From commitment to action:
healthDepartment for International Development
HM Treasury
September 2005

SUMMARY: THE POSITION NOW AND OUR PLAN OF ACTION
Better population health is a prerequisite if developing countries are to break out of
the cycle of poverty. Improving health outcomes is dependent on making progress inmany areas including economic growth, education, water, social exclusion andgender equality – any sector strategy must assess these linkages and health must
be prioritised in country-led plans.
Health statistics are stark. Each year almost 11 million children die before their fifthbirthday and more than 500,000 women die as a result of pregnancy or childbirth.
AIDS causes more than 3 million deaths and 2 million people die of tuberculosis(TB), often adults in their most productive years. Malaria causes almost 1 million
deaths. Beyond the numbers lies the long-lasting impact on individuals, families andsociety. AIDS is reversing past development gains in many countries.
Most of the major causes of ill health and mortality in low-income countries can beprevented or readily treated using known and affordable technologies. With
universal access to basic healthcare, child mortality could be reduced by two-thirds
and maternal mortality by three-quarters.
The health system faces many challenges in assuring universal access to services;long-term and severe under-funding, weak institutions and governance, andshortages of trained health workers. It also important to remove barriers toincreased demand, particularly financial barriers that limit poor people’s access.
A number of low-income countries have demonstrated that with commitment toexpanding access to services and a focus on equity and accountability, it is possible
to deliver improved health outcomes.
The WHO Commission on Macroeconomics and Health (CMH) estimated that anadditional US$22 billion in aid by 2007 and US$31 billion in aid by 2015 would leadto impressive benefits; a 65% reduction in maternal deaths, 2 to 5 million fewer childdeaths, 2 million fewer TB deaths each year, halving malaria deaths and 100 million
fewer HIV infections.
An additional $20-25 billion donor investment in health in low-income countries by2010, with half allocated to Africa, would represent a step change in support andwould deliver proportionate improvements in health outcomes. The impact will begreater if additional aid is targeted at the poorest countries and those where theburden of disease is greatest.
Increased aid resources for health need to be matched by greater predictability andefforts to reduce transaction costs. It will be important to find the right balance
between targeted investment through specific funds and long-term investment insystems building where currently progress is too little and too slow.
Donors need to demonstrate now that they are committed to increasing levels ofdevelopment assistance. Only then will countries have the confidence to increase
the level of ambition of existing plans to accommodate scaled up aid.

1Plan of action
To turn commitment into actions and support countries in expanding access tohealth services will require:
1. An increase in overall aid for health in low-income countries of at least$20 billion a year by 2010, with priority given to supporting efforts tostrengthen health systems.
• Donors must urgently turn commitments into information on forward
projections of finance at the country level. A first step will be a meeting
planned alongside the World Bank Annual Meetings in September 2005
where donors will discuss aid flows and the financing challenges
surrounding scaling up.
• The additional financing would be provided through a variety of channels
and wherever possible through increasing the proportion of resourceschannelled through budgets. This will allow for a more flexible use ofresources better aligned to national plans and processes.
2. Support to governments to develop ambitious plans once financing
commitments are clear.
• Countries cannot be expected to invest in developing ambitious sector ordevelopment plans until they are confident and clear how and when
additional resources will come, and for how long they will last.
• Technical agencies such as the IMF, World Bank and WHO have a majorrole to play but need to provide consistent advice on issues such as themacroeconomic effects of increasing external financing.
3. Donors to make real progress in implementing the Paris commitmentson aid effectiveness and recommendations of the Global Task Team on
AIDS, including efforts to make global health initiatives andpartnerships (GHIPs) more effective.
4. Donors to commit to developing and piloting mechanisms to increase
the predictability of development assistance for the expansion ofaccess to services. The High Level Forum on Health will address thisissue in November 2005.
5. Partner countries to meet their commitments to increase funding to thesocial sectors.
• The exact level will of course depend on national priorities and local
economic conditions, but African countries’ commitment to allocate 15%of their budget to health needs to be realised.
• Partner countries can also use the opportunity of additional long-term
financing for health to improve the performance and equity of their healthsystems and services.

2

INTRODUCTION
1.
The case for investing in health is clear. It saves and improves lives, drives
growth and reduces poverty. It helps address global inequalities and promotessocial justice. Better health is an essential prerequisite if developing countries areto break the poverty cycle.1 The devastating impact of AIDS adds a further urgent
dimension. Healthy people are more productive and productivity boosts investment.
Healthy children learn better and longer and informed adults make better use ofhealth services. Improved health and education help lower fertility and mortality
rates, slow population growth and reduce the numbers of dependents.2 The healthsystem is at the core of social and civic life and has enormous potential to contributeto democratic development.3
2.
Ill health pushes people into poverty. If people cannot access services thatthey can afford, it creates uncertainty and anxiety about the future and leads
individuals to prefer lower-risk activities; this in turn stifles innovation and prevents
the poor from seizing economic opportunities.4 Equitable financing systems can stop
the downward spiral into further poverty that can be caused by the catastrophic
costs of ill health.
3.
The Millennium Development Goals (MDGs) set benchmarks for progressagainst a range of human development indicators. Most countries are falling far
short of reaching their targets. With the right political commitment, even the poorest
countries can make progress. We know what to do to deal with the major causes ofill health and death. We know what is affordable and effective, yet many poor people
cannot get the most basic of services.2
4.
Essential health services need to be scaled up like never before. The G8commitments create the opportunity to fund a massive increase in access toessential health services. The UN’s 2005 World Summit will focus world attention on
this, and many other problems. There is a window of opportunity. However,translating commitments into improved health for populations in low-income
countries will be a challenge. This is not just about more donor resources: moremoney from developed countries will need to be matched by commitments fromdeveloping countries to prioritise health, to stamp out corruption, and to increaseaccountability to their populations, and will require donors to fundamentally change
the ways in which they provide development assistance.
5.
This paper reviews the current situation and the challenges in scaling up
access to services, and estimates the costs and benefits. It also sets out a proposedplan to translate commitments into investment for improved health outcomes.

