretroviral therapy (ART) coverage, and community-based care, the HIV response remains heavily donor-dependent, urban-centered, and fragmented across vertical program streams. The review concludes that to achieve long-term epidemic control (EC) and universal health coverage (UHC) in Nigeria’s HIV care and programming with there is a need for domestic financing, health system integration, decentralized service delivery, and data-driven accountability frameworks.
James Kinjanzi Sirite, Prof. David Minja, Jane Njoroge
Purpose: This study examined the effect of revenue decentralization on healthcare service delivery in Turkana County, Kenya. Materials and Methods: Using a mixed-methods approach, the research collected data from 271 respondents, including county health and finance officials, hospital administrators, and community health representatives. Findings: The findings reveal that revenue decentralization significantly improves healthcare service delivery, with a one-unit increase in revenue decentralization leading to a 0.49-unit improvement in healthcare outcomes. However, delays in budget disbursement (averaging 5.11 months) and reliance on external revenue sources (36.9% tax autonomy) highlight challenges in financial sustainability and resource allocation. Qualitative responses underscore both the benefits of increased autonomy and access to funding, as well as the drawbacks of concentrated financing and disparities in rural healthcare access. The study concludes that optimizing tax autonomy mechanisms, strengthening intergovernmental grants, and improving financial management are critical to enhancing the positive effects of revenue decentralization. These findings contribute to the broader discourse on fiscal decentralization and its potential to address healthcare inequities in marginalized regions. Unique Contribution to Theory, Practice and Policy: To improve healthcare in Turkana County, enhance revenue decentralization by refining tax autonomy, increasing equitable intergovernmental grants, and addressing rural disparities. Implement 'nomadic health vouchers' using 15% of decentralized revenues and 'fiscal health compacts' to reduce budget delays. Ensure autonomy, accountability via blockchain, and drought-responsive budgets work together to boost accessibility and patient support, transforming fiscal policy into a tool for healthcare justice, especially for mothers and herders facing long waits and travel for care.
HIV/AIDS continues to pose a significant public health challenge in Africa, with Sub-Saharan Africa accounting for the majority of global cases. While international donor funding has historically underpinned HIV/AIDS programs across the continent, the declining availability of external resources has emphasized the need for sustainable domestic financing. Local governments, situated at the intersection of national policies and community-level implementation, play a pivotal role in bridging this funding gap. This review examines the contributions of local governments to HIV/AIDS program funding in Africa through a comparative lens, focusing on successes, challenges, and opportunities for strengthening their role. Case studies from South Africa, Uganda, Nigeria, and Kenya highlight diverse approaches to resource mobilization, policy implementation, and community engagement. Persistent barriers, including limited fiscal capacity, donor dependency, weak governance structures, political instability, and competing priorities, are analyzed to inform strategic recommendations. The findings underscore the need for enhanced fiscal decentralization, capacity building, and innovative financing mechanisms to empower local governments in sustaining HIV/AIDS responses. By fostering greater local government participation, Africa can achieve more resilient and effective health systems, ensuring progress toward ending AIDS as a public health threat by 2030. Keywords: HIV/AIDS funding, Local government, Sustainable financing, Sub-Saharan Africa, Public health policy.
The concepts of the economic planning in Nepal starts form the Rana regime. Rana prime minister Juddha Samsher makes a concept to apply the program for development. From the initial stage of periodic plans health has given emphasis. The paper aims to overview the health priorities in periodic plans of Nepal. From the review of the literatures and documents it is found that from the First to Fourth Plans, Nepal focused on establishing essential healthcare infrastructure such as health posts and primary healthcare centers. Maternal and child health, alongside the control of communicable diseases, formed core priorities during this phase. The Fifth to Seventh Plans emphasized expanding healthcare services into rural areas through community-based approaches, aiming to improve healthcare access and outcomes across the population. From the Eighth to Tenth Plans, Nepal underwent health sector reforms, decentralizing healthcare services and focusing on universal health coverage. The transition into the Eleventh to Thirteenth Plans aligned with global health goals, emphasizing the reduction of maternal and child mortality, combating infectious diseases like HIV/AIDS, and addressing environmental health concerns such as air pollution. From Fourteenth to Sixteenth Plans, Nepal faces new challenges such as climate change impacts and COVID-19 pandemic and focus to strengthening health infrastructure, enhancing healthcare financing mechanisms, promoting health equity, and integrating mental health services into mainstream healthcare provisions. Every, periodic plans are influenced by the issues. So far, further plans should focus on non-communicable diseases (NCDs), actions to cope with climate change health impacts, health technologies and probable health emergencies.
Peter Binyaruka, John Maiba, Dastan Mshana, Agnes Gatome-Munyua · 5 authors
Primary care facilities' autonomy and the factors that influence it are understudied. Direct facility financing (DFF) is gaining popularity in low- and middle-income countries as a modality to finance primary care facilities. Tanzania has introduced DFF with the objectives of streamlining resource allocation, fostering fiscal decentralization, and granting autonomy to health facilities for enhanced service readiness and responsiveness. This study aims to contribute evidence on primary care facilities' autonomy to execute DFF funds and the factors influencing this autonomy.Qualitative interviews and group discussions were conducted with health workers, managers, and community representatives from two councils to understand their perceptions of the autonomy of primary care facilities under DFF and remaining bottlenecks to effective budget execution. Data were analyzed using thematic content analysis to explore factors that influence facility autonomy to execute DFF funds.Primary care facilities are well informed on financial management and have adequate autonomy to execute DFF funds. However, several factors constrain their autonomy, including delays in funds disbursement, complex procurement and approval processes, rigid spending caps, restrictions on reallocations, and weaknesses in financial management capacity.DFF is a promising modality for health financing that supports health system goals. However, various challenges continue to hinder the autonomy of frontline service providers to fully execute DFF funds. To improve DFF budget execution, policy makers in Tanzania and elsewhere should consider reforms to better align public financial management and health financing.
