This study estimated the risk of catastrophic and impoverishing health expenditures (CHE/IHE) among households with under-five children affected by malnutrition in Uganda. Using data from the 2019/2020 Uganda National Panel Survey (UNPS), this study estimates the risk of CHE and IHE, with CHE defined as out-of-pocket health expenditures exceeding 10% of total household consumption, and IHE as health expenditures that push a household below the poverty line. Both measures were evaluated on a per capita basis to ensure consistency and equity in the comparison of financial hardship across households of different sizes. The study found that 18% of households experienced CHE/IHE, with 17% facing CHE and 5% facing IHE. Wasting was significantly associated with increased risk of CHE/IHE, and households with wasted children were 55% more likely to experience CHE/IHE compared to those without wasted children. Households in the second and third wealth quintiles had higher odds of incurring CHE/IHE. The study identified a U-shaped relationship between socio-economic status and CHE/IHE risk, where wealthier households did not significantly differ from the poorest households. This study underscores the intersection between child malnutrition and health-related financial vulnerability in Uganda, highlighting acute malnutrition as a key marker of risk for catastrophic or impoverishing health expenditures. The analysis supports the need for an integrated, equity-sensitive approach to financial protection in health that considers both the nutritional and economic vulnerabilities of households.
Resource allocation and health financing
This paper assessed the cost-effectiveness of performance-based financing in comparison with the direct facility financing. A decision-tree model incorporating key maternal and child health (MCH) services was developed to estimate cost-effectiveness. A total of US$205.9 million in 2021 dollars was spent on the PBF arm over the five years, with 71% allocated as incentive payments to health facilities and 19% as financial transfers to provincial purchasing agencies for contracting performance-based financing facilities and managing the performance-based financing programme. On average, the annual cost per capita was estimated at US$2.05 and US$1.71 for implementing the performance-based financing and direct facility financing program, respectively. Without the quality adjustment, the improvement in MCH services resulted in 1,372 lives saved over 2017–2021. The incremental cost-effectiveness ratio of the performance-based financing program reached US$1374 per quality-adjusted life years with substantial variation. After adjusting for quality, the incremental cost-effectiveness ratio of performance-based financing became smaller. Using three times the gross domestic product per capita in 2021 as the threshold, while performance-based financing was cost-effective, it had substantial variation. .
A top-down approach was used to understand the costs incurred by the government to provide PHC services in public health facilities. All facility and community-level expenditures incurred by the government and development partners on human resources, medicines, medical supplies, and facility operations were collected and included in the costing. The total funding gap was calculated as the difference between actual expenditure and estimated normative cost. Government expenditure on PHC substantially increased between fiscal year 2021/22 and 2022/23. Nevertheless, the spending level is significantly lower than global benchmarks, and the resources required to deliver quality PHC services according to the basic service standards. Moreover, the analysis revealed there are important differences in the levels of spending per capita across regions and health service delivery productivity. The Government of Tanzania’s PHC spending increased significantly over the two years, raising the per capita PHC expenditure and the expenditure per outpatient visit. As the Government of Tanzania increasingly finances health services from domestic sources, the authors note a key consideration for long-term planning in the context of declining partner funding to be the total funding required to provide quality PHC services equitably to the population.
Most people who have the greatest health needs don’t have enough money in their pockets to pay for expensive private care. In contrast, enough money in the government’s public purse would make all the difference. Governments can finance better public healthcare systems, train, employ and equitably distribute more staff, and build the necessary infrastructure, so that more people will live longer, healthier lives. This blog examines how tax justice can make all the difference in improving health. It draws from a chapter in the Global Health Watch 7. The authors argue "Taxes may be society’s superpower. Yet deep historic and structural global injustices mean that governments are often unable or unwilling to generate and allocate taxes in ways that dismantle inequalities effectively". The blog presents options to deliver on the five principles of tax justice - revenue, redistribution, repricing, representation, reparations- that would better finance the features of public sector health systems that promote equity and the national and international reforms that are needed to back this.
This paper investigates the catastrophic impact of out-of-pocket health expenditure by estimating the levels, intensities and distribution of catastrophic health expenditure among households in Tanzania. The study applied the Wagstaff and va-Doorslaer methodology using panel data 2020/2021. The study found that 21.9% of the respondents reported visiting a healthcare facility within four weeks before the survey. Over 50% reported an incidence of illness or injury within the same period. Among those who used health care, about 7.1% experienced catastrophic health expenditures. Poor households are more likely to experience catastrophic health costs than rich households. The authors conclude that out-of-pocket health expenditures expose poor households to more poverty and forcing them to resort to coping mechanisms that compromise their welfare. They propose that this necessitates the development of new and reinforced existing systems to protect impoverished households against out-of-pocket and catastrophic healthcare costs.
