Sustainable Funding Mechanisms Research Articles

Effect of Micro Health Insurance on Access and Utilization of Health Services in Karnataka

Background:Lack of sustainable and affordable health financing mechanisms in India has exposed the poor ininformal sector to iatrogenic poverty. Hardship financing of health services has negative financial consequences on thefuture income of these households. This can be mitigated through micro health insurance (MHI) because it aims to removefinancial barriers to access and utilize health services.Objectives:Recognizing the dearth of studies on impact of MHI schemes in India, we carried out an in-depth study onSampoorna Suraksha Programme (SSP) in Karnataka to assess the effect on access and utilization of healthcare services.Methods:We designed a descriptive cross sectional household survey that collected data from 1146 households toevaluate the impact using logistic regression analysis.Results:Insured individuals were more likely to access and utilize inpatient services compared to uninsured individuals.Moral hazard measured as length of stay in the hospital was absent. Horizontal equity in utilization based on gender andincome was observed. Insured used private providers than public hospitals or self-medicine. The results of the studysupport the positive impact of MHI on access and utilization of health services.Conclusion:The findings of the study enhance our understanding of the positive role of MHI in the promotion of betterhealth behavior of the poor people who usually forego treatment during illness. This would reinforce policymakers toadvocate MHI to mitigate iatrogenic poverty in India, the land of villages.

Developing a co-management financing mechanism to enhance the financial sustainability of marine protected areas in Taiwan

Marine Protected Areas (MPAs) are a cost-efficient and management-effective tool. Fishery Resource Conservation Zones (FRCZs) are one type of MPA in Taiwan, and they were designated to ensure the sustainability of fishery resources since 1976; however, government appropriations are the only financing source for FRCZs, leading to manpower and equipment shortages for FRCZ management. This study selected the Touching and Suao FRCZs in Yilan County of Taiwan as cases studies. To assess the feasibility of establishing a sustainable financing mechanism for MPAs, the Contingent Valuation Method (CVM) was applied to examine respondents׳ willingness to pay (WTP) to setup a fund for FRCZ management. The empirical results indicated that approximately 90% of respondents would be willing to donate funding for MPAs, and the WTP per respondent is NT$586.51 (US$19.6). Thus, establishing an MPA fund is a feasible way to operate Taiwanese MPAs through a co-management framework involving the central government, local government, local communities and stakeholders. However, based on our empirical results, a co-management financing mechanism for MPAs should be established to ensure stable and diverse financing sources.

Environmental governance dimensions and perspectives for three transboundary African lakes

Factors considered necessary for effective environmental governance in large, transboundary lakes are presented. Institutional processes and governance structures are examined for three transboundary African lakes: Chad, Victoria and Tanganyika. Shortcomings in environmental governance for these lakes are: (i) inadequate linkages between science and policy and (ii) inadequate application of innovative, adaptive management approaches. Other shortcomings include: (i) untimely fulfillment of national and regional obligations by the riparian governments and (ii) lack of long-term sustainable financing mechanisms. Key recommendations for effective environmental governance are: linking scientific thinking and information to political decision making; investment in research and management; adoption and/or adaption of innovative management approaches; exchange of information and expertise; strategic partnerships; political commitment; long-term sustainable resource allocation; and development of mechanisms for addressing impacts of climate change and variability. Commitment to international conventions and sub-regional initiatives is also recommended for redressing environmental governance challenges for transboundary African lakes.

Chapter Eight - Establishment, Management, and Maintenance of the Phoenix Islands Protected Area

The Republic of Kiribati's Phoenix Islands Protected Area (PIPA), located in the equatorial central Pacific, is the largest and deepest UNESCO World Heritage site on earth. Created in 2008, it was the first Marine Protected Area (MPA) of its kind (at the time of inception, the largest in the world) and includes eight low-lying islands, shallow coral reefs, submerged shallow and deep seamounts and extensive open-ocean and ocean floor habitat. Due to their isolation, the shallow reef habitats have been protected de facto from severe exploitation, though the surrounding waters have been continually fished for large pelagics and whales over many decades. PIPA was created under a partnership between the Government of Kiribati and the international non-governmental organizations-Conservation International and the New England Aquarium. PIPA has a unique conservation strategy as the first marine MPA to use a conservation contract mechanism with a corresponding Conservation Trust established to be both a sustainable financing mechanism and a check-and-balance to the oversight and maintenance of the MPA. As PIPA moves forward with its management objectives, it is well positioned to be a global model for large MPA design and implementation in similar contexts. The islands and shallow reefs have already shown benefits from protection, though the pending full closure of PIPA (and assessments thereof) will be critical for determining success of the MPA as a refuge for open-ocean pelagic and deep-sea marine life. As global ocean resources are continually being extracted to support a growing global population, PIPA's closure is both timely and of global significance.