Background: Health financing is one of the focuses in the National Health System Reform major project in the 2022 Government Work Plan. However, obstacles have been found in health financing in Indonesia, including a lack of promote and preventive financing; less non-governmental involvement; and weak development of national health insurance (JKN) services. Purpose: To understand the principles of health financing for the realization of universal health coverage. This principle uses the concept of Kutzin et al (2017) and Atim et al (2021), namely revenue raising; pooling revenues; purchasing services; benefit design and rationing mechanism; and governance and institutional arrangements, including decentralization. Method: Focuses on the principles of health financing by utilizing secondary data sources through qualitative methods. The data sources were obtained from scientific journals, official government reports, related web pages, and others. Results: The effectiveness of increasing income for health financing cannot yet be measured. Revenue collection was found to overlap with health financing sources. There was a deficit for the JKN budget, and the community was not disciplined in paying contributions in purchasing services and distribution mechanisms. For the principle of decentralization, regional governments still depend on the central government in planning and budgeting health financing. Conclusion: The principles of health financing in Indonesia are not yet optimal in practice. This article contributes to looking at the gaps in information regarding the government's commitment to universal health coverage.
Abstract Health system is the backbone of delivering efficient preventive, promotive, curative and rehabilitative services. WHO has identified six building blocks of any health system. These include governance and leadership, infrastructure, workforce, financing, information management and access to essential medicines. Nepal has been striving to strengthen its health system despite several challenges in all WHO building blocks. Inadequate funds, geographical inequalities, insufficient health workforce, weak logistics, suboptimal health information system and inadequate health infrastructure have plagued Nepal health system for long. Natural calamities (e.g. earthquake of 2015) and COVID-19 pandemic overwhelmed the health system. In 2015, Nepal promulgated its new Constitution that devolved and decentralized several powers of generating revenue and exercising authority to sub-national governments viz the states/provinces and local civic bodies. Though functions of health system have been clearly defined at federal, state and local levels in the Constitution, transition of the erstwhile federal health system into new governance and implementation modalities continues to be challenging. There is a strong need to strengthen all building blocks of health system in Nepal at all levels of governance.
In this paper, it has been aimed to reveal the possible effects of Covid-19 Coronavirus epidemic on stock markets. In the analysis using daily data between 23 January 2020 and 13 March 2020, possible effects on stock markets has been investigated with Maki (2012) cointegration test using both Covid-19 daily total death and Covid-19 daily total case. According to the results obtained, all stock markets examined with total death act together in the long run. It has been understood that total cases have cointegration relationship of SSE, KOSPI and IBEX35 and do not have cointegration relationship with FTSE MIB, CAC40, DAX30. In this regard, it is considered as one of the optimal option for investors to avoid investments in stock markets, turn to investment in gold markets, which is the safe investment port of each crisis period in long run. Also, considering the possibility of turning all life into an internet environment, turning to cryptocurrencies is seen as another alternative option for investors. In this direction, it will be the preference of investors to turn to derivative markets and to the stock markets of countries where Covid-19 is relatively rare to avoid risk.
Nisha Bhat, Peter H. Kilmarx, Freeman Dube, Albert Manenji · 6 authors
BACKGROUND: We conducted a case study of the Zimbabwe National AIDS Trust Fund ('AIDS Levy') as an approach to domestic government financing of the response to HIV and AIDS. METHODS: Data came from three sources: a literature review, including a search for grey literature, review of government documents from the Zimbabwe National AIDS Council (NAC), and key informant interviews with representatives of the Zimbabwean government, civil society and international organizations. FINDINGS: The literature search yielded 139 sources, and 20 key informants were interviewed. Established by legislation in 1999, the AIDS Levy entails a 3% income tax for individuals and 3% tax on profits of employers and trusts (which excluded the mining industry until 2015). It is managed by the parastatal NAC through a decentralized structure of AIDS Action Committees. Revenues increased from inception to 2006 through 2008, a period of economic instability and hyperinflation. Following dollarization in 2009, annual revenues continued to increase, reaching US$38.6 million in 2014. By policy, at least 50% of funds are used for purchase of antiretroviral medications. Other spending includes administration and capital costs, HIV prevention, and monitoring and evaluation. Several financial controls and auditing systems are in place. Key informants perceived the AIDS Levy as a 'homegrown' solution that provided country ownership and reduced dependence on donor funding, but called for further increased transparency, accountability, and reduced administrative costs, as well as recommended changes to increase revenue. CONCLUSIONS: The Zimbabwe AIDS Levy has generated substantial resources, recently over US$35 million per year, and signals an important commitment by Zimbabweans, which may have helped attract other donor resources. Many key informants considered the Zimbabwe AIDS Levy to be a best practice for other countries to follow.
Although there is a burgeoning empirical literature on the rapid growth of health expenditures, there has been little systematic examination of the influence of central government financing behavior. In addition, studies examining the effect of political variables are relatively few and, as they seem to suffer from the omitted variable bias problem, generate improper inferences on health financing dynamics. Moving from this literature, and drawing on recent developments in the coalition governance, as well as researching on fiscal decentralization, in this paper the authors aim to gain insight into the Italian health care financing scenario taking into account the behaviors of government intervention in the sector. Specifically, they analyze regional political fragmentation and competition for effective political power between majority and opposition coalitions and the authors test if the fragmentation of both coalitions is the key variables that determine their effective political power. The authors test their hypothesis in the Italian framework with a new dataset. Data include financial, demographic and political variables. The empirical analysis is conducted with a panel of 15 Italian regions from year 2000 to 2010.