3

A. WHERE ARE WE NOW?
6.
Without a step change in investment most countries will fail to realise thehealth-related MDGs. Yet progress is possible in even the poorest countries.
Bangladesh made major reductions in child mortality in the 1990s and halved fertility
rates from 6.6 to 3.2 children. In the second half of the twentieth century, Sri Lanka
reduced its maternal mortality ratio from 555 to 24 per 100,000 live births5 – similar
reductions have been seen in Thailand, Malaysia, Tamil Nadu and Kerala. A
common factor was the priority successive governments gave to effective public
expenditure on social services. Significant child survival gains have been mademore recently in Tanzania and Mozambique.6
7.
Several recent publications5,7,8,9 have highlighted the differential progress
across countries and regions, and the challenges faced in attaining the MDGs. Halfof the goals are directly health-related and better health will impact upon all the
MDGs. The Millennium Project Review (2005) indicates that Africa is not on track toachieve any MDG and is the only region where child malnutrition is not declining. In
other regions there is progress but with widening gaps in health outcomes between
the richest and poorest populations. Table 1 illustrates progress in the most ‘offtrack’ regions – sub-Saharan Africa and Southern Asia.

4

Table 1: Progress towards the MDG targets in sub-Saharan Africa and Southern Asia
MDG Goals and Targets

Sub-SaharanAfricaGoal 1 Eradicate extreme poverty and hunger
Reduce extreme poverty by halfHigh – no changeSouthern Asia

Reduce hunger by half

Progress but
lagging

Very high – littlechangeGoal 2 – Achieve universal primary education
Universal primary schooling
Progress but
lagging
Goal 3 – promote gender equality and empower womenGirls’ equal enrolment in primary school
Progress but
lagging
Girls’ equal enrolment in secondary
No significant
changeschoolLiteracy parity between young women
Lagging
and men
Women’s equal representation in national
Progress but
lagging
parliaments
Goal 4 Reduce child mortality
Reduce mortality of under-five year olds
Very high – nochangeby two-thirds
Measles immunisation
Low, no change
Goal 5 Improve maternal health
Reduce maternal mortality by threeVery highquarters
Goal 6 Combat HIV/AIDS, malaria and other diseases
Halt and reverse spread of HIV/AIDS
StableHalt and reverse spread of malaria
Halt and reverse spread of TB
Goal 7 Ensure environmental sustainability
Reverse loss of forests
Halve proportion without improved
drinking water in urban areas
Halve proportion without improved
drinking water in rural areas
Halve proportion without sanitation in
urban areas
Halve proportion without sanitation inrural areas
Improve the lives of slum dwellers

On track

Progress but
lagging
Progress but
lagging
Progress but
lagging
No significant
changeVery low some
progress
Progress but
lagging
Progress but
lagging
Very high level

Increase

High

Moderate risl

High, increasing

High, declining

Declining

Small decline

No change

Met

Progress but
lagging
Low access, nochangeNo change

On track
On track

Rising numbers

Progress but
lagging
Some progress

Goal 8 A global partnership for development
Youth unemployment
High, no change

Low, increasing

No or negative change
Progress, but too slow
Met or on track
Source: Adapted from the UN Millennium Project Progress Report, 2005.

8.
The prospects are gravest in health and the statistics are stark. Each year
almost 11 million children die before their fifth birthday and more than 500,000
women die as a result of pregnancy or childbirth. AIDS causes more than 3 million
deaths and 2 million people die of tuberculosis (TB); both often kill adults in theirmost productive years. Malaria causes almost 1 million deaths, mainly of children. A
woman in a low-income country is over 100 times more likely to die in pregnancy
and childbirth than a woman in a developed country. Beyond the numbers lies thelong-lasting impact on individuals, families and society.
9.
AIDS has halted or reversed progress in many countries, particularly in Africa,
and the loss of skilled staff threatens the effectiveness of public services and private
5enterprise. In many southern African countries, gains in life expectancy are being
reversed by AIDS. Asia and Europe face mounting epidemics, and large countries
such as India and China are already adding millions more cases to the global
burden. Less than one person in five at risk has access to basic HIV prevention
services10 and, globally, funding for HIV prevention has declined despite substantial
increases in AIDS spending.
10.
Improving sexual and reproductive health is essential to human development
and attaining the MDGs. It will save and improve lives, slow the spread of HIV and
AIDS, encourage gender equality, help stabilise population growth and reducepoverty. Yet there is a severe shortage of vital reproductive health services andcommodities in many countries and millions are unable to avoid unwanted
pregnancy and sexually transmitted diseases including HIV.11 UNFPA estimates thatover 60% of couples in sub-Saharan Africa are unable to achieve their childbearing
intentions.
11.
Aggregate regional and national measures mask the lack of progress among
the poorest countries and among the most excluded groups in society who arealmost always worst off.12
Box 1: Social exclusion and the MDGs
•

•
•
•
•

In India, it is estimated that discrimination against girls increases the total rateof child mortality by 20%. Caste exacerbates this – low-caste Dalits haveinfant mortality rates of 83 against 61 for the general population and childmortality rates of 39 against 22.
In China 37% of the known HIV cases belong to ethnic minorities whoconstitute 8-9% of the population.
The gap between male and female malnutrition in Bangladesh has risen from
19% to 26% in recent years (1996-99).
The Dalit population of Nepal has a life expectancy almost 20 years less than
the national average.
In sub-Saharan Africa, wealthier women have five times more access tocontraception than poorer women.

12.
Health status is determined by many factors13 and will not be improved by a‘single-sector’ approach nor through economic growth alone. Improvements in basic
living conditions – nutrition, sanitation, and water – have a major impact on childmortality.5 Women’s literacy is strongly correlated with child mortality. Reliablecommunication and effective transport systems can impact on health – in Sierra
Leone it increased the number of women with major complications in childbirthreaching hospital and contributed to a 10% reduction in death rates.14 Advances inwomen’s equality and empowerment lead to them having an increased ability tomake more informed and effective health choices.
13.
For most countries, however, the combined efforts of economic growth,education and access to safe water will be insufficient to make the difference
between meeting and missing the health MDG targets.5 Much of the current burdenof disease in developing countries is caused by relatively few conditions that can beprevented or managed with existing affordable interventions (such as antibiotics forrespiratory infections, vaccinations and skilled attendance at birth) capable of being

6

delivered through health services in a low-income setting. The challenge is tomassively increase use of these interventions, especially by the poor. Reachingalmost universal (99%) coverage with these interventions could reduce under-five
deaths by almost two-thirds and maternal deaths by three-quarters.5
14.
Meeting the health MDGs requires an effective and equitable health systemthat can provide universal access to basic health interventions.13 Some low-income
countries are making real progress in expanding access to services. 85% ofpregnant women in Mozambique now receive antenatal care and 77% of children
are immunised against measles. Efforts to ensure high coverage with basic
preventive health services in remote areas have contributed to the reduction inunder-five mortality from 226 per 1000 live births in 1990 to 170 in 2003.
15.
Globally, however, the use of child health interventions is below 50%5 andhealth services in many developing countries remain unavailable to those in mostneed or are available only at low quality or high cost. Global and regional data hide
major differentials in access to services by different income groups. Fig 1 illustrates
the differences in access to immunisation and attended delivery across 21 subSaharan countries.
Figure 1: Access to health services by socio-economic group
Access to Essential Health Services by Socio Economic Group
population weighted average 21 sub Saharan African countries: Source DHA various years

