As low- and middle-income countries undertake health financing reforms to achieve universal health coverage, there is renewed interest in making allocation of pooled funds to health-care providers more strategic. To make purchasing more strategic, countries are testing different provider payment methods. They therefore need comprehensive data on funding flows to health-care providers from different purchasers to inform decision on payment methods. Tracking funding flow is the focus of several health resource tracking tools including the System of Health Accounts and public expenditure tracking surveys. This study explores whether these health resource tracking tools generate the type of information needed to inform strategic purchasing reforms, using Kenya as an example. A qualitative assessment of three counties in Kenya shows that different public purchasers, that is, county health departments and the national health insurance agency, pay public facilities through a variety of payment methods. Some of these flows are in-kind while others are financial transfers. The nature of flows and financial autonomy of facilities to retain and spend funds varies considerably across counties and levels of care. The government routinely undertakes different health resource tracking activities to inform health policy and planning. However, a good source for comprehensive data on the flow of funds to public facilities is still lacking, because these activities were not originally designed to offer such insights. The authors therefore argue that the methods could be enhanced to track such information and hence improve strategic purchasing, and also offer suggestions how this enhancement can be achieved.
Resource allocation and health financing
Increasing fiscal space is argued to be important for health sector public financing. One strategy is to mobilize additional government revenues through new taxes or increased tax rates on goods and services. The authors illustrate how countries can assess the feasibility and quantitative potential of different revenue-raising mechanisms. The processes and results from country assessments in Benin, Mali, Mozambique and Togo are reviewed and synthesized. The studies analysed new taxes or increased taxes on airplane tickets, phone calls, alcoholic drinks, tourism services, financial transactions, lottery tickets, vehicles and the extractive industries. Study teams in each country assessed the feasibility of new revenue-raising mechanisms using six qualitative criteria. The quantitative potential of these mechanisms was estimated by defining different scenarios and setting assumptions. Consultations with stakeholders at the start of the process served to select the revenue-raising mechanisms to study and later to discuss findings and options. Exploring feasibility was essential, as this helped rule out options that appeared promising from the quantitative assessment. Stakeholders rated stability and sustainability positive for most mechanisms, but political feasibility was a key issue throughout. The estimated additional revenues through new revenue-raising mechanisms ranged from 0.47–1.62% as a share of general government expenditure in the four countries. Overall, the revenue raised through these mechanisms was small. The authors advise countries to consider multiple strategies to expand fiscal space for health.
The author reports that Larry Summers, a former World Bank chief economist, viewed the Banks Ebola financing scheme as a problem. As recounted by another former World Bank economist, Olga Jonas, the World Bank involvement of the private sector in funding countries affected by Ebola in the wake of the 2014-2016 outbreak led to the Pandemic Emergency Financing Facility (PEF) as a form of investor scheme for private financing. However, as Jonas points out, the PEF stipulates a payout of $45 million for Ebola if the officially confirmed death toll reaches 250 (which occurred in the DRC [Democratic Republic of the Congo] by mid-December 2018), but only if at least 20 deaths occurred in a second country. Given that the WHO lists only one multi-country outbreak amid more than 30 that occurred in a single country, this requirement is viewed as inappropriate. Rather than a lack of funds, the author argues that vigilance and public-health capacity have been the main deficiencies. When governments and the World Bank are prepared to respond to infectious-disease threats, money flows within days. The World Bank has said that the PEF is working as intended by offering the potential of ‘surge’ financing. However its triggers are said to guarantee that payouts will be too little because they kick in only after outbreaks grow large. The author concludes that the best investment of funds and attention is in ensuring adequate and stable financing for core public-health capacities, that the PEF has failed. It should end early — and that IDA funds should go to poor countries, not investors.
This study examined the experiences of poor people with health financing reforms that target them. The authors conducted a qualitative cross-sectional study in two purposively selected counties in Kenya, using focus group discussions and in-depth interviews with people in the lowest wealth quintile and health insurance subsidy programme beneficiaries. Health financing reforms reduced financial barriers and improved access to health services for poor people in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that health insurance subsidy programme beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among poor people.