Background: In this era of decentralization , access and provision of drugs for people in the local area is the responsi- bility of local governments. Because the limitations of the local budget, the central government is obliged to guarantee the availability of drugs in the area. Financing sources of drugs from central and local government have not reached the stan- dard of WHO i.e. 2 dollars per capita. To cover demand of financing drug, a Specific Allocation Fund (DAK) proposed state budget that funds given to certain areas to fund special activities that are regional affairs and in accordance with na- tional priorities. General criteria to consider certain areas (re- gional fiscal capacity), specific criteria (regional characteris- tics) and technical criteria (policy formulation from Ministry of Health). Since drug financing is allocated in DAK in 2010, there is a need to evaluate the drug financing at the local level. The purpose : to evaluate the amount of DAK for Pharma- ceutical services in 2011 and 2012. Methods : The study used secondary data from 2010 and 2011 consist of 6 (six) factors: fiscal capacity, character of the area, population number, proportion of poverty , local bud- get for drugs and prediction for the remaining stock of the drug. The analysis statistics uses chi-square and multiple regression. Qualitative interviews is conducted with manag- ers of pharmacy in 2 districts with high financial capability. Results : Result from multiple regression test of the 6 factors used in the allocation of SAF 2011 and 2012 shows only 3 factors that really affects the allocation which are the number of population, the poor and the prediction of the remaining stock of the drug . However, the highest factor is the popula- tion. Result for qualitative with 2 respondents shows that since they got DAK they reduced local budget for drugs, because the drug financing is sufficient from DAK. Conclusion : local sense of ownership towards the health budget in the area is low resulting in reliance on the central health budget. The effeciency of the central budget causes reduction of health budget both in central and local level. Latar belakang : Dalam era desentralisasi ini, akses dan penyediaan obat bagi masyarakat di daerah menjadi tanggung jawab pemerintah daerah. Namun keterbatasan anggaran daerah maka pemerintah pusat berkewajiban menjamin ketersediaan obat di daerah. Sumber pembiayaan obat di daerah melalui APBN dan APBD belum mencapai standar WHO, 2 dol- lar per kapita. Untuk menutupi kekurangan pembiayaan obat, diusulkan DAK yaitu dana APBN yang diberikan kepada daerah tertentu untuk mendanai kegiatan khusus yang merupakan urusan daerah dan sesuai dengan prioritas nasional. Daerah tertentu mempertimbangkan kriteria umum (kemampuan fiskal daerah), kriteria khusus (karakteristik daerah) dan kriteria teknis (rumusan kebijakan Kementerian Kesehatan). Sejak kebijakan obat melalui DAK pada tahun 2010, perlu dilakukan evaluasi besaran DAK Bidang Kesehatan untuk Kefarmasian tahun 2011 dan 2012. Tujuan : tujuan penelitian ini adalah melakukan evaluasi besaran DAK Bidang Kesehatan untuk Kefarmasian 2011 dan 2012. Metode : Penelitian menggunakan data sekunder 2010 dan 2011 yang terdiri 6 faktor yaitu; kemampuan fiskal, karakter wilayah, jumlah penduduk, penduduk miskin, anggaran obat dalam APBD dan prediksi sisa stok obat untuk pengalokasian DAK 2011 dan 2012. Uji analisis menggunakan chi square dan multipel regresi. Kualitatif dengan wawancara pengelola farmasi di 2 kabupaten dengan kemampuan keuangan tinggi. Hasil: Dari uji multiple regresi terhadap 6 faktor yang digunakan dalam pengalokasian DAK 2011 dan 2012 hanya 3 yang mempengaruhi alokasi yaitu jumlah penduduk, penduduk miskin dan prediksi sisa stok obat. Namun yang paling tinggi adalah jumah penduduk. Untuk kualitatif pada 2 responden, sejak mendapat DAK terjadi pengurangan anggaran obat di APBD, karena pembiayaan obat cukup dengan DAK. Kesimpulan: daerah belum memahami ownership anggaran kesehatan di daerah sehingga masih mengandalkan anggaran dari pusat, dimana ketidakstabilan anggaran pusat dengan ef isiensi menyebabkan pemotongan merata anggaran kesehatan di pusat dan daerah.
The implementation Of National Social Health Insurance by BPJS-Health that has been started on January,I, 2014 gives an impact to integrating local health insurance into national scheme.This study aims to describe implementation of local social health insurance as a basic in formulating policy model whichallows integration of local health insurance, particularly in the area of management, benefit packages, and government payed member in the frame of health decentralization policy. Study design is embeddedmulticases, using case study interpretatif method. Primary and secondary data were collected by explorativeapproach. Study area includes implementation of social local health insurance at 33 provinces, conducted in2013-2014. Results of this study show a gap in understanding and capacity of local authorities in managinglocal health insurance; various characteristics of local social health insurance in term of local monetarycapacity, benefit packages, management, and government payed member. This study recommends toaccomodate public health effort financing into benefit packages scheme, perception equalizing betweennational and local policy maker in understanding policy steps, and giving more flexibility forprovince/district/municipal in local social health insurance integration policy.
INTRODUCTION: This article reports the results and the lessons learned from implementing the decentralized approach to tuberculosis (TB) detection and treatment, embedded with Human Immunodeficiency Virus (HIV) co-infection in health district. The objective was to increase the TB screening indicators in the district using the common ways for offering care to patients in health district. METHODS: Conducted from August 2006 to July 2007, this large-scale intervention using Non-experimental study Designs has implemented a decentralized approach for fighting against TB in Orodara Health District (OHD), Burkina Faso. Pretest-posttest design has been used for quantitative part using indicators in one hand, and postests-only design for the qualitative part in other hand. In the pretest-posttest design, the TB indicators from years before 2006 (from 2002 to 2005) were used as earlier measurement observations allowing examining changes over time. The decentralized approach was incorporated into the annual planning of the OHD. For the quantitative study design, indicators used were those from National TB Program in Burkina Faso: TB detection rate, incidence density of TB per 100,000 inhabitants per year, and HIV prevalence in incident TB cases with positive smears. Data entry and analysis employed Microsoft Access and Excel software. For the qualitative, in-depth interview was used in which a total of 16 persons have been interviewed. Discussions were tape-recorded and transcribed verbatim for analysis using the computer-based qualitative software program named QSR NVIVO. RESULTS: There were a total of 99,259 outpatient visits during the study period: the7,345 patients (7.43%) presented with cough. Of the 7,345 patient having cough, 503 cases (6.8%) were declared chronic coughing. These 503 patients were screened for TB, including 35.59% whose coughing had lasted 10 to 15 days. We observed an increase in a measured variable was observed. The TB detection rate and incidence-density rate based on positive smears were 16.11% (11.00% in 2005) and 10.42 per 100,000 inhabitants per year (6.88 per 100,000 inhabitants in 2005), respectively. There were 29 patients positive for TB: 41.37% of these had cough lasting 10 to 15 days, 10.34% were also positive for HIV, and 68.97% were from rural areas. Health workers and patients reported satisfaction with the intervention. It was found that implementing a decentralized approach to TB prevention in rural areas is plausible and effective under some conditions: considering that health district system is functional; carefully designing the intervention for TB case management; setting up and implementing of decentralized approach including strong monitoring; and taking into account the all financing, community and volunteer involvement, evaluation of the cost savings from integrating specific donor funding, and being supported by regional and central levels including National TB program. CONCLUSION: The study has shown that TB detection rate can be increased by implementing a decentralized approach to primary care. When carefully implemented, a decentralized approach is a suitable approach to TB and HIV prevention in rural and inaccessible settings.