This retrospective, bottom-up costing study in Mozambique estimated the financial and economic costs from a payer perspective of delivering COVID-19 vaccines in 2022 USD, during the first year of introduction. Recurrent costs were collected for the initial rollout period and for a later, higher-volume period. The cost per dose for the first year of implementation was $1.14 for economic costs and $0.50 for financial costs. For the initial rollout period, when the volume delivered was low, the economic cost per dose was $3.56 and decreased considerably to $0.85 when the program delivered at scale and volume delivered increased to 225 doses/vaccination day. Opportunity costs made up a considerable share of the economic cost per dose, 73% and 49% respectively during the initial rollout and when the program delivered at scale. Qualitative interviews found that political prioritization and workers’ commitment made the program possible despite little financial investment. The cost of delivering COVID-19 vaccines in Mozambique was found to be low compared to other countries, due to reliance on existing resources and little additional investment into the program.
WHO's Director for Health Financing and Economics states that "the world is faced with a health financing emergency" due to the US government's decision to freeze or discontinue aid programmes and European governments' announcements to reduce aid, creating significant disruptions in aid ecosystems and national health systems. Health aid is projected to decline by 35-40% in 2025 compared to 2023 baseline, decreasing by approximately US$10 billion from US$25.2 billion in 2023, with eleven OECD countries announcing aid-related budget reductions for 2025. The impact is reported to be particularly severe in sub-Saharan Africa where US Development Assistance for Health represented up to 30% of current health expenditure in countries like Malawi or 25% in Mozambique or Zimbabwe. The crisis occurs against a backdrop where since 2006, per capita external aid in low-income countries (US$12.8 in 2022) has consistently surpassed domestic public spending on health, with poor countries spending around $8 per person per year on health through public financing. WHO reports that out-of-pocket spending accounted for 35% in Sub-Saharan African countries and government spending for 33% in 2022, creating the most inequitable financing system where poor households must sacrifice food and schooling to access health services. The organization is working with countries to identify financing gaps, protect the poorest populations, mobilize new revenue through better taxation including tobacco and sugary drinks taxes, and through enhanced highly concessional lending for cost-effective treatments.
This paper explored Kenya’s current cigarette tax regime which fails to control cigarette consumption efficiently, especially among young people. For example, the 2007 Global Youth Tobacco Survey revealed that 1 out of 10 students aged 13 to 15 years were current smokers, and boys were twice more likely to be using tobacco than girls. In 2013, WHO reported that this prevalence estimate remained relatively unchanged despite the adoption of the Tobacco Control Act. To date, no comparable survey has been published in Kenya, but in 2022, preliminary findings of a study conducted by the Kenya Tobacco Board on the use of tobacco and its products in four counties showed that consumption of e-cigarette and nicotine pouches was increasing among young people in Kenya. These developments underscore the need for reforming tax policies to protect young Kenyans from nicotine- and tobacco-related harms.
This study investigated the global strategies for implementing health financing equity that emerged from political declarations made before 2024. The authors identified the political declarations from a search of United Nations databases and snowball searches and extracted the global strategies of health financing equity implementation that emerged from the political declarations, using the WHO Health Financing Progress Matrix framework. In total, 40 political declarations were included. From these declarations emerged strategies of targeted, selective, contributory, universal, claims, proportionate, experimental, united, and aggregated financing to implement health financing equity in countries. Thirty nine of the 40 political declarations that labelled the global health community from 1944 until 2023 placed more efforts on duplicating the prevailing strategies. The declarations, categorised into nine groups (target, unity, universality, selectivity, contribution, aggregation, claims, experience, and proportionality-oriented political declarations), were used to press countries to implement the strategies, although the strategies could not claim effectiveness nor to be optimal for providing efficient and sustainable UHC in all countries. Authors propose careful management and adaptation of global strategies for the diverse needs of the diverse population.
Kenya aims to apply the National Health Insurance Fund (NHIF) as the ‘vehicle’ to drive universal health coverage (UHC). While there is some progress in moving the country towards UHC, the availability and accessibility to NHIF-contracted facilities may be a barrier to equitable access to care. The authors estimated the spatial access to 3858 NHIF-contracted facilities, with data on road network, elevation, land use, and travel barriers. Nationally, 81.4% and 89.6% of the population lived within 60- and 120-minute travel time to an NHIF-contracted facility respectively. At the county level, the proportion of the population living within 1-hour of travel time to an NHIF-contracted facility ranged from as low as 28.1% in Wajir county to 100% in Nyamira and Kisii counties. Overall, only four counties had met the target of having 100% of their population living within 1-hour (60 min) travel time to an NHIF-contracted facility. The author argues that this evidence of the spatial access estimates to NHIF-contracted facilities can inform contracting decisions by the social health insurer, especially focussing on marginalised counties where more facilities need to be contracted. particularly if accelerating progress towards achieving UHC uses social health insurance as a key strategy in Kenya.