Geneva Health Forum Archive

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Present and Potential Roles of Global Health Funds and Health Systems Strengthening

Author(s): G. Ooms1
Affiliation(s): 1Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
Keywords: Global health funds, health systems strengthening, health workforce, recurrent costs

The crucial issue for health systems strengthening in low-income countries is to expand the health workforce, which requires additional funding for salaries. Classic international aid is not reliable enough to be used for recurrent costs, like salaries. Recently created global health funds seem to provide more reliable aid. But they also seem reluctant to finance salaries of health workers.

Results/Conclusions:  Different reasons might explain why global health funds are reluctant to finance salaries of health workers:
- The pressure to deliver quick results;
- Disease-specific objectives, in which salaries for health workers providing comprehensive primary health care do not fit;
- The informal ‘division of labor’ with the World Bank, leaving health systems strengthening with the World Bank. The final report of the Taskforce on Innovative International Financing for Health Systems reveals a new dichotomy between the ‘WHO normative’ and the ‘Marginal Budgeting for Bottlenecks’ (MBB) approach; global health funds might unintentionally push towards the MBB approach.

Making the Right to health a Reality in the Context of Social Inequalities and Rapid Economic Change in Brazil

Author(s): V. S. P. Coelho*1, A. Shankland2
Affiliation(s): 1Citizenship and Development Group, Brazilian Centre of Analysis and Planning, Sao Paulo, Brazil, 2IDS, Falmer, United Kingdom

SUS, the brazilian public health system; rights; social excluded groups; decentralization; PSF Family Health Program; health councils, accountability


In the two decades since Brazil recognised access to healthcare as a Constitutional right, the country has undergone wide-ranging transformations that have left their mark on the profile of the population and on the country’s health system. Initially, a brief overview of the changes that have taken place in recent years in the socio-demographic and epidemiologic profile of the Brazilian population is presented, showing the challenges facing the healthcare system. We go on to present a brief overview of the system, which includes both the publicly-funded services provided by the SUS (Unified Healthcare System) and those financed and provided by the private sector. Our analysis concentrates on the public sector, which is the sole source of healthcare for approximately 70% of the country’s population.


We outline the chief mechanisms – programs, financing and management – that have ensured the SUS’s capacity to respond to the challenges pointed out previously. We argue that two of the key mechanisms are the establishment of transparent financing mechanisms for promoting universal coverage within a highly decentralised health system where most service delivery responsibilities lie at the municipal level, and the innovative approaches to democratic accountability.
Some 32% of Brazil’s population of 184 million people are considered to be living in poverty. Despite a recent decline in overall income inequality, indicators show expressive inequalities in both income and life expectancy between rural and urban populations, and between the population as a whole and minority ethnic populations, in particular Afro-descendent and indigenous groups. It should also be noted that 85% of Brazil’s population lives in cities, with metropolitan areas expanding rapidly throughout the country. In this context, a key challenge is to overcome urban bias in health system organisation and healthcare models, ensuring the realisation of the universal right to healthcare among minority populations living in remote rural areas where municipal service delivery capacity is weakest.


Since it was established in the late 1980s as a public health system with universal and unconditional coverage, the SUS has achieved a rapid expansion in access to services. A key driver of this expansion has been the system of direct central government transfers to the municipal level, tied to the delivery of priority packages such as the Family Health Program or PSF (Programa Saúde da Família). The statutory participation and accountability institutions, known as Health Councils (Conselhos de Saúde) have facilitated coordination between health system managers, service providers and civil society groups. However, both the transfer system and the accountability institutions have been less successful in guaranteeing service quality, and in particular in ensuring that service provision models such as the PSF are adapted to address the specific health needs of the most marginalised and vulnerable population groups. In this presentation we focus on the ways in which the SUS is dealing with these challenges, and the innovative approaches emerging from ongoing change processes such as the reforms in health service provision for indigenous peoples.

