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.
Resource allocation and health financing
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.
Zimbabwe has received substantial external assistance for health since the early 2000s, including funding earmarked for, or framed as, health systems strengthening (HSS). This study sought to examine whether external assistance has strengthened the health system (i.e. enabled comprehensive changes to health system performance drivers) or has just supported the health system (by increasing inputs and improving service coverage in the short term). Between August and October 2022, the authors conducted in-depth key informant interviews with 18 individuals and reviewed documents to understand: (1) whether external funding has supported or strengthened Zimbabwe’s health system since the 2000s; (2) whether the experience of COVID-19 fosters a re-examination of what had been considered as HSS during the pre-pandemic era; and (3) areas to be reconsidered for HSS post COVID-19. The findings suggest that external funders have supported Zimbabwe to control major epidemics and avert health system collapse. However, the COVID-19 pandemic showed that supporting the health system is not the same as strengthening it, as it became apparent at that time that the health sector is plagued with several system-wide bottlenecks. The authors analyse external funding to be fragile and highly unsustainable, reinforcing the oft-ignored reality that HSS is a sovereign mandate of country-level authorities, and one that falls outside the core interests of external funders. The key positive lesson from the pandemic was that Zimbabwe is capable of raising domestic resources to fund HSS. However, they note that there is no guarantee that such funding will be maintained, calling for attention to government’s stewardship for HSS, and for external funders to re-examine whether their funding really strengthens the national health system.
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.
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.