90
80

All Immunisations
Attended Delivery

70
% 60
co
ve 50
ra
ge 40
30
20
10
0

Poorest20%

Second20%

Middle20%

Fourth20%

7Richest20%

AverageB. WHAT ARE THE CHALLENGES?
16.
A range of constraints – financial, institutional, political,15 social and systemic– contribute to poor-quality health services, that do not prioritise the most criticalinterventions or serve the poor and excluded. Countries consistently identify anumber of key barriers to improving the performance of their health systems. These
include finance, severe shortages of trained staff, limited access to essential
medicines, the performance of the non-state sector, and the difficulties of managing
a complex and geographically dispersed service. Weak monitoring and information
systems and the large number of donors involved in health also pose particularchallenges.
Challenge 1 – Balancing targeted approaches and health systemstrengthening
17.
The global health architecture is complex and fragmented. Recent years
have seen the rise of disease or issue-focused programmes (AIDS, TB, malaria,
and childhood immunisation). These programmes have raised the profile of specifichealth issues, mobilised significant additional resources and delivered results
against their specific targets. However, while they rely on a strong health system todeliver sustainable benefits they may perversely contribute to the undermining ofbroader heath service delivery through duplication of effort, distortion of national
health plans and budgets and particularly through diversion of scarce trained staff.
Yet they can complement country efforts and are adapting their operations to better
integrate with local planning cycles. There is a need to find the right combination of
investment in efforts to address both priority health problems and system-wide
problems. Without increased attention to strengthening health systems we cannot
make sustainable improvements in the health of individuals and populations.
Box 2: Expanding services to deliver a package of HIV prevention, treatment andcareWith the aim of an AIDS-free generation in Africa, the G8 has committed to: ‘significantly
reducing HIV infections and working with WHO/UNAIDS and other international bodies todevelop and implement a package for HIV prevention, treatment and care, with the aim ofas close as possible to universal access to treatment for all those who need it by 2010.’
Lack of resources has limited many nations’ ability to bring comprehensive AIDS
programmes to scale, and stem the tide of the epidemic. It is estimated that HIV
prevention programmes reach fewer than one in five of those who need them and that only
16% of those in need are receiving treatment. However, since the launch of the ‘3 by 5’
initiative, major advances have been made in every region in increasing access to AIDS
treatment. Sub-Saharan Africa and Asia have tripled numbers since mid-2004. Fourteen
low and middle-income countries have met the target of delivering treatment to half thenumber of those in need. Further success will depend upon a combination of political,
technical and financial support, invested in ways that strengthen overall capacity to deliver
essential health services, and making stronger links between treatment and prevention.

Challenge 2 – Universal access to health services will need massive increasesof resources that are spent more effectively and equitably
18.
Current levels of health spending in most low-income countries fall far shortof the minimum to deliver universal access to services. In sub-Saharan Africa public8

spending on health averaged 2.7% of GDP in 2002 (range <1% to >5%7) with total
health spending around 6.8% of GDP. In Abuja in 2000 African governments
committed to increase funding for health from an average of 8% to 15% of theirbudgets. However, most are far from reaching this target and in many countries
health spending appears to be below what is affordable. Countries can be supported
to mobilise additional domestic resources for health but additional external
resources are needed to help close the gap.5,7
19. While the relationship between public health spending and outputs andoutcomes is complex,16 there is evidence that increased public spending does resultin improved outcomes if well-targeted. Child mortality improves when healthspending is focused on the poor, while the impact of public health spending
increases in countries with good governance.5
20.
The Commission on Macroeconomics and Health report1 provides estimatesof the costs of expanding the supply of health services in low-income countries. It
calculated the additional costs of providing a ‘package’ of services that deal with themain causes of ill health and death at US$30 to US$40 per person each year. This
would require an additional $40-$52 billion annually by 2015 but would save 8
million lives each year. Recent exercises have also estimated the cost of meeting
individual global health goals or targets –TB (US$37 billion over the next 10 years),malaria ($2.9 billion each year), 17 AIDS ($15 billion in 2006, rising to $22 billion in
200818 – although these costs do incorporate broader health system costs). The
Global Fund to fight AIDS, TB and Malaria (GFATM) estimates a financing need of
US$7.1 billion over two years;19 maternal and newborn health ($39 billion between
2006 and 20153) and reproductive health (UNFPA estimate $1.5 billion up to 2015
needed for family planning, and an additional $300 million per year for reproductive
health supplies in sub-Saharan Africa).
21. Fig 2 illustrates the total health spend (public and private) across a range of
DFID partner countries. The message is clear – health spending needs to be of adifferent order of magnitude.13 Recent changes in the technologies and treatment
available for malaria and expanding provision of AIDS treatment will increase thecosts even further. Spend falls far short of the CMH estimates22.
Low-income countries have historically planned and budgeted based on
resources available rather than need. Where countries have made ambitious plans,
these have been scaled back due to lack of funds. In 2002 Uganda costed apackage of services at $28 per capita against the available $8.4.6,1 Estimates of thecost of achieving universal access can only be done credibly at the country level. To
date, donors have not supported the development of ambitious plans – countries
have understandably planned based on available resources not on need.

1

This figure in Uganda was consistent with WHO’s Commission for Macroeconomics and Health but may now be anunderestimate given recent changes in policy to scale up the supply of anti-retroviral treatment (ART) for HIV and artemisininbased combination therapy (ACT) for malaria.