10 years of HEPA Europe: what made it possible and what is the way into the future?

HEPA Europe, the European network for the promotion of health-enhancing physical activity, will have its 10th annual meeting in 2014. Membership of the network has grown to 129 institutions from 32 countries. Collaborations have been established with the World Health Organization (WHO), the European Union (EU), Agita Mundo, the global network for physical activity promotion, other regional networks, and the International Society for Physical Activity and Health. Physical activity has moved up on the public agenda; in 2013 the EU Council adopted its first ever Council Recommendation in sport, notably on promoting health-enhancing physical activity, and in 2014 WHO has begun the development of a Physical Activity Strategy for the European region. HEPA Europe has had strong involvement in these developments despite the absence of a long-term funding mechanism, changing priorities within its supporting institutions and difficulties of earlier attempts to establish a European physical activity network. This article reflects on four groups of enabling factors for this development. 1) The time was right: favourable secular developments, products of previous work and the momentum of an international pioneer phase met with windows of opportunity in key institutions. 2) A combination of commitment and conceptual clarity: clearly defined objectives, structures and approaches provided opportunities for individual commitment to blossom. 3) Institutional support: structural attachment to WHO and steady support from a sequence of key institutions was provided. 4) The deliverance of high visibility products: HEPA Europe’s events, its working groups, as well as its tools met with great interest. In Europe, the HEPA network has found a role which is not filled by any other institution and which is increasingly in demand. To meet these growing and changing expectations, HEPA Europe will need to continue evolving. This will take dedicated individuals, supportive member institutions as well as sustainable funding mechanisms.

Sustainable funding policies for environmental protection: the case of Maldivian atolls

This paper investigates several user-based funding mechanisms for protecting the marine resources in the Republic of the Maldives, by conducting an economic valuation of its recreational uses. We developed an individual travel demand model, corrected for truncation and endogenous stratification, to estimate the benefits of atoll-based marine tourism. The study found a large disparity between the amount of economic value generated from this opportunity for nature-based tourism and the amount going into atoll environmental conservation. More than half the environmental protection expenditure currently comes from unstable international sources, which makes it imperative that more stable financing sources be found. The results of the study show that even a small percent of tax added to tourist expenditure on the islands, or a direct conservation check-off as user fee collected from the tourists, would help defray the costs of atoll conservation. The paper concludes on a discussion of the policy implications of sustainable user-based financing mechanisms.

Health technology assessments as a mechanism for increased value for money: recommendations to the Global Fund

The Global Fund is experiencing increased pressure to optimize results and improve its impact per dollar spent. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. This paper assesses the efficacy of current Global Fund investment and examines how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidized by the Global Fund. In addition, this paper identifies areas where the application of HTAs can exert the greatest impact and proposes ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, it addresses the challenges facing the Global Fund in realizing the full potential of HTAs.

An economic analysis of ecosystem restoration concession policy in Indonesia: a new strategy for sustainable forest management?

To tackle the high rate of deforestation in Indonesia’s production forests, a new type of licence was introduced in 2004 known as an Ecosystem Restoration Concession (ERC) or IUPHHK-RE by the Indonesian Government. For the first time, production forests could be managed for the purpose of restoration instead of logging. At the same time, however, the economic feasibility of ecosystem restoration concessions has to be proved if they are to be made attractive as a business opportunity. This paper examines the business feasibility of ERCs using a cost-benefit analysis method. The results show that the benefits of natural ecosystems are not well recognised and hence it is difficult to attract funds or investment for ERCs. Therefore policy support and sustainable funding mechanisms are needed for ERCs to ensure their economic viability.

Moving from ideas to action - developing health financing systems towards universal coverage in Africa.

