BackgroundDonor funding for HIV programs has flattened out in recent years, which limits the ability of HIV programs worldwide to achieve universal access and sustain current progress. This study examines alternative mechanisms for resource mobilization.MethodsPotential non-donor funding sources for national HIV responses in low- and middle-income countries were explored through literature review and Global Fund documentation, including data from 17 countries. We identified the source, financing agent, magnitude of resources, frequency of availability, as well as enabling and risk factors.ResultsFour non-donor funding sources for HIV programs were identified: earmarked levy for HIV from country budgets; risk-pooling schemes such as health insurance; debt conversion, in which the creditor country reduces the debt of the debtor country and allocates at least a part of that reduction to health; and concessionary loans from international development banks, which unlike grants, must be repaid. The first two are recurring sources of funding, while the latter two are usually one-time sources, and, if very large, might negatively affect the debtor country’s economy. Insurance schemes in five African countries covered less than 6.1% of the HIV expenditure, while social health insurance in four Latin American countries covered 8–11% of the HIV expenditure; in Colombia and Chile, it covered 69% and 60%, respectively. Most low-income countries will find concessionary loans hard to repay, as their HIV programs cost 0.5–4% of GDP. Even in a middle-income country like India, a US$255 million concessionary loan to be repaid over 25 years provided only 7.8% of a 5-year HIV budget. Earmarked levies provided only 15% of the annual HIV funding needs in Zimbabwe and Kenya. Debt conversion provided the same share in Indonesia, but in Pakistan it was much higher - the equivalent of 45% of the annual cost of the national HIV program.ConclusionsDomestic sources of funding are important alternatives to consider and might be able to replace donor HIV funding in specific country contexts, coupled with effective prioritization and efficiency measures. Successful resource mobilization design and implementation require close collaboration with other sectors, particularly with the Ministry of Finance, to make sure that the new financing mechanism is fully synchronized with economic growth and that HIV investments yield returns in the form of higher social benefits.

This paper seeks to investigate the determinants of child health care seeking behaviours in rural Bangladesh. In particular, the effects of income, women's access to income, and the prices of obtaining child health care are examined. Data on the use of child curative care were collected in two rural areas of Bangladesh--Abhoynagar Thana of Jessore District and Mirsarai Thana of Chittagong District--in March 1997. In estimating the use of child curative care, the nested multinomial logit specification was used. The results of the analysis indicate that a woman's involvement in a credit union or income generation affected the likelihood that curative child care was used. Household wealth decreased the likelihood that the child had an illness episode and affected the likelihood that curative child care was sought. Among facility characteristics, travel time was statistically significant and was negatively associated with the use of a provider.

Community-based health insurance (CBHI) as a demand-side intervention is presumed to drive improvements in health services quality, and the quality of health services is an important supple-side factor in motivating CBHI enrollment and retention. There is, however, limited evidence on this interaction. This study examined the interaction between quality of health services and CBHI enrollment and renewal. A mixed-method comparative study was conducted in four agrarian regions of Ethiopia. The study followed the Donabedian model to compare quality of health services in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessments, client-exit interviews, and key informant interviews. In addition to manual thematic analysis of qualitative data, quantitative descriptive and inferential analyses were done using SPSS vs 25. The process related (composite index including provider-client interpersonal communication) and outcome related (client satisfaction) measures of service quality in CBHI woreda/districts differed significantly from non-CBHI woredas/districts, but there were no significant differences in overall measures of structural quality between the two. The study found better diagnostic test capacity, availability of tracer drugs, provider interpersonal communication, and service quality standards in CBHI woredas. A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with services. Individual and household factors including family size, age, household health care-related expenditures, and educational status, played a more significant role in CBHI enrollment and renewal decisions than health service quality. Key-informants reported in interviews that participation in the scheme increased accountability of health facilities in CBHI woredas/districts, because they promised to provide quality services using the CBHI premium collected at the beginning of the year from all enrolled households. This study indicates a need for follow-up research to understand the nuanced linkages between quality of care and CBHI enrollment.

The strategy of distributing material and child health and family planning (MCH‐FP) services at the doorsteps of the clients — through routine visits to the eligible couples by trained fieldworkers — has been instrumental in increasing the contraceptive prevalence rate (CPR), reducing fertility and attaining a considerably high immunization coverage of children and women in Bangladesh. The doorstep strategy, however, appeared to be labour‐intensive and costly. With the majority of the programme, priorities of the national MCH‐FP programme have shifted to a stage that calls for more cost‐ effective service‐delivery strategies, capable of offering a broader package of reproductive and other essential health services. The main objective of the present study was to examine the cost and effectiveness implications of the alternative strategies of delivering services from fixed sites — tested within an ICDDR.B operations research — in comparison to the conventional (existing) doorstep strategy. The key findings of the economic appraisal indicated that, at the end of the operations research intervention, both cost per birth averted and cost per QALY gained were lowest for the option of delivering services from static (fixed‐site) clinics: US$ 13 and US$ 17 compared with the corresponding values of US$ 18 and US$ 42 for the doorstep strategy. Provision of health and family planning services from clinics — complemented with a reduced system of outreach workers to inform and target the hard‐to‐reach clients — was found to be the most cost‐effective service‐delivery alternative. Copyright © 2000 John Wiley & Sons, Ltd.

The main goal of the health reform programme recently initiated in Bangladesh is to reduce costs and improve cost efficiency of the service delivery systems, and thereby ensure the sustainable provision of essential health and family planning services. With significant dependency on external funding, attainment of this objective is more critical for non-government organization (NGO) programmes. The paper analyzes costs of the NGO service delivery systems for maternal and child health and family planning, and identifies areas for increasing efficiency, especially through reducing labour costs and increasing service outputs. The operations research on cost analyses was conducted within the health and family planning programmes of a leading NGO, using the 'ingredients approach'. The findings demonstrated a significantly high proportion of personnel costs in field (outreach) service delivery systems, ranging between 70-85%. More than two-thirds of the working time of providers was spent on support activities, personal preoccupations and idle time. Simulations of various cost reduction options showed that considerable efficiency gains were possible through the combined effects of lowering personnel costs for field activities, increasing service outputs at the clinics, and ensuring more efficient use of providers' time. However, these factors, neither separately nor in combination, resulted in any substantive decrease for certain clinic services (e.g. antenatal care), implying the need to subsidize these services. The findings of the operations research indicated that cost analyses could be an effective decision-making tool for NGOs in developing cost-efficient service delivery strategies.