Resource allocation and health financing

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 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.

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.

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.