BackgroundAccelerating progress towards universal coverage in African countries calls for concrete actions that reinforce social health protection through establishment of sustainable health financing mechanisms. In order to explore possible pathways for moving past the existing obstacles, panel discussions were organized on health financing bringing together Ministers of health and Ministers of finance with the objective of creating a discussion space where the different perspectives on key issues and needed actions could meet. This article presents a synthesis of panel discussions focusing on the identified challenges and the possible solutions. The overview of this paper is based on the objectives and proceedings of the panel discussions and relies on the observation and study of the interaction between the panelists and on the discourse used.SummaryThe discussion highlighted that a large proportion of the African population has no access to needed health services with significant reliance on direct out of pocket payments. There are multiple obstacles in making prepayment and pooling mechanisms operational. The relatively strong political commitment to health has not always translated into more public spending for health. Donor investment in health in low income countries still falls below commitments. There is need to explore innovative domestic revenue collection mechanisms. Although inadequate funding for health is a fundamental problem, inefficient use of resources is of great concern. There is need to generate robust evidence focusing on issues of importance to ministry of finance. The current unsatisfactory state of health financing was mainly attributed to lack of clear vision; evidence based plans and costed strategies.DiscussionBased on the analysis of discussion made, there are points of convergence and divergence in the discourse and positions of the two ministries. The current blockage points holding back budget allocations for health can be solved with a more evidence based approach and dialogue based on a clear vision and costed strategic plan articulated by the ministry of health. Improving health in Africa is a driver for long-term economic growth and development and this is the reason why the ministries of health and finance will need to find common ground on how to create policy coherence and how to articulate their respective objectives.

The Crisis of Finance-Dominated Capitalism in the Euro Area, Deficiencies in the Economic Policy Architecture, and Deflationary Stagnation Policies

In this paper the euro crisis is interpreted as the latest episode in the crisis of finance-dominated capitalism. For 11 initial Euro area countries, the major features of finance-dominated capitalism are analyzed; specifically, the increasing inequality of income distribution and the rising imbalances of current accounts. Against this background, the euro crisis and the economic policy reactions of European governments and institutions are examined. It is shown that deflationary stagnation policies have prevailed since 2010, resulting in massive real GDP losses; some improvement in the price competitiveness of the crisis countries but considerable and persistent current account imbalances; reductions in government deficit–to-GDP ratios but continuously rising trends in gross government debt–to-GDP ratios; a risk of further recession for the euro area as a whole — and the increasing threat of the euro’s ultimate collapse. Therefore, an alternative macroeconomic policy approach tackling the basic contradictions of finance-dominated capitalism and the deficiencies of European economic policy institutions and strategies — in particular, the lack of (1) an institution convincingly guaranteeing public debt and (2) a stable and sustainable financing mechanism for acceptable current account imbalances — is outlined.

Public health bureaus: new players in health improvement in Lithuania

Particular emphasis in the development of the public health care system in Lithuania was put on strengthening public health at the municipal level. This paper aims at investigating the possibilities and barriers of the public health reform in Lithuania by analyzing the experience of establishing public health bureaus as the major players in public health development at the municipal level. The Lithuanian National Public Health Strategy and Action Plan have been adopted by the Government in 2006. Ministry of Health prepared legal acts and programmes that encourage local authorities to establish public health bureaus. By the end of 2010, 32 municipal Public health bureaus were set up. The core main functions of the bureaus are public health promotion, monitoring public health and child health care. The first steps of the bureaus were complicated by the lack of well-developed strategies of action and local support, as well as by financial challenges. For strengthening the position of the bureaus in society, benefits of these newly established institutions should be widely presented to the public; sustainable financing mechanisms and a focus on intersectoral cooperation, integrating public health into primary health care are needed; also, human resource development should be foreseen. In spite of the rather challenging beginning, bureaus are starting to provide means by which local governments, in partnership with the service providers, other stakeholders and the community can plan and implement public health services and programmes and play a significant role in improving the health of population. Keywords: Lithuania, public health reform, municipal level, public health bureau

Social policy and poverty: an introduction1

Hujo K, Gaia E. Social policy and poverty: an introductionInt J Soc Welfare 2011: 20: 230–239 © 2011 United Nations Research Institute for Social Development (UNRISD), International Journal of Social Welfare © 2011 Blackwell Publishing Ltd and International Journal of Social Welfare.This Guest Editorial introduces the context and main themes around which this collection of articles on social policy and poverty is framed. Against the backdrop of calls for accelerated progress towards achievement of the Millennium Development Goals in a context of multiple crises, the role of social policy for social development and poverty reduction is highlighted. Three key themes are addressed by the five contributions in the collection: (1) the role of social protection, in particular cash transfers, in poverty reduction; (2) the importance of labour markets and labour market policies for poverty reduction; and (3) the financing of welfare policies. The guest editors conclude that social protection policies should be grounded in values of social justice and human rights, which calls for strong state commitment towards universal programmes. They further point to the need of institutionalising long‐term social policies that benefit from broad‐based political support and are grounded in sustainable financing mechanisms.