Background: Accessibility to essential drugs is a public right, therefore it's the government responsibility to make them available.Previously before the era of regional autonomy, public drug management in all districts/cities was performed by the so-called District Pharmaceutical Warehouses (GFK).However, nowadays the situation has changed because of the difference in vision and perception of each regional government on the former warehouses.Some public drug management units in certain districts/cities are not functioning optimally.Inefficient drug procurement regarding the number and kind of drugs as well as timeliness results in gap between drug need and procurement.Furthermore, loosening in drug supply procedure makes essential drugs more unavailable to public.On the other hand, decentralization policy in drug management also undeniably brings advantages to the districts, for example capacity building in drug procurement, increasing capability in budget management and negotiation with district decision makers as well as enhancing regional economic activity.In revitalizing district pharmaceutical warehouses so as to attain minimal health care standards in districts/cities, baseline data in drug management and financing in several districts/cities should make a valuable contribution.Methods: A cross sectional descriptive study had been carried out during July-December 2006 in 26 districts/cities out of 11 provinces.Samples were 26 district health offices (Dinas Kesehatan Kabupaten/Kota) and 26 District Pharmaceutical Warehouses (GFK) where as respondents were head of drug section and head of warehousing respectively.Data were collected by means of structured questionnaires and in-depth interviews as well as the collection of secondary data of drug logistics.Qualitative and quantitative analysis was performed. Results:The study shows that: 1) although health budget in general had risen, the average percentage of drug budget allocation from 21 district health authorities was only 12.06%, reflecting the low drug priority in district health policy because drug expenditures may amount up to 40% of the total health budget.2) Public drug management was mostly performed by the so-called regional technical provider unit (UPTD) with some limitations concerning human resources and material in achieving an effective and efficient drug management, and 3) there was still lack of pharmacist assistants to manage drugs in primary health care (Puskesmas) up to 20% and even more piteously the lack of pharmacist in district drug management unit (GF/UPOP Kabupaten/Kota, 12,5%).Conclusions: Apart from the achievement of predetermined indicators stated in minimal health care standards in districts/ cities, especially regarding essential and generic drugs, drug management in general has been well performed concerning planning and drug availability.More support and commitment from the district government is a must considering that regional development can not be separated from the health development of the subject themselves.
Whether 15 million on antiretroviral therapy (ART) by 2015 is a realistic target or just a dream is posing the question in the wrong way. The real question is: how can we turn our dream of having 15 million HIV-infected people receiving adequate antiretroviral therapy in 2015 into reality? This issue of Current Opinion in HIV and AIDS, although far from comprehensive, provides building blocks to attain that goal, points out particular opportunities, but also identifies some of the obstacles that need to be overcome. The first article by Duncombe et al. (pp. 4–11) sets the stage by summarizing the WHO/UNAIDS Treatment 2.0 strategy. No need to duplicate or add to that here, because the article provides a thorough update on where we stand. One element needs to be highlighted, however: contributions of international donors have been stagnating over the past years, and although there is a continued increase in domestic funding, most African countries are far from reaching the Abuja Declaration targets for spending on healthcare. Sure, efficiencies in healthcare delivery can be improved [1], and the striking levels of fungibility or crowding out [2] may be tackled by innovative ways of donor financing [3]. But if there is too little money overall to provide decent healthcare, targets cannot be met. The second article by Vittoria and Vella (pp. 12–18) provides a very nice overview of the evolution of WHO HIV treatment guidelines, adapting to changing insights and possibilities throughout the years in an ever more timely manner. It also points at future trends, which take into account the beneficial effects early treatment can have on the health of individuals, HIV transmission, the incidence of tuberculosis and models of care delivery. If we do not succeed in simplifying models of care delivery, by decentralization and task-shifting a.o., we will be unable to reach the 15 million by 2015 target. The third article, by Hamers et al. (pp. 19–26) and the fourth article, by Sohn et al. (pp. 27–33) focus on transmitted HIV drug resistance in Africa and Asia, respectively, and point to an emerging and in some countries, like Uganda, already sizable problem. The Hamers article also presents data on the high rate of drug resistance mutations in those failing first-line therapy. It is clear that surveillance of both transmitted and secondary HIV drug resistance and measures to minimize the risk of their emergence (such as preventing drug stock-outs and increasing adherence) should be an integral component of the continuing ART scale-up. The 15 million target stands for 15 million people on effective, not failing, highly active antiretroviral therapy. Hill (pp. 34–40), in the fifth article, identifies three main problems with the current ART standard of care for many people in resource-poor settings: a large proportion of those on treatment are still taking stavudine-containing ART; there is limited diagnostic support – access to plasma viral load and drug resistance testing is still rare, which leads to late diagnosis of therapy failure and accumulation of drug resistance mutations; access to second-line treatment is limited. Thus, current practice often does not meet the standards deemed necessary by Hill to achieve ‘Universal Access’: a simple system of treatment, using a sequence of low-cost, coformulated antiretrovirals with strong efficacy profiles, nonoverlapping resistance profiles, and safety issues which are manageable with minimal medical expertise. He argues that only a relatively small subset of antiretrovirals may be needed for first-line, second-line and potentially third-line treatment in large-scale treatment access programs, and has several creative ideas about how this could be achieved in the most cost-effective manner, with a focus on ongoing research to use lower dosages of drugs (’dose-optimization’) which are cheap to manufacture. One can argue whether stavudine should have been included in this list, but, overall, simplifying therapeutic algorithms and lowering the dose and thus the cost of individual drugs are essential ingredients of a more effective scale-up. The sixth article (pp. 41–49), by the ‘fathers’ of Treatment as Prevention (TasP), advocates passionately for expansion of combination HIV prevention with an emphasis on the merits of expanding treatment: there is increasing evidence of health benefits of earlier treatment, a sharp reduction in incidence of tuberculosis in HIV-infected individuals, and with viral suppression through effective ART the risk of passing on the virus from a person living with HIV to a negative partners is close to zero. The authors remind us about the early skepticism regarding the feasibility and advisability of delivering ART in resource-poor settings, and how these skeptics have been proven wrong. Yes, we should never ever be discouraged by ‘the nattering nabobs of negativism’ (to use a phrase from the recently deceased William Safire). But we can also not be naïve and ignore the potential risks. The path to ‘Test and Treat’ will be paved by identifying – and managing – the potential risks; long-term side effects, and development of significant drug resistance, for example, because of breeches in adherence in particular of people living with HIV who have never been sick and as such have not felt themselves the dramatic benefits of treatment and full reconstitution of ill-health. The question should be less whether or not to treat earlier. But much rather about the ‘how’ and what needs to be in place to minimize, track and manage the potential risks. Let us move intelligently, and while proceeding, watch carefully for possible negative effects to take corrective action, and take the emerging results and lessons of ongoing TasP demonstration projects into account. The seventh article, by Hankins and Dybul (pp. 50–58), is a thorough review of the evidence for pre-exposure prophylaxis (PrEP), with