Leakage: can the primary case system address malaria?

The current global economic crisis has resulted in caution and worry for public health. The Global Fund Board at its 18th meeting decided that, “The Round 8 proposals to be approved for funding by the Board shall collectively be subject to a 10% adjustment (i.e. cut) for efficiency.”  While Global Fund money can help strengthen health systems, it is not meant to build systems or replace national financial commitment to health care.

What then happens when funds appropriated for health services do not reach the front line where primary care services, including malaria control, are delivered? Gauthier and Wane report on Chad that …

Although the regional administration is officially allocated 60% of the ministry’s non-wage recurrent expenditures, theshare of the resources that actually reach the regions is estimated to be only 18%. The health centres, which are the frontline providers and the entry point for the population, receive less than 1% of the ministry’s non-wage recurrent expenditures. Accounting for the endogeneity of the level of competition among health centres, the leakage of government resources has a significant and negative impact on the price mark-up that health centres charge patients for drugs. Furthermore, it is estimated that had public resources earmarked for frontline providers reached them in their entirety, the number of patients seeking primary health care in Chad would have more than doubled.

Gauthier and Wane surmise that donor support of health in Chad may actually contribute to the problem. Their study has “shown that current resource allocation seems to be linked to the discretion of regional and district administrators, and that international donor support introduces a strong crowding out effect, whereby health centres that received foreign assistance are less likely to be supported by higher administrative levels.”

Efforts had been made by the World Bank and other donors to ensure that Chad spent its burgeoning windfall of oil money on social services and poverty reduction, but the government managed to back out of its pledge. According to the New York Times, “Chad has been ranked with Bangladesh at the world’s two most corrupt countries by the corruption watchdog Transparency International. The hope that Chad would chart a more humane path fractured when its Parliament voted … to soften the oil revenue law, allowing the money to be diverted.”

dscn1720sm.JPGAnother World Bank study in Nigeria identified similar financial accountability problems with local government health funds. “Even when budget allocations were sufficient to cover estimated actual costs, the staff survey revealed non-payment of salaries for several months in the year before the survey. The paper argues that the pattern of evidence shows that non-payment of salaries cannot be explained by lack of resources available to local governments. The evidence therefore suggests that there is a general problem of accountability at the local government level in the use of public resources that are transferred from higher tiers of government.”

As seen in the picture, lack of accountability also means local government clinics are in disrepair, discouraging attendance by clients. The Nigerian study also laments that “local citizens may not be well informed” about these problems and are thus not disposed toward advocacy. Who then will be the advocates to prevent leakage?

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