9Figure 2: Per capita expenditure on health by source
Per Capita Expenditure on Health in 2001 by Source
Source: WHO excludes South Africa public = $92, private = $130
60

PrivatePublicCommission for Macroeconomics and
Health $35 Essential Package

World Bank $12
Basic Package

50$ per head, 2001

40

30

20

10

Africa excl South
AfricaAfrica PSA Countries

Asia PSA Countries

All PSA Countries

Zimbabwe

ZambiaTanzania

UgandaSudan

Sierra Leone

RwandaNigeria

Mozambique

MalawiLesotho

Kenya

Ghana

Ethiopia

DR Congo

Viet Nam

Pakistan

Nepal

Indonesia

India

China

Cambodia

Bangladesh

23.
New resources offer the potential to build more equitable, inclusive healthsystems and expand access to services – a prerequisite for achieving the MDGs .13
There is also potential for greater efficiency and equity of health spend. To date,public subsidies for health have often disproportionately benefited wealthierpeople,20, 21 as illustrated by Fig 3 below.
24.
Uganda increased total funding for health by only 19% (from $7 to $8.4 percapita) but with improvements in allocation (more needs-based, targeted to thepoorest districts),22 in making financing fair (official user fees for health were
removed) and in aid delivery (more budget support, fewer projects, sector-wide
approach). Drug budgets doubled, outpatient attendance rose by 117% andimmunisation coverage by 102%.23 Spending targeted at specific groups can lead togreater returns – in terms of reductions in under-five mortality – than extra spending
across –the board5 but both approaches can improve equity.24
Figure 3

share of benefit incidence

Benefit incidence of health public spending inselected countries
Poorest Quintile
Richest Quintile

C

ot

e

D

'Iv
o
G ir eha
G nauin
M K eaad e
ag nyaT a ascnz a rS aniaIn Afrdo ican
Vi esi
et a
na
m

60
50
40
30
20
10
0

Source: WHO25

10

Challenge 3 – Responding to the health-staffing crisis
25.
Adequate numbers of well-trained, motivated and supported health workers
are essential for effective service delivery. Many countries face a deep crisis instaffing their health service. Africa has led the call for an urgent international
response. These shortages are the result of chronic under-investment in staff andhealth systems and exacerbated by the additional burden of AIDS and outward
migration.26,27
26.
Many low-income countries, particularly in sub-Saharan Africa, struggle toprovide even basic health services. Many have less than one health worker per1000 population with many workers concentrated in urban areas or in the private
sector, further limiting access by the poorest. A minimum health worker density ofaround 1.5 per 1000 people is associated with achieving 80% coverage for measles
immunisation, and 2.5 with 80% for coverage of births with skilled attendance.28
Box 3: The human resource crisis in
the Malawi health sector
Since the late 1990s Malawi has experienced aserious exodus of health workers fromgovernment employment. This is largely due tothe inability of the government to raise the realvalue of the salary of health professionals andweaknesses in the health system, which mean
working conditions are extremely poor. (Salarycosts are typically 30-40% of the Ministry of
Health’s budget compared with 60-70% on
average in other African countries.)
Many staff have left to work either abroad ordomestically, in the private sector or in the
rapidly growing donor-funded NGO sector.
AIDS is a growing problem, contributing
indirectly and directly. In 1990 eight Ministry of
Health workers died; in 2000 this figure
reached 200 – AIDS is thought to be a key
factor in this increase
Combined, these factors have led to a
population-to-doctor ratio of 106,397:1 in 2004,
almost 12 times the recommended ratio of
9,000:1. Vacancies among nursing cadres areover 60%. Ten of Malawi’s 29 districts have nogovernment doctor; four districts have nodoctor at all. Vacancy rates are significantly
higher in rural areas.

27.
The Joint Learning Initiative2
estimated that sub-Saharan Africa willneed an additional 1 million health workers
between now and 2015 to rise from one
health worker per 1000 people to aminimum target of 2.5 per 1000. The global
need is for an additional 4 million healthworkers. Human resources in health is along neglected area and support is urgently
needed to develop and implement
comprehensive country strategies that
address: recruitment and training, skill
mix,29 retention of workers,30 performance
management and productivity,31
distribution32 and planning.
28.
Between 30% and 50%, or about $4
billion of current development assistancefor health, funds human resources. Most isinvested in fragmented, short-term
technical assistance and training inputs
that are rarely linked to an overall humanresource strategy. There is great scope formore effective and coordinatedinterventions.

29.
Low-income countries are currently subsidising high-income ones bysupplying them with highly trained staff. The African Union has estimated a net
outflow of about $500 million a year. Changes to international recruitment practice
may help to manage the flow of migrants but migration is a symptom of a deeper
malaise – planning failures, the inability to pay fairly, lack of career prospects andpoor working conditions in ‘source’ countries, and poor planning and low investment
in workforce self sustainability in ‘destination’ countries.
2

Joint Learning Initiative -a programme on Human Resources for Health involving more than 150 global health leaders11Box 4: What will it cost?
The Commission for Africa estimated that an initial $0.5 billion can be spent on
training and retention of health workers in Africa in 2006, but as training andhealth system capacity are built up, this amount could increase by $1 billion eachyear, rising to about $6 billion by 2011. The WHO’s early estimates suggest thatan additional 1 million health workers could be trained for between $0.6 billion
and $1.6 billion, based on the current skill mix and depending on how wellattrition rates can be driven down. This includes the costs for building andresourcing educational facilities.1 Retention of existing health workers makes up
the bulk of the additional financing required. Specific costs include improvements
to salaries and other conditions, as well as opportunities for career development.

30.
Increasing the supply of health workers will only impact on health outcomesin an environment where the health system functions effectively. A critical element isreliable access to safe, appropriate, affordable and high-quality medicines. WHO
estimates that one in three people living in developing countries do not have regularaccess to essential medicines.
Challenge 4 – Harnessing the contribution of non-state service providers
31.
In many settings governments are not the main providers of health services.
In India 80% of out-patient treatments are delivered through the private sector.9
Using a range of non-state providers (private sector, non-government, community
organisations) offers the potential for rapid expansion in access to health services.
Non-state providers may be more successful than the state at providing efficientclient-orientated, responsive services,33 but an unregulated private sector may also
provide poor-quality services. Increased resources provide an opportunity forpartnerships between the state and non-state providers through successful
approaches such as social marketing, franchising and contracting (in Cambodia
contracting has helped to increase the coverage of some key services in a short
time9). The government’s stewardship role needs to be strengthened to provide
oversight and regulation of non-state providers.
32.
To achieve universal access, whether through state or non-state providers,requires the removal of barriers to use of services including financial barriers – asignificant proportion of current health expenditure in low-income countries is private(Fig 3). In Nigeria, 70% of total health expenditure is ‘out-of-pocket’.34 Out-of-pocket
expenditure is an inefficient and inequitable way of financing health care;35 it
restricts access and denies basic care to the poor.36 Some countries are therefore
choosing to shift from reliance on out-of-pocket payment towards a greater elementof risk pooling, based on tax or social insurance. Removal of user fees in Uganda37
led to dramatic increases in service use. However, in low-income countries,
irrespective of whether there are official user fees, there are other fees and charges
incurred by patients that serve as significant barriers to access to basic healthservices. The removal of official user fees should be part of broad-based efforts tofund and deliver quality, equitable healthcare for all.
Challenge 5 – Increasing demand and accountability
33.
Increased supply of health services needs to be matched by investments indemand by poor people and in strengthening the ways that institutions and service
providers can be held to account. Transparent, participative processes for budget
12

