Donor Funding for Malaria and National Health Accounts

“National Health Accounts (NHA) is a tool being used today in more than 50 low- and middle-income countries as a framework for measuring total public and private national health expenditures. NHA methodology tracks the flow of funds through the health sector, from their sources, through financial institutions, to providers and functions,” according to Health Systems 20/20 (Abt Associates). Of particular interest is tracking the influence of donor funding on malaria programming.

nha_rwanda_sm.jpgThe 2006 NHA for Rwanda published by Health Systems 20/20 shows that the total funds from public, private and donor sources for malaria rose from about $25 million in 2003 to $43 million in 2006. The proportion coming from donor sources rose is both absolute and proportionate terms from 38% to 50%.  Household sources increased from 29% to 44%, while public sources decreased from 24% to 5%.Overall malaria spending accounted for 14% of total health expenditure in 2006 (HIV was 24%).

It is likely that the bulk of the donor support came from the Global Fund, from which Rwanda received a malaria grant in Rounds 3 and 5. The US President’s Malaria Initiative did not develop its first Malaria Operations Plan for Rwanda until 2007. A NHA for Rwanda in 2008 would therefore, likely show even greater malaria expenditure as well as a greater donor proportion of funding.

Health Systems 20/20 presented the Rwanda NHA Malaria results at the recent Conference of the American Public Health Association, and expressed that, “While these findings show the positive effects of national policies, such as the focus on bed nets and donor coordination, increased malaria funds have not reduced overall household financial burden. The Government and its partners intend to use such findings to inform future resource allocation decisions.”

They acknowledged that additional study is needed to determine why household expenditure rose, although one migh speculate that higher costs of anti-malarials through private pharmacies might contribute to the problem. On the positive side, the World Malaria Report 2008 includes Rwanda among the “four countries/areas (that) reduced the malaria burden by 50% or more between 2000 and 2006–2007, in line with WHA targets.” One assumes that the increase in malaria funding did help achieve these targets.

At the same time, contributors to the current issue of the WHO Bulletin debate the question of donor support for health. Kirigia and Diarra-Nama argue for a weaning from donor reliance as follows:

Armed with a clear vision and backed by effective programmes for improving economic efficiency of public and private expenditure; identifying and pruning unproductive public expenditures; strengthening of tax administration systems; creating an environment for enabling private health sector growth; and boosting health development governance, countries of the African region have a high probability of weaning off donor funding for health in this century. Pursuit of such a noble vision should be supported by an enabling macroeconomic and political (i.e. internally secure) environment.

In contrast Ooms & Van Damme believe that, “Even if some countries of the African region might be able to wean themselves from international health aid, others obviously cannot: they need increased aid, urgently.” This may be especially true for malaria and the move to universal LLIN and ACT coverage as Rwanda reaches toward elimination of the disease. Unfortunately until such time as eradication becomes feasible, there needs to be constant attention to a balanced and equitable donor, national government and household commitment to funding malaria control.

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