This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world’s highest burdens of maternal mortality. The authors analysed Malawi’s recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of external funding, a shift in political leadership and priorities and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. The authors report that different actors are frustrated about user fees and their impact on poor people, especially because in Malawi non-institutional deliveries have become strongly associated with maternal deaths. This especially affects women in rural areas, where access to care is already minimal. In addition, the poorest rural women struggle most to pay user-fees, and would have to travel to the district hospital. User-fees eroded trust between women and health workers. The authors indicate that the fact that local maternity services excluded of the most vulnerable rural women from care rather than address higher level sources reflect the power dynamics involved in this issue.
This report summaries the methods for analyzing health equity available to policymakers regarding the allocation of health sector resources. The authors provide an overview of the major tools that have been developed to measure, evaluate and promote health equity, along with the data required to operationalise them. These are organized into four key policy questions facing decision-makers: What is the current level of inequity in health? Does government health expenditure benefit the worst-off? Can government health expenditure more effectively promote equity? and which interventions provide the best value for money in reducing inequity? Benefit incidence analysis is identified as the principal tool for estimating the distribution of current public health sector expenditure, with geographical resource allocation formulae and health system reform being the main government policy levers for improving equity. Techniques from the economic evaluation literature, such as extended and distributional cost-effectiveness analysis can be used to identify ‘best buy’ interventions from a health equity perspective. A range of inequality metrics, from gap measures and slope indices to concentration indices and regression analysis, can be applied to these approaches to evaluate changes in equity. Methods from the economics literature can be used to generate novel evidence on the health equity impacts of resource allocation decisions. They provide policymakers with a toolkit for addressing multiple aspects of health equity, from health outcomes to financial protection, and can be adapted to accommodate data commonly available in either high income or low and middle income settings. However, the quality and reliability of the data are crucial to the validity of all methods.
The authors estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance for health (DAH) from 1990 to 2018. Future scenarios of health spending using an ensemble of linear mixed-effects models were estimated, with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. Between 1995 and 2016, health spending grew at a rate of 4% annually, although it grew slower in per capita terms and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries, mainly due to growth in government health spending, and in lower-middle-income countries, mainly from DAH. The decomposition analysis identified governments’ increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending.
Hundreds of people marched through Cape Town to Parliament in April to demand that government implement the National Health Insurance (NHI) system, including members of Sonke Gender Justice; Movement for Change and Social Justice (MCSJ) and the People’s Health Movement South Africa. They sang and danced holding banners and placards. MCSJ founder Mandla Majola, described the NHI as the “first step to better our public healthcare system”. He said the NHI was a fund that would ensure the implementation of proper healthcare for all and would bridge the gap between private and public sectors. Before the march, the MCSJ identified ten private hospitals and sent a small group of people to each hospital to picket outside to try and get help for one member in each group who was struggling to get help at a public clinic. In a memorandum, addressed to Minister of Health Aaron Motsoaledi, the MCSJ highlights structural problems in public clinics and hospitals, such as overcrowding and bed shortages; understaffing and maladministration, such as the disappearance of patient folders and staff shortages; the rural and urban divide, such as the long commutes to and from facilities; and the disparities between private and public sectors, such as drug shortages and long queues. The marchers demanded that NHI be implemented rapidly and adequately; that national government widen the awareness of NHI through initiatives like road shows and campaigns and that there be transparency in the NHI process.
This study assessed the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa, using a synthesis model. In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision. However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to women having transactional sex was the most cost-effective. To maximize population health within a fixed budget, the authors argue that CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality.
From 2012 to 2017, the Belgian governmental cooperation and the Senegalese authorities implemented a project aimed at organising health insurance for rural poor people (‘PAODES’) to fund basic health care services at local and district level. It aimed to develop a health insurance model that had been tested long enough on a large enough scale to scale it up. PAODES intervened in four health districts with 480 000 people. The report found that health insurance coverage after two years was at 64% (more than 300,000 people). The health insurance scheme was reported to be financially viable at 30% coverage. Utilisation of primary care was up from 0.6 to 1.2 consultations per person per year for insured people. The authors report that large-scale health insurance for the informal sector can be efficient if it is operated by professional teams, if it is significantly subsidised by government so as to allow poor people to adhere, and if it is embedded in a nation-wide institution with a public purpose. The authors report that the credibility of a health system depends on the quality and packages of care offered. It is argued that large-scale health insurance cannot exist and function without the government addressing at least technical and procedural matters with regard to governance, such as a uniform and government-regulated fee-paying system and a digitalised accounting system for all health facilities and districts.