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Why we need a world social health insurance

Institute of Tropical Medicine Antwerp

ANTWERP - We are in need of a social security fund on a global scale. That is what scientists of the Institute of Tropical Medicine Antwerp (ITM) argue in a Viewpoint in the leading medical journal The Lancet. Such a 'Global Fund for Health' would make the use of international donor money a lot more transparent and efficient.

Today, 44% of international health aid money cannot be traced in the budgets of the receiving countries. This doesn't necessarily mean it has disappeared in somebody's pockets, but it is unclear when nor on what it has been spent. For convenience's sake it often is assumed that governments trim down their own health expenditure in proportion to the aid they receive. An article in the same issue of The Lancet, by a group of researchers led by Christopher Murray of the Institute for Health Metrics and Evaluation (University of Washington) states that for every dollar of international health aid provided to governments, on average government health funding falls by $0•43𔂿•14.

The Lancet asked Gorik Ooms and colleagues at the ITM to comment. Their reaction: it's not as simple as it might seem at first sight. One cannot just assert that for every euro rich countries spend on international assistance, poor countries spend one euro less. For some countries, the domestic contribution indeed goes down in response to increasing international assistance, but for other countries the domestic contribution goes up. Global averages seem to mask important variances.

There is much more work to be done to accurately trace health funding both from foreign and domestic sources, Ooms learned from a survey of 15 countries. Do governments shift money form their own health budget to other sectors as soon as aid money comes in? Do they put their own money aside, assuming external aid will run dry? Or do they spread the aid money over several years to avoid short peaks in the health service supply to their people? While at the same time tailoring their budget to give the impression that the donor money was immediately and fully used? Do governments keep the valuable hard currency, while reporting domestic expenditure as aid? Every case is different.

International assistance would be more effective if it were not as unpredictable as it is, the ITM scientists argue. The Global Fund to fight AIDS, Tuberculosis and Malaria has shown that one can pool different streams of international assistance into one stable and reliable aid source. Why don't we broaden the mandate of the Global Fund to all elements of a comprehensive primary health care, into a World Social Health Insurance fund, to which every country contributes according to its means, and receives according to its needs? The receiving countries would no longer have to shuffle money around or adapt unpredictable charity to what they perceive as their real needs.


To the editors

The article "Crowding out: are relations between international health aid and government health funding too complex to be captured in averages only?" by Gorik Ooms and colleagues appears in The Lancet, April 9. It provides a larger framework to an article by the group of Christopher Murray (Institute for Health Metrics and Evaluation, University of Washington) in the same issue: "Public financing of health in developing countries: a cross-national systematic analysis".

On occasion of the articles in The Lancet, Imperial College in London organises that very day a round table debate on the financing of public health in developing countries.

More information: Gorik Ooms (, +1 510 705 3889) or prof. Wim Van Damme (, ++32 (0)3 247 64 78 or ++32 (0)486 88 32 03.) Gorik Ooms will be on the panel of the round table and can not easily be reached on his US phone on April 9, but on +44 781 840 64 02.

The Antwerp Institute of Tropical Medicine (ITM) is one of the world's leading institutions for education and research in tropical medicine (including AIDS), tropical medical services and health care development in developing countries.

At ITM, 400 scientist and technicians work in 5 scientific departments and specialized medical units. Yearly, an average of 700 medical doctors, veterinarians and biomedical scientists follow advanced courses; some 100 young researchers are completing their PhD. Yearly, the medical services handle over 30 000 consultations.

ITM also carries out an extensive capacity strengthening program in developing countries, and is part of a large network of institutions in Africa, South America and Asia.

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