Timothy Powell-Jackson

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

Countdown to 2015: tracking donor assistance to maternal, newborn, and child health

BACKGROUND Timely reliable data on aid flows to maternal, newborn, and child health are essential for assessing the adequacy of current levels of funding, and to promote accountability among donors for attainment of the Millennium Development Goals (MDGs) for child and maternal health. We provide global estimates of official development assistance (ODA) to maternal, newborn, and child health in 2003 and 2004, drawing on data reported by high-income donor countries and aid agencies to the Organisation for Economic Development and Cooperation. METHODS ODA was tracked on a project-by-project basis to 150 developing countries. We applied a standard definition of maternal, newborn, and child health across donors, and included not only funds specific to these areas, but also integrated health funds and disease-specific funds allocated on a proportional distribution basis, using appropriate factors. FINDINGS Donor spending on activities related to maternal, newborn, and child health was estimated to be US1990 million dollars in 2004, representing just 2% of gross aid disbursements to developing countries. The 60 priority low-income countries that account for most child and newborn deaths received 1363 million dollars, or 3.1 dollars per child. Across recipient countries, there is a positive association between mortality and ODA per head, although at any given rate of mortality for children aged younger than 5 years or maternal mortality, there is significant variation in the amount of ODA per person received by developing countries. INTERPRETATION The current level of ODA to maternal, newborn, and child health is inadequate to provide more than a small portion of the total resources needed to reach the MDGs for child and maternal health. If commitments are to be honoured, global aid flows will need to increase sharply during the next 5 years. The challenge will be to ensure a sufficient share of these new funds is channelled effectively towards the scaling up of key maternal, newborn, and child health interventions in high priority countries.

Financial incentives in health: New evidence from India's Janani Suraksha Yojana.

This paper studies the health effects of one of the worlds largest demand-side financial incentive programmes--Indias Janani Suraksha Yojana. Our difference-in-difference estimates exploit heterogeneity in the implementation of the financial incentive programme across districts. We find that cash incentives to women were associated with increased uptake of maternity services but there is no strong evidence that the JSY was associated with a reduction in neonatal or early neonatal mortality. The positive effects on utilisation are larger for less educated and poorer women, and in places where the cash payment was most generous. We also find evidence of unintended consequences. The financial incentive programme was associated with a substitution away from private health providers, an increase in breastfeeding and more pregnancies. These findings demonstrate the potential for financial incentives to have unanticipated effects that may, in the case of fertility, undermine the programmes own objective of reducing mortality.

Countdown to 2015: assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006

BACKGROUND To track donor assistance to maternal, newborn, and child health-related activities is necessary to assess progress towards Millennium Development Goals 4 and 5 and to foster donor accountability. Our aim was to analyse aid flows to maternal, newborn, and child health for 2005 and 2006 and trends between 2003 and 2006. METHODS We analysed and coded the complete aid activities database for 2005 and 2006 with methods that we developed previously to track official development assistance. For the 68 Countdown priority countries, we report two indicators for use in monitoring donor disbursements: official development assistance to child health per child and official development assistance to maternal and neonatal health per livebirth. FINDINGS Donor disbursements increased from US

The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal

2119 million in 2003 to

Financial incentives for maternal health: Impact of a national programme in Nepal

3482 million in 2006; funding for child health increased by 63% and that for maternal and newborn health increased by 66%. In the 68 priority countries, child-related disbursements increased from a mean of

Impact of user fees on maternal health service utilization and related health outcomes: a systematic review

4 per child in 2003 to

The impact of Nepal's national incentive programme to promote safe delivery in the district of Makwanpur.

7 per child in 2006; disbursements for maternal and neonatal health increased from

A decade of improvements in equity of access to reproductive and maternal health services in Cambodia, 2000–2010

7 per livebirth in 2003 to

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study

12 per livebirth in 2006. Nonetheless, disbursements fell in some countries. After adjustment for other determinants, countries with higher under-5 mortality received more official development assistance per child, but official development assistance to maternal and newborn health did not seem to be well targeted towards countries with the greatest maternal health needs. INTERPRETATION Donor resource tracking should be continued to help hold donors accountable and encourage targeting of resources to countries with greatest needs.