Small fish in a big pond? External aid and the health sector in South Africa

Since a new government was elected in 1994, South Africa has become a favoured nation for the many bilateral and multi-lateral agencies providing aid to developing countries. Despite several relatively large pledges of 'transition support', however, external resources constitute less than 2% of the annual government budget. This non-dependence has established a degree of equilibrium in a relationship normally regarded as highly unequal in other African countries. Although international donors funded the antiapartheid movement in South Africa prior to 1994, the new government inherited a chaotic administration that had little institutional experience of conventional development aid. Many of the new cadres entering government had not been exposed to the workings of government, let alone donor, bureaucratic processes. It is not surprising, therefore, that in the first few years after 1994, the aid relationship was characterized by low disbursements, unrealistic expectations and a degree of conflict. Since 1997, however, aid supported projects have started to become more visible. Within the broad objective of supporting transformation of the health system, one of the key areas of donor support is managerial capacity development, particularly of district, hospital and provincial health structures. These initiatives tend to be poorly coordinated, a problem compounded by a quasi-federal system in which provinces have large amounts of autonomy. The contribution of donor aid to strengthening the health system could be enhanced by the establishment of a clear national framework to guide the many externally supported projects building managerial skills and systems.

Tackling the emerging pandemic of non-communicable diseases in sub-Saharan Africa: the essential NCD health intervention project

There is evidence that the prevalence of certain non-communicable diseases, such as diabetes and hypertension, is increasing rapidly in parts of sub-Saharan Africa. Others, such as asthma and epilepsy, are known to be common but to be poorly managed. This paper describes a project, funded by the Department for International Development of the British Government, which aims to provide costed and evaluated treatment packages for use at primary health care level, methods and materials for evaluating the quality of non-communicable disease care, and a protocol for the assessment for national opportunities for the prevention of hypertension, heart disease and diabetes. Methods are being developed and piloted in urban and rural Tanzania and Cameroon.

Cost-effectiveness analysis of humanitarian relief interventions: visceral leishmaniasis treatment in the Sudan

Spending by aid agencies on emergencies has quadrupled over the last decade, to over US$6 billion. To date, cost-effectiveness has seldom been considered in the prioritization and evaluation of emergency interventions. The sheer volume of resources spent on humanitarian aid and the chronicity of many humanitarian interventions call for more attention to be paid to the issue of 'value for money'. In this paper we present data from a major humanitarian crisis, an epidemic of visceral leishmaniasis (VL) in war-torn Sudan. The special circumstances provided us, in retrospect, with unusually accurate data on excess mortality, costs of the intervention and its effects, thus allowing us to express cost-effectiveness as the cost per Disability Adjusted Life Year (DALY) averted. The cost-effectiveness ratio, of US$18.40 per DALY (uncertainty range between US$13.53 and US$27.63), places the treatment of VL in Sudan among health interventions considered 'very good value for money' (interventions of less than US$25 per DALY). We discuss the usefulness of this analysis to the internal management of the VL programme, the procurement of funds for the programme, and more generally, to priority setting in humanitarian relief interventions. We feel that in evaluations of emergency interventions attempts could be made more often to perform cost-effectiveness analyses, including the use of DALYs, provided that the outcomes of these analyses are seen in the broad context of the emergency situation and its consequences on the affected population. This paper provides a first contribution to what is hoped to become an international database of cost-effectiveness studies of health interventions during relief operations, which use a comparable measure of health outcome such as the DALY.

Making Cairo work

The 1994 International Conference on Population and Development set broad new goals for family planning and reproductive health. The resources available to fund these much needed programmes, however, are much smaller than was originally calculated. To divide the limited budgets for the maximum health impact, likely resource flows need to be set against the cost of various family planning and reproductive health interventions. Preliminary analysis suggests that selection of cost-effective delivery of family planning services would still meet much of the need for family planning, and that some progress could be made towards improved control of sexually transmitted diseases.