allocation and the design of frameworks to tackle discrimination can go a long way
in building systems of accountability.
34.
Giving communities a greater voice in service planning, management,
monitoring budgets and ensuring service quality and responsiveness increases
accountability. Such approaches should aim to reduce direct and indirect costs,
increase information, reduce household and cultural constraints to access, andpromote greater health awareness and use of available health and education
services.38
35.
Appropriate information and communication strategies can increase poor
people’s knowledge of their entitlements to health, including access to exemptions,39
tackle cultural and gender constraints, and increase knowledge of specific healthand behaviour change issues to enable them to make informed decisions. There aremany examples of successful mass media and community-based communication
strategies in health, such as radio dramas to promote family planning in Nepal.40
36.
Greater community participation and information sharing needs to bematched by strengthened public institutions at all levels to make them moreaccountable and responsive. This includes parliamentary oversight, and politicalprocesses that enable people to make demands on, and hold government toaccount, including supporting and encouraging tax raising, the establishment of afree and informed media and the publication of information on budgets.
37.
Social transfers and demand-side financing can boost demand and use ofservices, particularly when combined with actions to improve quality of services.
Programmes targeted at excluded groups who face systematic barriers to accessing
services may be required. In Latin America, conditional cash transfer programmes
increased use of preventive health services and improved nutrition.41 Transfers thatare not tied to service use, such as pensions in South Africa, have also improved
the health status of the older person as well as other family members when thehousehold pooled income.42 Voucher schemes have been successful in increasinguse of particular health services (treatments for sexually transmitted infections,skilled care at delivery, TB treatment), and have potential for expansion.36
Challenge 6 – Strengthening governance38.
The health MDGs will not be achieved by pouring money into poorly
performing systems with weak institutional environments. Much poor performance inhealth reflects weaknesses in institutions, budgeting and public expenditure
management and public spending on health is more effective where there are strong
governance and effective institutions.5 The 2005 Commission for Africa reportconcluded that without progress in improving governance, all other reforms would
have limited impact.8
39.
Better service delivery will require greater attention to public financial
management and accountability (maintaining fiscal discipline, ensuring resources
are allocated and spent in line with stated priorities and not lost through corruption
or mismanagement, and used to achieve maximum impact on health outcomes).43
Making information more accessible and promoting transparency in fees, budgets
and expenditure will promote an environment where corruption can be tackled more13effectively. Better-managed services that deliver and make a real difference to thelives of poor people9 can win and retain public support for wider reform efforts.
40.
Where low-income countries have made major progress in improving healthoutcomes, political commitment was a common feature. Governments are more
likely to prioritise health when it becomes an issue that wins or loses elections.
Challenge 7 – Investing in better health in fragile states
41.
One-third of maternal deaths and nearly half of under-five deaths occur infragile states,44 those least likely to achieve the health MDGs. While such states
tend to receive little aid, donors face particular challenges in engagement. Improving
health is a particular challenge and an imperative. Improving service delivery in suchsettings can act as a catalyst to restore confidence in government.13 Where it isdifficult to work directly through governments there may be other channels, such asa UN oversight body, an umbrella fund or a variety of non-state providers (NGOs,
faith-based organisations, for-profit companies and community-based providers).
42.
One-third of GFATM resources have gone to fragile states with evidence ofgood performance. Any mechanism will need to be complemented by thedevelopment of the role of the state and its capacity to oversee and regulate service
provision. States emerging from a period of fragility often have extremely weak
institutional environments and it may be a long time before these countries will beable to put in place accountable institutions capable of delivering public services.45
Such environments need creative approaches and collaborations to provide
services and a balance between the short-term imperative to improve health service
delivery and the longer-term aim of the development of an effective state. Many lowincome countries (and particularly those emerging from a period of fragility) haveextremely weak institutional environments. It is likely to be a long time before thesecountries will be able to put in place effective systems.
Challenge 8 – Building effective health information systems
43.
Many policy-makers do not have access to basic information on births,
deaths and disease. Only 2% of countries in WHO’s Africa and South-east Asia
regions have complete death registration data and national vital registrationworldwide covers less than one-third of the world’s estimated mortality.46 Without
such data policy-makers and managers risk making bad decisions based on bad
information. There is an urgent need for better data systems to guide results-based
performance monitoring, better disaggregation to allow analysis of equity anddistributional issues, and better capture of quality measures.6 Health informationneeds to be linked to poverty monitoring systems.
Challenge 9 – Research into the health problems of low-income countries
44.
Only 10% of the annual $70 billion spent on global health research targets
the diseases responsible for 90% of the world’s health problems.47 The CMH
estimated research funding needs to be $1.5 billion annually (and a further$1.5 billion for co-ordinating and building country capacity for health research).
Global advocacy has increased investment from $200 million in the 1990s to over
$1 billion in 2004. However, there remains a significant gap. A recent review found14

that, despite new commitments, the financing shortfall to the end of 2007 for themost urgently needed products amounts to over $ 2 billion.1