Non-adherence to antiretroviral treatment and unplanned treatment interruption among people living with HIV/AIDS in Cameroon: Individual and healthcare supply-related factors

In low-income countries, health system deficiencies may undermine treatment continuity and adherence to antiretroviral therapy (ART) that are crucial for the success of large-scale public ART programs. In addition to examining the effects of individual characteristics, on non-adherence to ART and treatment interruption behaviors – i.e. treatment interruption for more than 2 consecutive days during the previous 4 weeks, this study aims to extend our knowledge on the role played by healthcare supply-related characteristics in shaping these two treatment outcomes. These effects are examined using multilevel logistic models applied to a sub-sample of 2381 ART-treated patients followed-up in 27 treatment centers in Cameroon (ANRS-EVAL survey, 2006–2007).Multivariate models show that factors common to both non-adherence and treatment interruption include binge drinking (at the individual-level) and large hospital size (at the healthcare supply-level). Among the individual factors, financial difficulties of paying for HIV-care are the major correlates of treatment interruption [Adjusted Odds Ratio (AOR) 95% confidence interval (CI) = 11.73(7.24–19.00)]. By contrast, individual factors associated with an increased risk of non-adherence include: having a main partner but not living in a couple compared to patients living in a couple [AOR(95%CI) = 1.51(1.14–2.01)]; experience of discrimination in the family environment [AOR(95%CI) = 1.74(1.14–2.65)]; a lack of regular meals [AOR(95%CI) = 1.93(1.44–2.57)], and switching antiretroviral drugs (ARV) regimen [AOR(95%CI) = 1.36(1.08–1.70)]. At healthcare facility-level, the main correlate of ART interruption was antiretroviral stock-outs [AOR(95%CI) = 1.76(1.01–3.32)] whereas the lack of psychosocial support from specialized staff and lack of task-shifting to nurses in medical follow-up were both associated with a higher-risk of non-adherence [respective AOR (95%CI) = 2.81(1.13–6.95) and 1.51(1.00–3.40)].Results reveal different patterns of factors for non-adherence and treatment interruption behaviors. They also suggest that psychosocial support interventions targeted at the individual patient-level will not be sufficient to achieve favorable treatment outcomes if not combined with interventions focused on strengthening health systems, including appropriate drug supplies and human resources policies, as well as sustainable and equitable financing mechanisms.

Microfinance: an alternative means of healthcare financing for the poor

Microfinance: an alternative means of healthcare financing for the poor

Workshop report – Public transport markets in development

Developing countries and countries in transition represent between 85% and 90% of the world’s population and face unique public transport challenges that are not necessarily present in developed countries. Issues such as the affordability and accessibility of public transport, funding support and capacity to implement are some of the challenges these countries face. Barriers to strategy implementation in these countries could be a failure to understand the broader business and social environment, poor leadership, a lack of inter-disciplinary and inter-implementer collaboration, and weak monitoring and feedback loops. Weak institutional frameworks are evidenced in inappropriate structures often resulting in institutional inertia and conflict. Over-promising of potential impacts and benefits together with a failure to develop sustainable funding mechanisms often lead to a lack of implementation. The workshop argued that different competition and ownership solutions are needed for a range of factors. This poses a challenge to the THREDBO community as it could mean that the traditional concepts are either not relevant or not usable in the majority of the world’s developing countries, or that the traditional approaches are relevant in many respects but need to be substantially extended and adapted to be applicable and usable in the rest of the world.

Financing children's vaccines

A 2006 Commonwealth Association of Paediatric Gastroenterology and Nutrition workshop on financing children's vaccines highlighted the potential for vaccines to control diarrhoea and other diseases as well as spur economic development through better health. Clear communication of vaccination value to decision-makers is required, together with sustainable funding mechanisms. GAVI and partners have made great progress providing funding for vaccines for children in the poorest countries but other solutions may be required to achieve the same gains in middle- and high-income countries. World Health Organization has a wealth of freely available country-level data on immunisation that academics and advocates can use to communicate the economic and health benefits of vaccines to decision-makers.

