Global health: Time for "world social health insurance?"

Wealthy governments are constantly struggling with how to fund their overburdened health systems. This has become apparent in the ongoing saga of US health reform, efforts in China to change health reimbursement, and even the search among the health-elite, such as Denmark and Sweden, for new ways to fund health systems. Now researchers publishing in this weeks edition of The Lancet show how creative financing of health systems extends to the poorest nations as well.

In the decade between 1995 and 2006, inflation -adjusted public financing of health increased by nearly 100%, to a total of around $18 billion in 2006, or three times the amount of foreign development aid. This primarily reflects increases in GDP. Government expenditures in health tended to increase, with the exception of many countries in greatest need: The sub-Saharan region of Africa, for example, saw decreases in numerous countries.

Interestingly, there's a negative correlation between foreign health-related development aid, and government funding: Each dollar of foreign aid distributed through governments results in a $0.43 to $1.14 decrease in domestic funding, a phenomenon known as "crowding out." Foreign aid to NGOs, however, did not negatively effect domestic spending on health. An associated commentary by researchers from Antwerp, Belgium and Pretoria, South Africa notes the difficulties in attempting to track funding over multiple years. The International Monetary Fund, for example, recently found that 56% of aid was actually spent in the first year, and 13% the second year. This means that "$10 million a year" for 3 years could mean $5.6 million spent the first year, and $1.3 the following. Or would it be $6.9 the second year ($1.3 from the previous plus $5.6 from the current)?

The Lancet papers propose 5 global health policy steps to help ensure appropriate allocation of resources:

1. Clear standards for reporting government health spending that tracks the source of resources, and which health-related sectors are being funded

2. Collaborative targets developed by ministries of health and finance, and foreign donors aiming to increase the amount of health spending from domestic governments

3. Helping to build accounting and planning capacity within recipient nations so they can more efficiently allocate foreign aid

4. Assessment of possible unintended consequences of letting health and development funding bleed into other sectors

5. Considering alternative methods of funding health, such as price subsidies and product transfers.

Finally, there's an open call made to consider something called "world social health insurance," essentially one fund with one set of standards tasked with providing health funding for the globe.

This is obviously a highly complex picture with multiple variables, and subtle differences between nations or regions that can make any aggregated analysis amount to much less than the sum of its constituent parts. But it does raise some questions, for example: Is there anything wrong with a resource poor nation offsetting domestic spending with international aid? Do the proposed policy "fixes" amount to economic and political neo-colonialism, or sincere efforts to improve global health?