15

C. MAKING AID MORE EFFECTIVE
45.
The scaled-up development assistance implied by the 2005 G8 commitment
will amount to an additional 10-20% of GNI for many African countries. If usedeffectively, this increase could lead to a massive expansion, and near universal
access to essential health services. Achieving this will, however, require donors andgovernments to make fundamental changes in their operations.
46.
Increased development assistance for health should support country-definedpriorities and strategies linked to sector planning and budgeting processes within
the context of the overall national development plan.
47.
The G8 commitments will likely be channelled through a range of aid
instruments. Wherever possible, additional resources should be channelled throughflexible programmatic instruments (poverty reduction budget support, sector budget
support). While there are risks associated with this approach that need to becarefully managed, the advantages include:• It builds on commitments made in Paris in 2005 to scale up assistance inways which strengthen partner countries’ national development strategies,
ensures aid is aligned with countries’ priorities and enhances government
accountability to citizens for development policies and performance.
• The additional public spending needed to scale up service delivery will belargely for recurrent costs, especially human resources.
• It will allow for management of potential undesirable macroeconomic effects
of higher aid volumes.
• It allows a broad-based approach to tackling the MDGs (such as the need forincreased capacity in the education sector to train more health workers).
48.
Development assistance for health from all external sources rose from $6.4
billion in 1997-99 to about $8.1 billion in 2002. This period also saw a proliferation of
global programmes and funds aimed at increasing awareness and funding against
major diseases. The major resource transfer funds, including the Global Fund , theGlobal Alliance for Vaccines and Immunisation (GAVI), the US President’s
Emergency Plan for AIDS Relief (PEPFAR), together disburse over $5 billion per
year. In addition, there are more than 80 other global health initiatives andpartnerships – much smaller in financial terms, mainly with a focus on advocacy andresearch.48 Individually, these programmes have had a major impact yet there is aconcern that their cumulative impact may undermine sector planning and financing5
and distort sector priorities.13 Collectively GHIPs impose transaction costs on
governments, and may undermine national ownership and planning processes.
49.
GHIPs will continue to play an extremely important role in developing
countries – GFATM provides a substantial proportion of external assistance for
AIDS (20%), TB (66%) and malaria (45%). But priorities for increased spending
should be to strengthen health sector systems, with an emphasis on recurrent costs
as well as investment needs. Currently less than 20% of donor disbursement isprovided as budget support and less than half is available for public expenditure.
The majority of development assistance continues to be committed through projects
and parallel arrangements that are often imperfectly coordinated with government
strategy. Governments are understandably reluctant to take politically irreversible

16

actions that have long-term costs, such as hiring additional staff, increasing wages
to retain staff, or committing to lifelong AIDS treatment, if long-term, predictablefinance is not forthcoming.
50.
Development assistance is a notoriously undependable source of publicfinance in poor countries,49 across all sectors. As the graphs illustrate, donor
commitments for health can vary tremendously from year to year.
Figure 4: Donor commitments for health as % of total health expenditures
60.00

90.00
80.00

50.00

70.00

40.00

60.00

Guinea

Mauritania

50.00

Tanzania

40.00

Benin

30.00

Burundi

Mali

30.00

20.00

Liberia

20.00

10.00

10.00
0.00

0.00
1997

1998

1999

2000

2001

1997

1998

1999

2000

2001

Source: WDI and OECD DAC donor funding database. World Bank staff estimates.

51.
Bilateral aid commitments are relatively short-term (onetotwo years) anddisbursements can diverge substantially. On average, less than 60% of the aid‘committed’ actually makes it to programmes and there is evidence that donors’
track record has deteriorated in the past five to 10 years.49
52.
Past precedent gives countries every reason to mistrust the reliability or
permanence of donor promises. Further work is urgently needed to design
mechanisms that provide greater assurance of sustained long-term financial
support5 and increase the credibility of long-term commitments. Reducing thevolatility of aid flows will become even more crucial where increased development
assistance further increases aid dependency.
53.
Increased flows of development assistance will present a number ofmacroeconomic challenges that need to be managed yet evidence suggests that‘aid inflows that are reasonably predictable and persistent are neither intrinsicallyinflationary nor do they necessarily generate macroeconomic instability’.50
54.
Increasing aid dependency over a longer period also brings additional
governance challenges. Historically, the need for governments to be responsive totaxpayer concerns has been critical in the development of improved governance.
There is a risk that significantly increasing external funds inhibits the development ofpolitical legitimacy through the ‘fiscal social contract’ between a government and its
population.45 If aid dependency is not to become a constraint to development in
itself, it must be balanced with measures to protect sovereignty, maintain thelegitimacy of political leadership and the processes that broker power and to support
the accountability of a state to its citizens.9 Country-led processes and reducing
conditionality will be central elements in achieving this balance.

17

55.
Even small volumes of aid for small countries flow through hundreds ofparallel bilateral, multilateral and global programme channels, each with its own
negotiation, reporting, and administrative requirements. These development
assistance transaction costs must be lowered. Mozambique has more than 100
development partners in health and Vietnam received approximately 400 separate
donor missions in 2003, of which just 2% were undertaken jointly. Low-income
countries are often forced to allocate limited human resources away from managing
service delivery to managing donors.7 Real and urgent progress is needed on donor
harmonisation.

18

D. PLAN OF ACTION
56.
An additional $20-25 billion donor assistance for health could permit a
massive expansion in access and increase in quality, equity and responsiveness ofservices. Early up-front investment is needed and can be made – in training,
infrastructure, policy reform, drugs and procurement processes – and will provide
the basic building blocks of a more effective health system.
57.
However, the funding gap for health is greater than $20-25 billion. UNAIDS
estimate that the AIDS resource gap for sub-Saharan Africa is in the region of $18
billion in 2006 $13.3 billion for health and an additional $4.3 billion for AIDS
services). This would achieve 50% coverage of anti-retroviral treatment (ART). To
achieve universal coverage for AIDS services in 2010 would require US$10 billion ayear just for AIDS-specific services in addition to resources to fund the healthsystem.
58.
Costing an expansion of access to health services can only be done crediblyat the country level, linked to national priorities and comprehensive sector andbroader development strategies. To date, countries have been encouraged andhave understandably chosen to develop health sector plans based on available
resources rather than need. Therefore accurate country-by-country estimates of
how much it will cost to achieve universal access to health services are not readily
available.
59.
To date, the most comprehensive work to estimate the cost of expanding a‘package’ of services (i.e. not just for one disease or intervention) in developing
countries has been undertaken by the WHO Commission on Macroeconomics and
Health3. The CMH estimated the additional funding needed to scale up to specifictargets of coverage for 49 essential, cost effective interventions in 83 developing
countries (countries with GNP (2002) of under $1200 and all sub-Saharan Africa).
Annex one provides more detail on these estimates of additional resources required.
60.
The CMH estimated that increasing donor assistance for health by $22billion
in 2007 and $31billion in 2015, together with increased domestic funding for healthwould bring impressive benefits by 2015:• a 65% reduction in maternal deaths;• 2-5 million fewer childhood deaths each year;• 2 million fewer TB deaths each year;• halving malaria deaths from the current million annually and• 100 million fewer HIV infections each year.
61.
Based on the work of the CMH, it is estimated that investing an additional$25 billion by 2010 in the expansion of health services across low-income countries
could make a very significant impact on health outputs and outcomes, including
ensuring that each year:• More than 14 million more women receive antenatal care;3

It should be noted that whilst these are the best estimates available on expanding the coverage of a
package of services, they do not include all interventions that respond to a particular country’s
priorities e.g. they do not include all resource needs for Sexual and Reproductive Health.

