Resource allocation and health financing

Costing of HIV services, Uganda and United Republic of Tanzania
McBain R, Jordan M, Kapologwe N, et al: Bulletin of the World Health Organisation 101(10), 626–636, 2023

This study evaluated resource allocation and costs associated with delivery of HIV services in Uganda and the United Republic of Tanzania. Time-driven activity-based costing was used to determine the resources consumed and costs of providing five HIV services: antiretroviral therapy (ART); HIV testing and counseling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. In Uganda, service delivery costs ranged from US$8.18 per visit for HIV testing and counseling to US$43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$3.67 per visit for HIV testing and counseling to US$28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. The authors state that establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden.

Health expenditure: how much is spent on health and care worker remuneration? An analysis of 33 low- and middle-income African countries
Toure H, Garcia M, Izquierdo J, et al: Human Resources for Health 21:96, 1-14, 2023

This paper assessed the amount spent on health and care workforce remuneration in the African countries, its importance as a proportion of country expenditure on health, and government involvement as a funding source. Calculations are based on country-produced disaggregated health accounts data from 33 low- and middle-income African countries, disaggregated wherever possible by income and subregional economic group. Per capita expenditure health and care workforce remuneration averaged US$38, or 29% of country health expenditure, mainly coming from domestic public sources. The contributions from domestic private sources and external aid both measured around one-fifth each—23% and 17%, respectively. Spending on health and care workforce remuneration was uneven across the 33 countries, spanning from US$3 per capita in Burundi to US$295 in South Africa. West African countries, particularly members of the West African Economic and Monetary Union, were lower spenders than countries in the Southern African Development Community, both in terms of the share of country health expenditure and in terms of government efforts/participation. By income group, health and care workforce remuneration accounted for a quarter of country health expenditure in low-income countries, compared to a third in middle-income countries. An average 55% of government health expenditure is spent on health and care workforce remuneration, across all countries. The results clearly show that the remuneration of the health and care workforce is an important part of government health spending, with half of government health spending on average devoted to it. Comparing health and care workforce expenditure components allows for identifying stable and volatile sources, and their effects on health and care workforce investments over time.

Future health expenditure in the BRICS countries: a forecasting analysis for 2035
Sahoo P, Rout H, Jakovljevic M: Globalization and Health 19:49, 1-17, 2023

The BRICS nations’ economies are distinguishable from other emerging economies due to their rate of expansion and sheer size. Health spending in the BRICS countries (includes South Africa) has been increasing, but is still below health security needs and with high out-of-pocket spending. This study examined the health expenditure trend among the BRICS from 2000 to 2019 and made predictions with an emphasis on public, pre-paid, and out-of-pocket expenditures to 2035. Health expenditure data for 2000–2019 were taken from the OECD iLibrary database. Except for India and Brazil, all of the BRICS countries show a long-term increase in per capita health expenditure, most sharply rising in China, and only India’s health expenditure is expected to decrease as a share of GDP. The authors suggest that BRICS countries have the potential to be important leaders in health policies. Each BRICS country has set a national pledge to the right to health and is working on health system reforms to achieve universal health coverage, and estimations of their future health expenditures may help policymakers decide how to allocate resources to achieve these goals.

Inequality and private health insurance in Zimbabwe: history, politics and performance
Mhazo T; Maponga C; Mossialos E: International Journal for Equity in Health 22:54;1-13, 2023

Zimbabwe has one of the highest rates of private health insurance (PHI) expenditures as a share of total health expenditures in the world, through medical aid societies. This study considers the roles of history and politics in shaping PHI and determining its impact on health system performance in Zimbabwe. The authors reviewed 50 sources of information using a conceptual framework that integrates economic theory with political and historical aspects and present a timeline from the 1930s to present. The authors observe that Zimbabwe's current PHI coverage is segmented along socio-economic lines due to a long history of elitist and exclusionary politics in coverage patterns. While PHI was considered to perform relatively well up to the mid-1990s, the economic crisis of the 2000s eroded trust among insurers, providers, and patients. That culminated in agency problems which severely lessened PHI coverage quality with concurrent deterioration in efficiency and equity-related performance dimensions. The present design and performance of PHI in Zimbabwe is thus argued to be primarily a function of history and politics rather than informed choice. The authors propose that reform efforts to expand PHI coverage or improve PHI performance explicitly consider the relevant historical, political and economic aspects for successful reform.