either local (e.g. vaginal microbicides) or systemic (e.g. oral) use of antiretrovirals. Based on the positive results of several clinical trials, oral PrEP with Truvada [tenofovir disoproxil fumarate/emtricitabine (TTDF/FTC)] has now been approved by the United States Food and Drug Administration (FDA) to reduce risk of sexually acquired HIV infection in high-risk adults. Public health experts are struggling with how to translate scientific findings from PrEP effectiveness trials into real-world implementation. For several reasons PrEP cannot be seen in isolation from treatment, and thus deserves a place in this issue of Current Opinion in HIV and AIDS. First: the same drugs (TDF and FTC) that are used for PrEP are a mainstay of ART regimens (for this purpose lamivudine is considered similar to FTC), which is not an ideal situation considering the risk of HIV drug-resistance development. Second, both human and financial resources for the treatment scale-up are already limited; are we now going to spend resources on these relatively expensive drugs for prevention, while, in addition to the effect of HIV treatment on HIV transmission, other HIV prevention modalities are available (male and female condoms, male circumcision)? Hankins and Dybul carefully review the prerequisites for, challenges to and dilemma's of a PrEP rollout. They also briefly review exciting products in the pipeline, including long-acting agents. The cascade of HIV care, which has the ultimate aim to achieve and undetectable plasma viral load – for the benefit of the individual and to prevent onward transmission – goes way beyond ‘Test and Treat’. It also involves linking people to care after a positive HIV test, retaining them in care, getting them to initiate ART (if they want so), and getting them to adhere to the treatment regimen. All assuming that the care given is adequate, and that the antiretrovirals are present every time and of good quality. In the eighth article of this issue, with the catchy title ‘Patching a Leaky Pipe’, Kilmarx and Mutasa-Apollo (pp. 59–64) review the recent literature on these multiple Achilles’ heels of the treatment scale-up. Fixing just one or two is not enough: they can all work as ‘chain terminators’. Carefully examining the gaps at each step of the cascade, country by country and community by community, will be among the most useful approaches for planers and decision makers to improve scale-up and quality of care – essential elements to reaching and keeping the 15 million on ART. Article number nine, by Samuel Oti (pp. 65–69), who has the privilege to work at the unique African Population and Health Research Centre in Nairobi, is a compassionate and well reasoned plea for a coordinated response to HIV and noncommunicable diseases (NCDs). It is amazing that the advantages of this are not yet evident to everyone. How can we defend testing every adult for HIV and not take a blood pressure measurement at the same time. Hypertension is the biggest risk factor for premature death in the world [4] and its treatment is relatively straightforward and affordable. To secure continued funding for HIV it is essential to show that this money adds value beyond HIV and helps to build viable and sustainable health systems. Last but not least, article number 10 in this issue, by ‘t Hoen and Passarelli (pp. 70–74), looks at the role of intellectual property rights in HIV treatment access. It is hard to understand for us, why thus far only one research-based pharmaceutical company (Gilead) has had the courage and common sense to contribute to the Medicines Patent Pool. What are the others afraid of and what do they want to accomplish? However, we are living in a rapidly changing world and access to medicines is a complex issue beyond licensing agreements. With significant economic growth in the developing world the old concepts of rich and poor countries are increasingly invalid. Already today, the significant majority of all people living with HIV is living in middle and high-income countries, up from less than one-third, 10 years ago. And this trend is to continue. We need new approaches to access and equity, differential pricing approaches that address poverty within a given country, more systematic approaches to price negotiations that protect the smaller and less powerful states in their attempts to negotiate access to life-saving medicines, and the full use of TRIPS flexibilities including compulsory licensing if we are to reach the 15 million, and beyond. All in all, although some pieces, like healthcare financing, are missing, this issue of Current Opinion in HIV and AIDS presents a relevant mix of articles about opportunities of and challenges to a continued antiretroviral therapy scale-up. It has been a privilege to have served as its editors. J.M.A.L. and B.S. Acknowledgements None. Conflicts of interest J.M.A.L. institution has been receiving educational grants from the following pharmaceutical companies: Abbott, Boehringer Ingelheim, Bristol Meyers Squibb (BMS), Crucell, Gilead, ViiV, Johnson and Johnson, Merck, Mylan, and Roche. I have received honoraria for speaking engagements or consulting from Bristol Meyers Squibb, Gilead, Roche and Tibotec (Johnson and Johnson). B.S. has no conflicts of interest.
OBJECTIVE: Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics. PRINCIPAL FINDINGS: Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE. CONCLUSION: The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.
Historically, health care in Zimbabwe was provided primarily to cater to colonial administrators and the expatriate, with separate care or second-provision made for Africans. There was no need for legislation to guarantee its provision to the settler community. To address the inequities in health that had existed prior to 1980, at independence, Zimbabwe adopted the concept of Equity in Health and Primary Health Care. Initially, this resulted in the narrowing of the gap between health provision in rural areas and urban areas. Over the years, however, there have been clear indications of growing inequities in health provision and health care as a result of mainly Economic Structural Adjustment Policies (ESAP), 1991–1995, and health policy changes. Infant and child mortality have been worsened by the impact of HIV/AIDS and reduced access to affordable essential health care. For example, life expectancy at birth was 56 in the 1980s, increased to 60 in 1990 and is now about 43. Morbidity (diseases) and mortality (death rates) trends in Zimbabwe show that the population is still affected by the traditional preventable diseases and conditions that include nutritional deficiencies, communicable diseases, pregnancy and childbirth conditions and the conditions of the new born. The deterioration of the Zimbabwean health services sector has also partially been due to increasing shortages of qualified personnel. The public sector has been operating with only 19 per cent staff since 2000. Many qualified and competent health workers left the country because of the unfavourable political environment. The health system in Zimbabwe has been operating under a legal and policy framework that in essence does not recognize the right to health. Neither the pre-independence constitution nor the Lancaster House constitution, which is the current Constitution of Zimbabwe, made specific provisions for the right to health. Progress made in the 1980s characterized by adequate financing of the health system and decentralized health management and equity of health services between urban and rural areas, which saw dramatic increases in child survival rates and life expectancy, was, unfortunately, not consolidated. As of 2000 per capita health financing stood at USD 8.55 as compared to USD 23.6, which had been recommended by the Commission of Review into the Health Sector in 1997. At the beginning of 2008 it had been dramatically further eroded and stood at only USD 0.19 leading to the collapse of the health system. Similarly, education in Zimbabwe, in addition to the changes it has undergone during the different periods since attainment of independence, also went through many phases during the colonial period. From 1962 up until 1980, the Rhodesia Front government catered more for the European child. Luckily, some mission schools that had been established earlier kept on expanding taking in African children who could proceed with secondary education (high school education). Inequity in education existed when the ZANU-PF government came into power in 1980. It took aggressive and positive steps to redress the inequalities that existed in the past. Unfortunately, the government did not come up with an education policy or philosophy in spite of massive expansion and investment. The government had cut its expenditure on education because of economic and political instability. This has happened particularly in rural areas, where teachers have left the teaching profession.