19

•
•
•
•

62.

more than 33 million additional births are attended by skilled healthcare
providers (a key strategy to reduce maternal deaths);
over 130 million more children are treated for acute respiratory infections –one of the leading killers of under-fives in developing countries;
over a million more cases of TB are diagnosed and treated; andcoverage rates for measles immunisation for measles and other childhood
immunisations could reach 73% and 81% respectively.
To turn commitment to actions and support countries in expanding accessto health services will require:•

An increase in overall aid for health in low-income countries of at least$20 billion a year by 2010, with priority given to supporting efforts tostrengthen health systems.
• Donors must urgently turn commitments into information on forward
projections of finance at the country level. A first step will be a meeting
planned alongside the World Bank Annual Meetings in September
2005 where donors will discuss aid flows and the financing challenges
surrounding scaling up.
• The additional financing would be provided through a variety ofchannels and wherever possible through increasing the proportion of
resources channelled through budgets. This will allow for a more
flexible use of resources better aligned to national plans andprocesses.

•

Support to governments to develop ambitious plans once financing
commitments are clear.
• Countries cannot be expected to invest in developing ambitious sector
or development plans until they are confident and clear how and when
additional resources will come, and for how long they will last.
• Technical agencies such as the IMF, World Bank and WHO have amajor role to play but need to provide consistent advice on issues
such as the macroeconomic effects of increasing external financing.

•

Donors to make real progress in implementing the Paris commitmentson aid effectiveness and recommendations of the Global Task Team on
AIDS, including efforts to make GHIPs more effective.

•

Donors to commit to developing and piloting mechanisms to increase
the predictability of development assistance for the expansion ofaccess to services. The High Level Forum on Health will address thisissue in November 2005.

•

Partner countries to meet their commitments to increase funding to thesocial sectors.
• The exact level will of course depend on national priorities and local
economic conditions, but African countries’ commitment to allocate
15% of their budget to health needs to be realised.

20•Partner countries can also use the opportunity of additional long-term
financing for health to improve the performance and equity of theirhealth systems and services.

63.
A process of mutual confidence building is now needed to facilitate thedevelopment and launch of scaled-up spending plans supported by flexible aid
instruments. Some countries are ready and able to use increased development
assistance now. Likely early responders often have a history of sector-wide working
within a poverty reduction strategy and have taken steps to strengthen governanceand financial management, but more fragile states should not be left behind. It will
be important to deliver an effective international response in 2005–2006 to
demonstrate to other countries the seriousness of the donor commitment toincrease the quantity and quality of development assistance.

21

References
1

Commission on Macroeconmics and Health, (2001), Macroeconomics and Health:investing in health for economic development. WHO.
2
OECD, (2003), Poverty and Health. DAC Guidelines and Reference Series. WHO
3
Freedman L., et al, (2005), Who’s got the power? Transforming health systems for womenand children, United Nations Millennium Project Task Force on Child Health and Maternal
Health.
4Matthew Greenslade research, unpublished, DFID.
5
Wagstaff A. and Claeson M., (2004), Rising to the Challenges: the Millennium
Development Goals for Health. World Bank
6
DFID, (2005), Review of Health and Education Progress in Selected African Countries.
Synthesis Report. Africa Policy Dept.
7World Bank, (2005), Global Monitoring Report. MDGs From Consensus to Momentum.
Washington DC; World Bank.
8
Commission for Africa, (2005), Our Common Interest: Report of the Commission for Africa.
London.
9World Development Report, (2004), Making Services Work for Poor People. World Bank.
10
UNAIDS, (2005), Intensifying HIV prevention, Policy Position Paper adopted by the
UNAIDS PCB 29 June.
11
DFID, (2004), Sexual and Reproductive Health and Rights Position Paper.
12
DFID, (2005), Reducing Poverty by Tackling Social Exclusion. DFID Policy Paper.
13WHO, (2005), Health and Millennium Development Goals. Geneva.
14
Samai O., and Sengeh P., (1997), Facilitating emergency obstetric care throughtransportation and communication, Bo, Sierra Leone, Bo PMM Team, International Journalof Gynaecology and Obstetrics 59 (Supply. 2): S157-S164.
15
See DFID resources on drivers of change at www.grcexchange.org/g_themes/politicalsystems_drivers.html
16. Levine and Blumer, (2004), Gaps and Missing Links: What do we need to know about
resource flows in global health? Centre for Global Development
17
Roll Back Malaria and Stop TB Depts, (2005). WHO.
18
UNAIDS, (2005), Resource Needs for an expanded response to AIDS in low and middle
income countries. Presented at the PCB. June 2005.
19
Addressing HIV/AIDS, Tuberculosis and Malaria: The Resource Needs of the Global
Fund 2005-2007'
20
Castro-Leal F. et al, (2000), Public spending on health care in Africa: do the poor benefit?
Bulletin of the World Health Organisation 78: 66-74
21
EQUITAP Project, (2005), Who benefits from public health spending on health care in
Asia? Working Paper no. 3.
22Diderichsen F., Sept 2004, Resource Allocation for Health Equity: issues and methods.
World Bank HNP Discussion Paper.
23
Yates, R., (2004), Review of Progress in the Uganda Health Service. DFID
24
Victora C. et al., (2003), Applying an equity lens to child health and mortality: more of thesame is not enough. The Lancet, vol 362: 233-241.
25
Castro-Leal F, Dayton J, Demery L, Mehra K, (2000), Public spending on health care in
Africa: do the poor benefit? WHO Bulletin 78(1) 66-74
26
Buchan and Dovlo, (2004), International recruitment of health workers to the U.K., DFID.
27
Martineau and Dovlo, (2004), International Recruitment of Health workers – background
paper for JLI report.
28
Joint Learning Initiative, (2004), Human Resources for Health: Overcoming the Crisis.

