Índice de Riesgo de la Calidad del Agua para Consumo Humano – IRCA. 25

Health financing: dominated by out-of-pocket and ear-marked funding

In the immediate post-conflict period, the landscape of health sector funding (including for HIV) was very much dominated by ear-marked funding. Beside the remaining emergency / humanitarian aid (various United Nations‘ agencies for emergency, international NGOs, European Community Humanitarian aid Office - ECHO), HIV received two large amounts of funding from the WB (Multisectoral AIDS Project 1-MAP1- from 2001) and GFATM-HIV from 2002; malaria ad TB was funded by GFATM; and immunization by Global Alliance for Vaccines and Immunization (GAVI). The reason for this probably lies in the fact that it was easier for disease- specific donors to organize themselves since they had a narrower objective than rehabilitating the entire health system. Also, funding fitting disease-specific objectives was available at global level.

As shown in Graph 4, private expenditures represented 43% of total health

expenditures (40% out-of-pocket and 3% from private enterprises), whereas external donors represented 39% (12% GHIs and NGOs, 17% multilateral donors and 10%

bilateral) and public sources only 18% (6% Highly Indebt Poor Country Initiative – HIPCI - and 12% Ministry of Finance).

Graph 4: Proportion of health financing according to the source, 2007 (adapted from original National Health Account 2007 in French (Ministère de la

Santé Publique 2007))

The main source of health financing is therefore out-of-pocket funding, as is the case in many sub-Saharan countries. Due to the scarcity of funding in the MoH as well as in the country generally, from 2002 public sector health facilities started charging user fees. Thus while the population still had access to a certain extent of free care during the conflict, as provided by emergency NGOs, once the conflict had ended, access to health care for the majority of the population was dramatically reduced, given the general introduction of user fees (Philips et al. 2004).

External 39% Private 43% Public 18%        

primary schools and free health care for all children under five and for women delivering babies (May 2006). Despite the alignment of these policies with MDGs and this attempt at health equity, their implementation was chaotic as the policies had not been discussed beforehand with the ministries who must implement them. As a result insufficient numbers of HRH and a lack of preparation for these measures has led to clear cases of overwork in PHC centres (Observatoire de l‘Action Gouvernementale 2009).

Emphasis on HIV: HIV distinct from the health sector and linked to the conflict

Just after the peace agreement was signed in 2000 in Arusha, a PRS began to be devised by donors and negotiating parties. It was also generally believed that the civil conflict, with the large numbers of internally displaced people and the chronic failure of the health system, fuelled the HIV epidemic. The alarming figure of 12% prevalence in the general adult population was cited several times, in funding proposals and the HIV plan 2002-2006.

“At the early stage, HIV sounded like a doomsday, resulting in a panic generating situation. It was urgent to put a halt to its propagation. “ (ITW22N09, group 4, local)

Later, a national survey funded by the WB proved this figure was exaggerated, since the national adult prevalence was 3.2% (Dec 2002). However, the figure of 12%, used many times, combined with the global awareness around HIV and strategies to contain the epidemic globally, was the probable reason for HIV being cited as one of the six strategic axes of the PRS paper (see Figure 2). The PRS paper is the leading document for donors. The United Nations Development Program (UNDP) financed its elaboration in a ‗participative way‘. The six strategic lines had a strong orientation towards alleviating poverty and the consequences of the conflict, as well as preventing the resurgence of conflict, in a virtuous circle of development. The visibility given to HIV by allocating one strategic line to it (which, in turn, justified the extent of the funding allocated to HIV), gave an exceptional statute to HIV, considered as a ‗sector‘ per se.

“What was clear is that disease was given priority over health”. (ITW28N09, policy analyst, local”)

“This is another point which I have never understood. I think that under the influence of whom I don‟t know […] but when the poverty reduction strategy paper was developed, HIV was included as a sector. Its budget is bigger than the budget of health and education and agriculture altogether, which seems to be abnormal. This is what I was told not long ago, that there are abnormal things even if I don‟t know how it has all happened. I know that we have criticized it. It is still appearing in the documents, I have not discussed about with people working in the ministry of planning so that I know exactly the state of things. Otherwise at the level of the sectoral approach, as for the MoH, even before thinking that the two ministries would merge, one always thought that the HIV was part of the health sector.” (ITW13N09, group 1, local)

Figure 2: The six strategic lines of the interim poverty reduction strategic paper, 2003 (created from the original document in French on PRS paper)

The emphasis put on HIV, starting from the fact that it was one of the axes of the PRS paper, had consequences in terms of health planning, as described below.