David Katzenstein, Sinata Koulla‐Shiro, Marie Laga, Jean‐Paul Moatti
The extraordinary success of antiretroviral therapy (ART) in the North during the closing years of the last century directly led to the United Nations' resolutions in 2000, about universal access to HIV treatment, and to the inclusion of this target among the Millenium Development Goals [1]. A previous AIDS supplement, supported by the French Agency for AIDS Research (ANRS) and published as early as 2003, presented the evaluation of the first national pilot programs for access to antiretroviral HIV treatment in three African countries (Côte d'Ivoire, Senegal and Uganda). These results contributed to a consensus on the feasibility of scaling-up access to HIV treatment in low-resource settings, an issue that had been heavily debated among clinical, public health and development experts [2]. Since then, antiretroviral therapy coverage rose from 7% in 2003 to 42% in 2008, with especially high coverage achieved in eastern and southern Africa (48%) [3]. There are no longer doubts that access to ART results in a remarkable reduction in mortality, which may be as high as 95% in comparison to no intervention [4]. In addition, retention in care and treatment may exceed levels seen in the North: for example, a remarkable 79% of adults enrolled in the early stages of Botswana's antiretroviral therapy scale-up are alive five years later [5]. On a macro scale, Bendavid and Bhattacharya [6] found that after four years of the US President's Emergency Plan for AIDS Relief (PEPFAR) funding and support for ART, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, although trends in adult prevalence did not differ. Despite the community stigma, political denial and tensions between government policy and medical practice, South Africa with the largest number of HIV infected individuals is also home to the largest antiretroviral therapy program in the world with accelerating impact. In the Western Cape Province, six-month mortality among patients at an HIV treatment centre fell from 12.7% to 6.6% between 2001/2002 and 2005 as access expanded [7]. The recent statement, on World AIDS Day on December 1st 2009, about universal access to HIV care and treatment by the new South-African President, Jacob Zuma, raises hope that South Africa will henceforth assume a leadership role in the region [8]. However, scaling-up access to HIV treatment in Africa, home to two thirds of those living with HIV/AIDS, poses new and largely unexplored challenges in the delivery of a complex set of public health, medical and psychosocial interventions. The transition from an emergency response to robust and sustainable health services delivery systems for HIV is a work in progress. Building these systems must be mindful of cultural context and existing health systems in the affected communities. The most recent [9] report on the epidemic describes a highly varied picture of remarkable progress in some African countries and huge unmet needs in others. Access to treatment in Africa is often taking place in the context of fragile states, struggling with social, political and economic turmoil, where investment in healthcare systems has been limited. Particularly in resource limited settings, there is an unavoidable competition for infrastructure, resources and personnel between donor driven programs targeting specific diseases (ie. AIDS, TB and malaria) and long standing programs in primary care, maternal and infant health. The “Maximizing Positive Synergies Collaborative Group” (MPSCG), coordinated by WHO, has recently synthesized the existing evidence regarding interactions between disease-targeted programs and country health systems [10]. Although it concluded that this impact “on health outcomes and health systems, though variable, has been positive on balance and has helped to draw attention to deficiencies in health systems”, available evidence also pointed out that further improvements and efficiency gains are needed especially to strengthen the health workforce, align health information systems, and to reduce out-of-pocket payments for financing health-care expenditures. Operational research encompasses a broad range of investigation, primarily the evaluation of outcomes among the health programs. Systematic observation and analysis of data collected alongside ART programs can provide guidance to implementers and policy makers with the aim of achieving sustainable access to care. Critical in any operational research project is the development of partnerships and capacity building between the wide array of actors who contribute to deliver healthcare, including national health services, community based organizations and advocacy groups, national and transnational NGOs, as well as the international donor agencies on the one hand, and academic researchers and research organizations on the other [11]. There are certainly general principles of treatment that can be broadly applied and evaluated in Africa. But ultimately, in each context, it may be anticipated that the design of programs for access to ART will vary. Critical unanswered questions remain about how access to ART will impact social stigma, individual risk behavior and ultimately the course of the epidemic. Because of the heterogeneity of affected populations and societies, the psychosocial and behavioral consequences of ART access and methods to ensure adherence, retention and to provide sustained treatment across Africa are not likely to be distilled to a single set of best practices. Thus, in the face of the HIV epidemic in Africa, operational research is a process of “learning by doing” in each of the diverse contexts, sharing the outcomes and observations among countries and programs. A myriad of local evaluations of process and outcome may be the most flexible way to effect sustainable implementation of ART access and the development of robust medical and social responses to AIDS in various contexts across a continent. One regrets that in spite of significant investment in evaluation exercises, global health initiatives such as the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), PEPFAR or the World Bank still have limited contributions to effective operational research [12,13]. Operational issues in scaling up access to ART This supplement presents original results documenting the progress, as well as obstacles, in scaling up HIV treatment in Africa. Papers from Burkina-Faso and Cameroon are based on operational research carried out alongside the national ART programs of these two countries that have been directly supported by ANRS. Other papers present fruitful experiences from operational research in additional African countries (Botswana, Lesotho, Mozambique and South Africa) while one paper (Celletti et al., S45–S57) focuses on a multi-country effort associating four African countries (Ethiopia; Malawi; Namibia and Uganda) and Brazil. It must be noted that the paper by Bassett et al. (S37–S44) about initiation of ART in Durban, Kwazulu-Natal, South Africa, one of the epicenters of the epidemic, was awarded the joint International AIDS Society (IAS)/ ANRS “Young Investigator Prize” for Operations Research at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, that took place in Capetown in July 2009. Finally, one paper (Jerome & Ivers, S73–S78) deals with rural Haiti, a non-African country, whose experience with ART in very deprived and vulnerable populations has been worthwhile for other low-resource settings. The process of improving and sustaining access to ART begins with surveillance and testing to understand the magnitude of the epidemic locally, and requires assessment and consultation with Ministries, healthcare providers, communities and stakeholders to identify the key operational issues in access. Access to ART begins with the effective implementation of voluntary testing on a scale not yet realized, effective post-test counseling, linkage to care, and has already led to monitoring, care and retention of 3 million people on ART in Africa. How to accomplish each of these tasks with health systems that are often insolvent and frequently understaffed is the focus of the papers presented in this supplement. All papers emphasize that advances in access to ART have only been made possible through implementation of innovative ways of delivering and monitoring care, and also illustrate some of these innovations. Clinical research programs continue to evaluate