22

29

Buchan and Dal Poz, (2002), Skill mix in the health care workforce: reviewing theevidence. WHO Bulletin.
30
Tawfik et al. (2001), Impact of HIV AND AIDS on the health sector in Sub-Saharan Africa:
the issue of human resources.
31
Buchan,J., (2005), Scaling up health and education workers: increasing the
responsiveness and productivity of an existing stock of health workers. DFID Healthsystems resource centre
32
Hammer and Jack (2001), Overcoming the challenges faced in rural locations that act as
disincentives for rural health care providers. World Bank.
33
Reinikka and Svensson. Working for God ? Policy research working paper 3058
34
Federal Government of Nigeria. (2004). National Health policy.
35
Pearson, M., (2004), Issues Paper: The Case for Abolition of User Fees for Primary
Health Services. DFID Health Systems Resource Centre.
36
Pearson, M. (2004), Demand side financing for health care. DFID Health Systems
Resource Centre
37
Nabyonga J et al., Abolition of cost-sharing is pro-poor: evidence from Uganda. Health
Policy and Planning 20(2): 100-108
38
Ensor T. and Cooper S, (2004), Overcoming barriers to health service access: influencing
the demand side. Health Policy and Planning 19(2): 69-79
39
See case of Ghana in DFID, (2005), How to reduce maternal deaths: rights andresponsibilities. DFID Policy Division.
40
Heerey M., and Kols M, (2003), cited in Wagstaff and Claeson, 2004 (ibid).
41
Rawlings L., (2004), A new approach to social assistance: Latin America’s experience
with conditional cash transfer programs. Social Protection Discussion Paper Series No
0416. World Bank
42
Case A., Does money protect health status? Cited in Gorman, (2004), Age and Security:
how social pensions can deliver effective aid to poor older people and their families.
HelpAge International.
43
http://www.grc-exchange.org/g_themes/pfma.html
44
DFID, (2004), Why we need to work more effectively in Fragile states. DfiD policy paper
45
Moore, M., (2005), Centre for the future state, DfID sponsored research team.
46
Stumbling around in the dark, Lancet 2005, vol 365 p 1983
47
. Global Forum for Health Research, (2004) The 10/90 Report on Health Research 2003 04
48
DFID, (2004), Review of Global Health Initiatives and Partnerships. DFID Health
Systems Resource Centre
49
Levine,R., (2005) From aid dependency to dependable aid. Global Future – Second
Quarter.
50
DFID, (2004), “How to Note” Macroeconomic Issues for Scaling up Aid Flows23

ANNEX 1
1.
Based on the CMH estimates, Table 1 illustrates the incremental costs, byglobal region and level of development, of expanding the district health system toachieve high levels of service coverage by 2015. The cost across low-income
countries (LICs), where the G8 has committed to increase funding, is highlighted.
Table 1: Annual incremental costs of scaling up by region (US$ 2002)
2007

2015

TOTAL DOLLARS (‘000 000 000, BILLIONS OF US DOLLARS)All countries
26(23 - 29)
All low income countries
19(17 – 22)
All Middle income countries
6(6 – 7)
SSA
13(11 - 15)EAP
5(5 - 6)SA
7(6 - 7)EEC
0.4(0.4–0.4)
LAC
0.4(0.4 -0.5)

46
33
13
23
10
11
1
1

(40 - 52)
(28 - 37)
(11 - 14)(20 - 26)
(9 - 11)(9 - 12)(1 - 1)(1 - 1)PER CAPITA ($)
All countries
All low income countries
All Middle income countries
SSA
EAP
SA
EEC
LAC

10
10
8
24
5
7
7
16

(8 – 11)(9 – 12)(7 – 9)(21 – 27)
(5 – 6)(6 – 7)(6 – 7)(14 – 19)

6
7
4
16
3
4
4
10

(5 – 7)(6 – 8)(4 – 5)(14 – 18)
(2 – 3)(4 – 5)(3 – 4)(9 – 11)

Note: Data is presented in terms of averages, the midpoint between the top and bottom of the lowhigh range. Figures in parentheses are the rounded low-high range estimates for scaling-up theintervention.

2.
Effective scaling up will require not only the costs of service delivery at a
district level but also additional costs to support effective implementation of thescaling up process, for example, management costs, increased salaries for healthworkers, additional expenditure to allow for the fact that current levels of expenditure
are inadequate to ensure quality services, and expenditures needed to improveabsorptive capacity. The CMH estimated that these additional costs approximately
doubled the total incremental costs of scaling up as shown in Table 2.
Table 2: Incremental annual costs adjusted for scaling-up process($US 2002) from CMH report
2007 Average
estimate
TOTAL DOLLARS (‘000 000 000, BILLIONS OF US DOLLARS)All countries
57
All low income countries (least
developed countries and other low
income countries)
40
Least developed countries
17
Other low income countries
23
Low middle income countries
14
Upper middle income countries
3

242015 Average
estimate
94

66
29
37
24
4

Per capita ($)
All countries
All low income countries (least
developed countries and other low
income countries)
Least developed countries
Other low income countries
Low middle income countries
Upper middle income countries

13

20

14
22
12
9
57

21
32
17
15
91

Source: (CMH 2001)

3.
Recent developments may impact on the CMH estimates: AIDS treatment is
now widely accepted and the G8 committed to ensure universal access to treatment
by 2010. While the numbers on treatment will rise greatly the cost of treatment has
declined substantially. Additionally, artemisinin-based combination therapies(ACTs) and rapid diagnostic tests (RDTs) for malaria, while more expensive (ACTcosts projected to decline from $2.40 to $1.00), are likely to make a major impact on
the epidemiology of malaria.
4.
The G8 commitment of an incremental investment in health of $20-25 billion
by 2010, with half for Africa, would enable a proportionate but none-the-less verysignificant improvement in health outcomes in low-income countries. Table 3
illustrates what could be achieved in terms of increased coverage of services acrossall low-income countries with an increased spend on health of £25 billion. The
impact could be even greater if existing and additional resources are spent more
efficiently and equitably, and in countries where the burden of disease is greatest.
Table 3: Baseline and achievable level of coverage with $25 billion (LIC)
Interventions
Scenarios

Tuberculosis
Diagnosis and treatment
Malaria
Diagnosis and treatment
Prevention (ITN, RIS)
HIV and AIDS*
Prevention (outside health sector)
Prevention (within health sector)
Care of OI
ART*
Childhood diseases
Vaccinations (BCG, OPV, DPT, HiB*, HepB*)
Vaccinations (Measles)
Diagnosis and treatment ARI
Diagnosis and treatment fever
Maternity related conditions
Antenatal care
Skilled birth attendance

25

2002
Baseline

2010
Minimum
Coverage

44%

57%

31%
2%

54%
40%

10-20%< 1% - 10%
6%-10%
970,000

58%
32%
33%
2,561,608**

75%
68%
59%
52%

87%
77%
68%
66%

65%
45%

77%
72%

Notes:* These figures are calculated on the basis of the earlier CMH estimates, however the mostrecent and accurate resource estimates have been done by UNAIDS18** The G8 has committed to as close as possible to universal access to treatment for all
those who need it by 2010, as discussed above current estimates are that achieving this will
require in the region of $10 billion a year just for AIDS specific services

26