Justine Hsu

Countdown to 2015: changes in official development assistance to maternal, newborn, and child health in 2009–10, and assessment of progress since 2003

BACKGROUND Tracking of financial resources to maternal, newborn, and child health provides crucial information to assess accountability of donors. We analysed official development assistance (ODA) flows to maternal, newborn, and child health for 2009 and 2010, and assessed progress since our monitoring began in 2003. METHODS We coded and analysed all 2009 and 2010 aid activities from the database of the Organisation for Economic Co-operation and Development, according to a functional classification of activities and whether all or a proportion of the value of the disbursement contributed towards maternal, newborn, and child health. We analysed trends since 2003, and reported two indicators for monitoring donor disbursements: ODA to child health per child and ODA to maternal and newborn health per livebirth. We analysed the degree to which donors allocated ODA to 74 countries with the highest maternal and child mortality rates (Countdown priority countries) with time and by type of donor. FINDINGS Donor disbursements to maternal, newborn, and child health activities in all countries continued to increase, to

Universal health coverage and universal access.

6511 million in 2009, but slightly decreased for the first time since our monitoring started, to

Financial Risk Protection and Universal Health Coverage: Evidence and Measurement Challenges

6480 million in 2010. ODA for such activities to the 74 Countdown priority countries continued to increase in real terms, but its rate of increase has been slowing since 2008. We identified strong evidence that targeting of ODA to countries with high rates of maternal mortality improved from 2005 to 2010. Targeting of ODA to child health also improved but to a lesser degree. The share of multilateral funding continued to decrease but, relative to bilaterals and global health initiatives, was better targeted. INTERPRETATION The recent slowdown in the rate of funding increases is worrying and likely to partly result from the present financial crisis. Tracking of donor aid should continue, to encourage donor accountability and to monitor performance in targeting aid flows to those in most need. FUNDING Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Canada, Norway, Sweden, and the UK.

Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012

Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda.1 Whether it is a means to an end or an end in itself and whether it is measureable are subjects of heated debate.2 In this issue of the Bulletin, Kutzin argues that universal health coverage not only leads to better health and to financial protection for households, but that it is valuable for its own sake.3 More recently, attention has shifted to just what the goal should be: whether universal coverage or universal access. This editorial focuses on this question. Universal health coverage is the goal that all people obtain the health services they need without risking financial hardship from unaffordable out-of-pocket payments.4 It involves coverage with good health services – from health promotion to prevention, treatment, rehabilitation and palliation – as well as coverage with a form of financial risk protection. A third feature is universality – coverage should be for everyone. Although many countries are far from attaining universal health coverage, all countries can take steps in this direction.3,4 Improving access is one such step. Universal health coverage is attained when people actually obtain the health services they need and benefit from financial risk protection. Access, on the other hand, is the opportunity or ability to do both of these things. Hence, universal health coverage is not possible without universal access, but the two are not the same. Access has three dimensions:5-8 Physical accessibility. This is understood as the availability of good health services within reasonable reach of those who need them and of opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain the services when they need them. Financial affordability. This is a measure of people’s ability to pay for services without financial hardship. It takes into account not only the price of the health services but also indirect and opportunity costs (e.g. the costs of transportation to and from facilities and of taking time away from work). Affordability is influenced by the wider health financing system and by household income. Acceptability. This captures people’s willingness to seek services. Acceptability is low when patients perceive services to be ineffective or when social and cultural factors such as language or the age, sex, ethnicity or religion of the health provider discourage them from seeking services. Services must be physically accessible, financially affordable and acceptable to patients if universal health coverage is to be attained. The requirement that services be physically accessible is fulfilled when these are available, of good quality and located close to people. Service readiness is said to exist when the inputs required to produce the services (e.g. buildings, equipment, health personnel, health products, technologies) are also available and of good quality. Financial affordability can be improved by reducing direct, out-of-pocket payments through insurance prepayments and pooling – e.g. the collection of government revenues and/or health insurance contributions to fund health services – or through demand-side stimuli such as conditional cash transfers and vouchers. Social and cultural accessibility can be enhanced by ensuring that health workers and the health system more generally treat all patients and their families with dignity and respect. Addressing the broader social determinants of health will also improve access to health services; differences in access in particular will be ameliorated by reducing poverty and income inequalities. Improvements in education will raise the average income, make health services more affordable and equip people with the awareness needed to demand and obtain the health services they need. Efforts to address these social determinants will help to reduce inequalities in income, service affordability and access to services, and this, in turn, will help to attenuate differences in health service coverage and in financial risk protection. These actions alone, however, will not guarantee that all people obtain the health services they need. Even if the services exist and people have access to them, they might not use them. They may be unaware, for instance, of having a condition requiring treatment (e.g. hypertension), of how health promotion or preventive services can benefit them, or of the availability of different types of health services or financial risk protection plans. Or they might not recognize that others’ health may be affected by their health-care decisions (e.g. if they fail to get treated for a communicable disease). In essence, universal health coverage is the obtainment of good health services de facto without fear of financial hardship. It cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable. Yet universal access, although necessary, is not sufficient. Coverage builds on access by ensuring actual receipt of services. Thus, universal health coverage and universal access to health services are complementary ideas. Without universal access, universal health coverage becomes an unreachable goal.

Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010

As part of a PLOS Collection on universal health coverage, Priyanka Saksena and colleagues examine existing measures of financial risk protection and suggest future developments that could be valuable in monitoring progress towards universal health coverage.

Progress on catastrophic health spending in 133 countries: a retrospective observational study

BACKGROUND Tracking of aid resources to reproductive, maternal, newborn, and child health (RMNCH) provides timely and crucial information to hold donors accountable. For the first time, we examine flows in official development assistance (ODA) and grants from the Bill & Melinda Gates Foundation (collectively termed ODA+) in relation to the continuum of care for RMNCH and assess progress since 2003. METHODS We coded and analysed financial disbursements for maternal, newborn, and child health (MNCH) and for reproductive health (R*) to all recipient countries worldwide from all donors reporting to the creditor reporting system database for the years 2011-12. We also included grants from the Bill & Melinda Gates Foundation. We analysed trends for MNCH for the period 2003-12 and for R* for the period 2009-12. FINDINGS ODA+ to RMNCH from all donors to all countries worldwide amounted to US

Progress on impoverishing health spending in 122 countries: a retrospective observational study

12·2 billion in 2011 (an 11·8% increase relative to 2010) and

Developing a dataset to track aid for reproductive, maternal, newborn and child health, 2003-2013.

12·8 billion in 2012 (a 5·0% increase relative to 2011). ODA+ to MNCH represents more than 60% of all aid to RMNCH. ODA+ to projects that have newborns as part of the target population has increased 34-fold since 2003. ODA to RMNCH from the 31 donors, which have reported consistently since 2003, to the 75 Countdown priority countries, saw a 3·2% increase in 2011 relative to 2010 (

Health Services in Low- and Middle-Income Countries: Financing, Payment, and Provision

8·3 billion in 2011), and an 11·8% increase in 2012 relative to 2011 (

Measuring financial protection against catastrophic health expenditures: methodological challenges for global monitoring

9·3 billion in 2012). ODA to RMNCH projects has increased with time, whereas general budget support has continuously declined. Bilateral agencies are still the predominant source of ODA to RMNCH. Increased funding to family planning, nutrition, and immunisation projects were noted in 2011 and 2012. ODA+ has been targeted to RMNCH during the period 2005-12, although there is no evidence of improvements in targeting over time. INTERPRETATION Despite a reduction in ODA+ in 2011, ODA+ to RMNCH increased in both 2011 and 2012. The increase in funding is encouraging, but continued increases are needed to accelerate progress towards achieving MDGs 4 and 5 and beyond. FUNDING Bill & Melinda Gates Foundation.