'Historic Win': UN Members to Start Talks on 'Inclusive and Effective' Global Tax Standards
Corbett J: Common dreams, online, November 24, 2022

Tax justice advocates around the world on Wednesday celebrated the unanimous adoption of a resolution to begin intergovernmental discussions in New York at United Nations Headquarters on ways to strengthen the inclusiveness and effectiveness of international tax cooperation. "African countries stood together and made historic strides, breaking through the long-standing blockade by the OECD countries," said Global Alliance for Tax Justice executive coordinator Dereje Alemayehu. The U.N. General Assembly (UNGA) resolution on the "promotion of inclusive and effective international tax cooperation at the United Nations" was spearheaded by the African Group—which is composed of the continent's 54 member states—and comes after about a decade of delays on the topic at the Organization for Economic Cooperation and Development (OECD). "We note that the OECD has played a role in these areas," a representative of the Nigerian delegation to the U.N. reportedly said Wednesday. "It is clear after 10 years of attempting to reform international tax rules that there is no substitute for the global, inclusive, transparent forum provided by the United Nations."

UN vote on new tax leadership role
Tax Justice Network: Live Blog, online, 24 November 2022

The UN General Assembly adopted on Wednesday 23 November 2022 by unanimous consensus a resolution that mandates the UN to set course for a global tax leadership role. The historic decision is likely to mark the beginning of the end of the OECD’s sixty-year reign as the world’s leading rule maker on global tax, and will now kick off a power struggle between the two institutions with implications for global and local economies, businesses and people everywhere for decades to come. The adopted resolution will now open the way for intergovernmental discussions on the negotiation of a UN tax convention and a global tax body. This blog captures information on the resolution, on policy analysis commentary on its passing, and on evidence supporting moving tax rule-making to a globally inclusive and transparent forum at the United Nations.

The economic burden of treating uncomplicated hypertension in Sub-Saharan Africa: a systematic literature review
Gnugesser E; Chwila C; Brenner S; et al: BMC Public Health 22(1507), 1-20, 2022

This paper identified costs and major cost drivers across countries in Sub-Saharan Africa, drawing on published literature. The costs are in US$. Medication costs were accountable for most of the expenditures and varied across countries, with a range from $1.70 to $97.06 from a patient perspective and $0.09 to $193.55 from a provider perspective per patient per month. Major cost drivers were multidrug treatment, inpatient or hospital care and having a comorbidity like diabetes. Hypertension is argued from the findings to pose a significant economic burden for patients and governments in SSA, with medication costs one of the biggest cost contributors. The authors suggest that addressing the economic burden of hypertension implies reducing medication costs, including in the form of subsidies for patients.

Analysis of aid flows to Uganda before and during Covid-19
Owori M: Development Initiatives, Online, 2021

The overall profile of official development assistance (ODA) in Uganda is reported to be switching from grants to increased proportions of concessional loans, as international financial institution (IFI) lending became a significant source of foreign aid in 2020. Growth in IFI aid flows to Uganda between 2018 and 2020 was mainly driven by the World Bank, which contributed 77% of the total reported IFI contributions in the three years reviewed. The health sector received the largest share (US$205 million) of bilateral grant aid disbursements in 2020, but this allocation represented a 10% decline from 2019 to 2020. The allocation to the humanitarian sector in 2020 also declined, but the allocation to the agriculture and food security sector increased by 34% to US$128 million between 2019 and 2020,

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis
Eze P; Lawani LO; Agu UJ; Acharya Y: Bulletin of the World Health Organisation 100(5), 337-351J, doi: 10.2471/BLT.21.287673, 2022

This study estimated the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa. A systematic review of scientific and grey literature was conducted to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. A meta-analysis was performed using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model. The authors identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% for a threshold of 10% of total household expenditure and 8.7% for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher. Although data on catastrophic health expenditure for some countries were sparse, the available data suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services, and that stronger financial protection measures are needed.

Everywhere basic income has been tried, in one map
Samuel S: Vox, Online, 2020

The idea of a basic income was, for decades, something of a policy fantasy. But in the last decade many basic income programs have emerged. This site maps there presence with links to information on them. For example in Kenya a big experiment in universal basic income (UBI) is described. The charity GiveDirectly is making payments of roughly 75 cents (US$) per adult per day, delivered monthly for 12 years to more than 20,000 people spread out across 245 rural villages, with some evidence from a related intervention that this stimulated the local economy and benefited not only the recipients themselves but also people in nearby villages. This site lists all the places that are trying or have tried some version of basic income, noting that UBI is unconditional and different to conditional cash transfers, which may require recipients to send their kids to school or go for health checkups.