new, less toxic and potentially less costly drug cocktails, more effective monitoring algorithms and programs to reinforce and maintain treatment adherence that would be better adapted to the practical constraints of health systems with very scarce resources. Notably, the DART study results in Uganda and Zimbabwe suggest that some of the accepted guidelines for laboratory monitoring need careful reassessment [14], and the forthcoming results of the STRATALL study in Cameroon will evaluate the impact of the WHO public health approach to monitor ART at a decentralized level of care [15]. Similarly, the management of first-line ART is fraught with issues even in the choice of Non-nucleoside reverse transcriptase inhibitors (NNRTIs). Consideration of Efavirenz and Nevirapine as first line NNRTIs as described in the paper by Wester et al. (S27–S36) in Botswana reflect trade-offs among cost, potency, potential side-effects and concerns about teratogenicity and toxicity. These issues will continue to expand as additional drugs become available and as the price proposed by pharmaceutical firms for new first-line and for second-line regimens, as recommended by WHO, remain prohibitively high compared to those of the “old” generation of antiretroviral drugs [16]. It is estimated that at least 57 countries, mostly in sub-Saharan Africa, face crippling health workforce shortages, and there are simply not enough physicians and nurses on the ground to begin to address the magnitude of the HIV epidemic through traditional clinic based care. Rational redistribution of tasks between physicians and other healthcare personnel, and the introduction of community and family health aids and NGO volunteers, as medical officers, adherence counselors or treatment “buddies” is a key part of the “task-shifting” agenda articulated by WHO [17]. The multi-country paper by Celletti et al. (S45–S57), papers by Sherr et al. (S59–S66) on Mozambique, Jerome and Ivers (S67–S72) on Haiti and Ivers et al. (S73–S78) on the Haiti-Lesotho collaborative model detail the certain conditions that have to be fulfilled for the reorganization of clinical services under a task shifting model to be successful. One of the most innovative contributions of HIV programs has been to promote meaningful multi-stakeholder partnerships between governments, civil society and affected communities at the global and local levels. Civil society has critically important roles ranging from advocacy, demand creation, and service delivery, to policy-setting and providing oversight by emphasizing accountability to service users [18]. Papers by Desclaux et al. (S79–S85) on Burkina-Faso and Ivers et al. (S73–S78) on the south-south collaboration between Haiti and Lesotho illustrate how such involvement of civil society offer opportunities for creative operational research. Quite logically, it is the relationship between scaling up access to HIV treatment and health systems strengthening that bears the greatest scrutiny across most of the papers of this supplement. In a comprehensive evaluation of ART access through a national program in Cameroon, Boyer et al. (S5–S15) present analysis from the EVAL study where the quality and quantity of care at central, provincial and district levels was contrasted. This evaluation clearly shows that decentralization of ART delivery can increase equity in access for the poorest sectors of people living with HIV while maintaining clinical effectiveness, and even improving adherence and quality of life. Experiences in other African countries, like Uganda, suggest that even further decentralization of ART may be effective and cost-effective [19], but this needs more investigation and may differ according to each specific socio-economic and health systems context. Future challenges for long term sustainability of ART In this supplement, another paper on Cameroon by Marcellin et al. (S17–S25) provides compelling evidence that access to ART at higher CD4 levels reduces reported risk behaviors and can improve quality of life. This paper, and the one from Bassett et al. (S37–S44) describing considerable gaps in bringing and retaining people with AIDS into treatment in a well resourced program in South Africa, supports the recent revision of WHO guidelines [20]. These new guidelines increase the recommended CD4 count for starting treatment to 350 cc/mm3 (rather than the previous lower 200 threshold) and imply that an additional number of 5 million HIV-infected patients world-wide should be considered eligible for immediate access to ART. These papers, however, anticipate some of the new challenges and tensions that would logically derive from this extension of treatment eligibility and from the urgent need to revisit the relationship between HIV prevention and treatment. Despite the actions of many agencies and national health autorities, an estimated 1.9 million [1.6 million–2.2 million] new HIV infections occurred in sub-Saharan Africa in 2008. This high incidence, and consequent increase in unmet treatment needs over time, represents an additional key challenge for ART program scale up to remain feasible and sustainable [21]. The recognition that the speed at which people are infected exceeds the speed at which they can be put on treatment has been a powerful message to advocate for enhancing prevention efforts. Treatment programs offer many opportunities to strengthen prevention, through increased uptake of testing, viral load reduction in patients and models of “prevention counseling” for and by positive people. These synergies should be fully recognized and monitored. As an illustration, in a paper on Cameroon in this supplement (Marcellin et al. [S17–S25]), patients not yet on ART reported more frequent inconsistent condom use compared to those on ART, confirming positive effects of intense patient-healthcare worker contact on behavior. (Re)-emphasizing and maximizing synergies between the ART roll out and prevention is essential and urgent but should be seen as a component of a comprehensive “Treatment and Prevention Combination” approach, including behavioral, social and structural interventions. Over the coming decade, the challenges of expanding, enhancing and sustaining treatment for the more than 22.4 million people living with HIV in Africa, will consume immense monetary, human and social resources. Evaluating the long-term outcomes of access to ART on a population level across diverse urban and rural and multiple cultural contexts in Africa present a formidable challenge. If the patterns of behavior and transmission observed in the North are any indication, large-scale access to care may increase transmission of drug resistant viruses [22]. The best way to prevent this will be the development of robust and affordable programs for retention, monitoring and management of ART by skilled providers and robust systems of care. Papers in this supplement support the optimistic view that innovative solutions can be found to tackle the multiple medical, public health, socio-economic and logistic issues related to long term sustainability of ART programs in Africa. Ensuring their financial sustainability through appropriate growth of domestic and international funding however remains a prerequisite for success, and this is far from guaranteed in the context of one of the worst economic crises the world has ever faced. Because overall demand has been higher than anticipated in the funding scenario of its previous replenishment, the Global Fund faces a resource gap for the period 2009–10 for the first time since its creation. Its future contribution to scaling up the response to the HIV epidemic will depend on the willingness of donor governments to provide significantly higher pledges for its next replenishment (2011–2013) than the 9.8 billion US$ obtained for the previous one (2008–2010) [23]. In the US, a debate is growing about whether or not a further expansion of PEPFAR would be the best use of international health funding [24]. Demonstrations, as presented in this supplement, contribute evidence-based advocacy in favor of sustainability of HIV/AIDS treatment and provide clear examples of how health systems are adapting to meet the challenges of HIV. Of course, we also present these examples to underscore the importance of continuing, flexible operational research and evaluation to maintain international and domestic funding, the life-blood of treatment access for millions in Africa, and around the world.
