There has not been a systematic effort to synthesize findings of domestic fiscal space for health (DFSH) assessments, despite the existence of a commonly applied conceptual framework. To fill this gap and provide support to policy makers designing health financing policies toward universal health coverage (UHC), this study uses both qualitative and quantitative methods to assess the scope of possible sources of DFSH in low- and middle-income countries (LMICs). First, the findings of 28 studies assessing DFSH in LMICs were reviewed. A quantitative assessment was then conducted to assess potential expansion from increased tax revenues, a greater prioritization of health in the overall budget, and improved technical efficiency of health spending in a sample of 64 LMICs. The analysis found that macroeconomic conditions and budget prioritization are the key sources of DFSH expansion in 90% of the reviewed studies. Improved efficiency was referenced as having high potential for DFSH expansion in 60% of the studies. The quantitative analysis converged with these findings and further confirmed that an increase in tax revenues is, on average, the largest source of potential DFSH expansion (95% confidence interval [CI], 60%, 96%) in the studied countries. However, even without injecting new revenues, reprioritization of budget and technical efficiency improvements could significantly expand DFSH (95% CI, 77%, 102%). While highlighting the critical role played by fiscal conditions and tax policies, the study provides strong rationale for explicitly incorporating efficiency as a core source of DFSH in a more systematic manner in future assessments.

SummaryIn sub-Saharan Africa, lowlands developed for rice cultivation favour the development of Anopheles gambiae s. l. populations. However, the epidemiological impact is not clearly determined. The importance of malaria was compared in terms of prevalence and parasite density of infections as well as in terms of disease incidence between three agroecosystems: (i) uncultivated lowlands, ÔR0Õ, (ii) lowlands with one annual rice cultivation in the rainy season, ÔR1Õ and (iii) developed lowlands with two annual rice cultivation cycles, ÔR2Õ. We clinically monitored 2000 people of all age groups, selected randomly in each agroecosystem, for 40 days (in eight periods of five consecutive days scheduled every 6 weeks for 1 year). During each survey, a systematic blood sample was taken from every sick and asymptomatic person. The three agroecosystems presented a high endemic situation with a malaria transmission rate of 139-158 infective bites per person per year. The age-standardized annual malaria incidence reached 0.9 malaria episodes per person in R0, 0.6 in R1 and 0.8 in R2. Children from 0 to 9-year-old in R0 and R2 had two malarial attacks annually, but this was less in R1 (1.4 malaria episodes per child per year). Malaria incidence varied with season and agroecosystem. In parallel with transmission, a high malaria risk occurs temporarily at the beginning of the dry season in R2, but not in R0 and R1. Development of areas for rice cultivation does not modify the annual incidence of malarial attacks despite their seasonal influence on malaria risk. However, the lower malaria morbidity rate in R1 could be explained by socio-economic and cultural factors.

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BackgroundThis study aimed to determine the epidemiological impact of rice cultivation in inland valleys on malaria in the forest region of western Côte d’Ivoire. The importance of malaria was compared in terms of prevalence and parasite density of infections and also in terms of clinical malaria incidence between three agro-ecosystems: (i) uncultivated inland valleys, (R0), (ii) inland valleys with one annual rice cultivation in the rainy season, (R1) and (iii) developed inland valleys with two annual rice cultivation cycles, (R2).MethodsBetween May 1998 and March 1999, seven villages of each agro-ecosystem (R0, R1 and R2) were randomly selected among villages pooled by farming system. In these 21 villages, a total of 1,900 people of all age groups were randomly selected and clinically monitored during one year. Clinical and parasitological information was obtained by active case detection of malaria episodes carried out during eight periods of five consecutive days scheduled at six weekly intervals and by cross-sectional surveys.ResultsPlasmodium falciparum was the principal parasite observed in the three agro-ecosystems. A level of holoendemicity of malaria was observed in the three agro-ecosystems with more than 75% of children less than 12 months old infected. Geometric mean parasite density in asymptomatic persons varied between 180 and 206 P. falciparum asexual forms per μL of blood and was associated with season and with age, but not with farming system. The mean annual malaria incidence rate reached 0.7 (95% IC 0.5-0.9) malaria episodes per person in R0, 0.7 (95% IC 0.6-0.9) in R1 and 0.6 (95% IC 0.5-0.7) in R2. The burden of malaria was the highest among children under two years of age, with at least four attacks by person-year. Then malaria incidence decreased by half in the two to four-year age group. From the age of five years, the incidence was lower than one attack by person-year. Malaria incidence varied with season with more cases in the rainy season than in the dry season but not with farming system.ConclusionIn the forest area of western Côte d’Ivoire, inland valley rice cultivation was not significantly associated with malaria burden.