An experiment with community health funds in Afghanistan

As Afghanistan rebuilds its health system, it faces key challenges in financing health services. To reduce dependence on donor funds, it is important to develop sustainable local financing mechanisms. A second challenge is to reduce high levels of out-of-pocket payments. Community-based health insurance (CBHI) schemes offer the possibility of raising revenues from communities and at the same time providing financial protection. This paper describes the performance of one type of CBHI scheme, the Community Health Fund (CHF), which was piloted for the first time in five provinces of Afghanistan between June 2005 and October 2006. The performance of the CHF programme demonstrates that complex community-based health financing schemes can be implemented in post-conflict settings like Afghanistan, except in areas of high insecurity. The funds raised from the community, via premiums and user fees, enabled the pilot facilities to overcome temporary shortages of drugs and supplies, and to conduct outreach services via mobile clinics. However, enrolment and cost-recovery were modest. The median enrolment rate for premium-paying households was 6% of eligible households in the catchment areas of the clinics. Cost recovery rates ranged up to 16% of total operating costs and 32% of non-salary operating costs. No evidence of reduced out-of-pocket health expenditures was observed at the community level, though CHF members had markedly higher utilization of health services. The main reasons among non-members for not enrolling were being unaware of the programme; high premiums; and perceived low quality of services at the CHF clinics. The performance of Afghanistan's CHF was similar to other CHF-type programmes operating at the primary care level internationally. The solution to building local capacity to finance health services lies in a combination of financing sources rather than any single mechanism. In this context, it is critical that international assistance for Afghanistan's health sector continues.

User fees as sustainable financing mechanisms for marine protected areas: An application to the Bonaire National Marine Park

Marine protected areas (MPAs) have proliferated globally in the past three decades. However, inadequate funding often prevents these management regimes from fulfilling their missions. Managers have become increasingly aware that successful protection of marine ecosystems is dependent not only upon an understanding of their biological and physical processes, but also their associated social and economic aspects. Unfortunately, economic values associated with MPAs and the natural resources they protect are rarely considered in decision-making and policy development. This study addresses this information gap by examining scuba divers’ willingness to pay for access to quality recreational sites in the Bonaire National Marine Park, Bonaire, Netherlands Antilles. The findings indicate that the US$10 annual diver user fee in effect at the time of the study could be increased substantially without a significant adverse effect on island tourism. Depending on question format, mean willingness to pay for annual access ranged from US$61 to US$134 (2002$). All model specifications support the conclusion that doubling the US$10 user fee would have virtually no impact on visitation rates. The increased revenue generated from this sustainable financing mechanism is more than sufficient to fund both current and enhanced marine park operations.

Creative financing solution for water supply and sanitation in the Philippines

This paper discusses the ongoing initiative to establish a sustainable financing mechanism for water supply and sanitation (WSS) projects, anchored on the principle of public–private partnership. It tackles the magnitude of investment requirements and financing gaps, and the rationale and objectives of the Philippine Water Revolving Fund (PWRF) and its financial structure. PWRF responds to the government's policy to shift financing of WSS projects, starting with existing creditworthy water utilities, from concessional to market-based sources. PWRF is initially designed as a co-financing credit facility combining official development assistance (ODA) with private financing institution funds. However, its ultimate goal is to access the domestic capital market through pooled bond financing.

Skills development, employment and sustained growth in Ghana: Sustainability challenges

Abstract Against a backdrop of some two decades of sustained economic growth in Ghana, this paper argues that there are a series of sustainability challenges related to technical and vocational skills development (TVSD) that need to be addressed. This paper analyses several sustainability dimensions of TVSD related to: promoting the sustainability of education-for-all achievements through expanding post-basic education and TVSD; identifying sustainable financing mechanisms for an expansion of TVSD; promoting and sustaining equitable access; ensuring that expansion in quantity does not lead to a compromise on the achievement and sustainability of quality and relevance issues; promoting the sustainability of TVSD expansion by widening opportunities for lifelong learning; creating an enabling environment for skills utilization through sustainable employment growth.