Threats and Opportunities of Financial Aid for Health

Author(s): U. R. Laaser1
Affiliation(s): 1World Federation of Public Health Associations, Bielefeld, Germany
Keywords: Finance, Global Health

Our world is confronted with vital risks which can be categorized under the headings of global warming, global divides, global security and global health. To cope with such threats, financial investment is essential though not sufficient. I shall focus here on the monetary dimension. (1) The liberalisation of services from tariff and non-tariff barriers is likely to be advantageous as long as essential social services including the health sector are exempted even if provided in competition with other service suppliers. (2) The global financial crisis may still lead to cutting off essential spending for the poorest populations in order to meet debt payments. (3) The steep global gradient between rich Highly Developed Countries (HDL) and the poor Least Developed Countries (LDC) is well known. (4) The Monterrey consensus of 2002 reiterated the obligation of developed countries to make concrete efforts towards the target of 0.7% as ODA (art. 42) which is reached only by some smaller donor countries. (5) One of the obvious reasons for imbalances is the extreme fragmentation and therefore ineffectiveness of international aid. (6) Loans are mainly spent for experts and equipment from the crediting countries but have to be repaid from tax money later. (7) The Paris/Accrah indicators are not met. (8) The percentage of aid through bilateral channels against declarations has increased. (9) In developing and transitional societies coordinative capacities and competences are limited. In addition international and even more bilateral aid very often is disrupting coherent national development plans.


The concept of Sector-wide Approaches should be developed. II. A code of conduct for NGO’s has to be developed and enforced. III. A global awareness in the sense of a New Global Health is a first essential step.

New Challenges for Government, Civil Society and the Private Sector in India’s highly Marketized Health System

Author(s): B. Kanjilal1
Affiliation(s): 1Indian Institute of Health Management Research, Jaipur, India
Keywords: Liberalization, health market, India

Indian health care market is under rapid transition. The economic liberalization process started in early 1990s unleashed enormous potential for economic advancement. Simultaneously, it also triggered a fast growth of private players in the health sector leading to a significant expansion of consumers’ choice set for medical care. However, there is also a growing concern that liberalization has brought forth a new set of vulnerabilities, inequalities, and insecurities especially when people seek curative care. The response of public and voluntary sector to this transition has been grossly inadequate and often misguided so far. The study highlights the need for a change in paradigm of traditional public financing and state governance in health care in the context of unchained markets in health care of India.

Methods: The present study is based primarily on secondary data sourced from various rounds of national level health surveys, such as NFHS and NSSO, conducted since 1990. A set of primary data on households’ health care utilization, collected from three districts of West Bengal, India was used to supplement the findings. Simple descriptive statistics and an extensive review of literature were used to highlight the key issues.

The share of private sector in Indian inpatient care market has increased from 40 percent to 60 percent during the last two decades. The rural outpatient care market, on the other hand, has been consistently dominated by unqualified private practitioners. The drug industry has experienced an unprecedented growth – nearly six times - during the same period. However, the rapid marketisation process has also triggered catastrophic out of pocket payments which accounts for more than 75 percent of total health spend in India and led to increase in poverty by 3.6 percent and 2.9 percent respectively for rural and urban areas. The government and other non-profit agencies, therefore, require restructuring their roles in this transition. Specifically, the public sector needs to provide (1) a safety net to protect people from poverty induced by health care, (2) an equity-based public financing mechanism to reduce sharp inequalities in health care utilization, and (3) an effective regulatory framework to internalize the growth of private sector and realign its direction to national health policy targets.

Economic Vulnerability and Health Reform in Latin America

Author(s): R. Guerrero1
Affiliation(s): 1Harvard Global Equity Initiative, Harvard University, Cambridge MA, United States
Keywords: Economic vulnerability, health reform
Results/Conclusions: It is widely recognized that health systems should not only improve the health status of the population but also protect households from the adverse economic consequences of health shocks. The share of public funding in the overall financing of health services, and the extent to which services are prepaid, are indicators of the capacity of the health system to provide this protection to households. Evidence of the economic vulnerability of households in the face health shocks can be a catalyst of reforms that improve access and equity. A case in point is Mexico. In the nineties, when evidence became available of the great extent to which Mexicans had to rely on out-of-pocket payments and private services, it became clear that there was a wide and inequitable gap in public service coverage. This vulnerability is even greater in periods of economics crisis. Evidence of this, as well as of the high incidence of catastrophic expenditures at the household level due to health shocks, provided the rationale for a reform process that lead to the creation of the Seguro Popular, a social health insurance that entitles Mexican citizens to an explicit benefit package.