Taskforce on Innovative International Financing for Health Systems: what next?

The high-level Taskforce on Innovative International Financing for Health Systems was set up in 2008 and chaired by Gordon Brown, Prime Minister of the United Kingdom of Great Britain and Northern Ireland, and Robert Zoellick, President of The World Bank. Its aim was to identify innovative and additional sources of funding for health systems strengthening in the 49 lowest-income countries of the world. The taskforce delivered its final recommendations in September 2009 together with two detailed working group papers. 1, 2 Here we summarize the main outputs and recommendations of the taskforce according to three areas: (i) costing the financing gap; (ii) new and innovative sources of finance; and (iii) making development assistance for health work better (Box 1). We then examine their limitations and propose further actions for the international health community. Box 1 Summary of recommendations by the high-level Taskforce on Innovative International Financing for Health Systems3 New sources of finance: Extend the mandatory solidarity levy on airline tickets to more countries (currently in place in several countries and used primarily to finance paediatric AIDS treatment through UNITAID) ; Explore the viability of levies on tobacco and currency transactions; Encourage voluntary private giving through: (i) voluntary levies on the purchase of airline tickets and mobile phone minutes (expected to raise US 3. 2 billion by 2015) ; and (ii) a scheme called a “de-tax” which would earmark a share of value added tax receipts when participating businesses agree to add a share of their profits (estimated potential of US 220 million in 2010) ; Secure more private investment in health systems through establishing capital/risk mitigation fund (s). Out-sourcing to non-government providers and encouraging greater use of advanced market commitments, such as for vaccine purchases, were also mentioned as ways of securing investment from private sector actors. Making development assistance for health work better: More frontloading (i. e. concentrating payments at the beginning of an agreement) and predictability of aid, possibly by expanding the mandate of the International Financing Facility for Immunization. Expand the use of results-based “buy-down” (use of grant funding to reduce the cost of loans when specific performance targets are met) funding and more performance-based donor funding for the health sector. Establish a common health systems funding platform for the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance and The World Bank. Undertake a review of technical assistance, in view of evidence that it consumes a large proportion of aid and appears to be poor value for money. Gaps and challenges Costing Three issues stand out. The first relates to the models used for calculating the costs of scaling-up essential health services, including the assumptions on what is required to achieve that scale-up. 1 The different models used by the taskforce did not just produce alternative costings, but also reflected different approaches to health systems strengthening as well as different levels of ambition. The World Health Organization (WHO) ’s normative approach, for example, was bolder and advocated the simultaneous scaling-up of facility and community-based services, while The World Bank and the United Nations Children’s Fund (UNICEF) were less ambitious and advocated expanding low-cost, community-based services before undertaking any strengthening or expansion of facility-based services. In addition to the confusion of having different costing models, the taskforce reveals fundamental differences in opinion about the minimum requirements to strengthen health systems and the best way to expand coverage of essential health services. The second issue is that the individual country costings used to produce an aggregated “price tag” for all low-income countries are unavailable. And yet a full and proper discussion about the best way to fund and scale-up essential health services can ultimately only be conducted at the country level. In addition, the costings generated for health systems inputs such as “governance” are novel and need further empirical testing. A disaggregation of the data by country is therefore a vital next step. Third, an implicit recommendation of the taskforce is that a significant proportion of funding should come from private expenditure, in spite of the need to reduce the burden of health expenditure on poor households. This suggests that the required future funding from governments and donors has been underestimated.