Sylvie Boyer, Fred Eboko, Mamadou Camara, Claude Abé · 7 authors
BACKGROUND: The independent evaluation of the Cameroonian antiretroviral therapy (ART) Programme, which reached one of the highest coverage in the eligible HIV-infected population (58%) in Sub-Saharan Africa, offered the opportunity to assess ART outcomes in the context of the decentralization of HIV care delivery. MATERIALS AND METHODS: A cross-sectional survey (EVAL, ANRS 12-116, 2007) was carried out in a random sample of 3151 HIV-positive patients (response rate 90%) attending 27 treatment centres at the different level of the healthcare delivery (central, provincial and district), as well as in the exhaustive sample of doctors in charge of HIV care in these centres (response rate 92%, n = 97). Multivariate two-level analyses were conducted to assess the impact of the level of healthcare delivery on CD4 cell gains since initiation of treatment and adherence to treatment in the subsample of patients who were ART-treated for 6 months or more (n = 1985). RESULTS: District treatment centres were characterized by more limited technical and human resources but a lower workload. ART-treated patients followed up in these centres had significantly lower socioeconomic status. After adjustment for other explanatory factors, immunological improvement was similar in patients followed up at the central and district level, whereas adherence to ART was better both at provincial and district levels. CONCLUSION: Success in scaling-up access to ART in Cameroon has been facilitated by decentralization of the healthcare system. Long-term sustainability urgently implies better integration of this HIV-targeted programme in the global healthcare reform of financing mechanisms, management of human resources and drug procurement systems.
The global financial crisis poses a threat to global health, and may exacerbate diseases of poverty, e.g. HIV, malaria and tuberculosis. Exploring the implications of the global financial crisis for the health sector response to tuberculosis is useful to illustrate the practical problems and propose possible solutions. The response to tuberculosis is considered in the context of health sector development. Problems and solutions are considered in five key areas: financing, prioritization, government regulation, integration and decentralization. Securing health gains in global tuberculosis control depends on protecting expenditure by governments of countries badly affected by tuberculosis and by donors, taking measures to increase efficiencies, prioritizing health expenditures and strengthening government regulation. Lessons learned will be valuable for stakeholders involved in the health sector response to tuberculosis and other diseases of poverty.
Options for health financing reform are often portrayed as a choice between general taxation (known as the Beveridge model) and social health insurance (known as the Bismarck model). Ten years of health financing reform in Kyrgyzstan, since the introduction of its compulsory health insurance fund in 1997, provide an excellent example of why it is wrong to reduce health financing policy to a choice between the Beveridge and Bismarck models. Rather than fragment the system according to the insurance status of the population, as many other low- and middle-income countries have done, the Kyrgyz reforms were guided by the objective of having a single system for the entire population. Key features include the role and gradual development of the compulsory health insurance fund as the single purchaser of health-care services for the entire population using output-based payment methods, the complete restructuring of pooling arrangements from the former decentralized budgetary structure to a single national pool, and the establishment of an explicit benefit package. Central to the process was the transformation of the role of general budget revenues - the main source of public funding for health - from directly subsidizing the supply of services to subsidizing the purchase of services on behalf of the entire population by redirecting them into the health insurance fund. Through their approach to health financing policy, and pooling in particular, the Kyrgyz health reformers demonstrated that different sources of funds can be used in an explicitly complementary manner to enable the creation of a unified, universal system.
Rifat Atun, Martin McKee, Francis Drobniewski, Richard Coker
OBJECTIVE: To develop a methodology and an instrument that allow the simultaneous rapid and systematic examination of the broad public health context, the health care systems, and the features of disease-specific programmes. METHODS: Drawing on methodologies used for rapid situational assessments of vertical programmes for tackling communicable disease, we analysed programmes for the control human of immunodeficiency virus (HIV) and their health systems context in three regions in the Russian Federation. The analysis was conducted in three phases: first, analysis of published literature, documents and routine data from the regions; second, interviews with key informants, and third, further data collection and analysis. Synthesis of findings through exploration of emergent themes, with iteration, resulted in the identification of the key systems issues that influenced programme delivery. FINDINGS: We observed a complex political economy within which efforts to control HIV sit, an intricate legal environment, and a high degree of decentralization of financing and operational responsibility. Although each region displays some commonalities arising from the Soviet traditions of public health control, there are considerable variations in the epidemiological trajectories, cultural responses, the political environment, financing, organization and service delivery, and the extent of multisectoral work in response to HIV epidemics. CONCLUSION: Within a centralized, post-Soviet health system, centrally directed measures to enhance HIV control may have varying degrees of impact at the regional level. Although the central tenets of effective vertical HIV programmes may be present, local imperatives substantially influence their interpretation, operationalization and effectiveness. Systematic analysis of the context within which vertical programmes are embedded is necessary to enhance understanding of how the relevant policies are prioritized and translated to action.