Resource allocation and health financing

Sugar tax could make SA a world leader in obesity prevention – WHO
Medical Brief: African Medical Digest February 2017.

South Africa could prevent almost half-a-million deaths over 40 years by introducing its proposed tax on sugary drinks, according to the World Health Organisation (WHO). “No country in the world has hit obesity with a 20% tax, so South Africa could be a world leader and reduce childhood obesity,” said the WHO’s Dr Temo Waqanivalu. He was speaking at the recent public hearing on the proposed tax on sugary drinks, convened by parliament’s committees of finance and health. “A child eating burger and chips, washed down with sugary drink and followed by crisps and chocolate bar, would have to run a half-marathon to get rid of the effects. You cannot out-exercise a bad diet,” said Waqanivalu. The report says at the packed meeting, all parties agreed that South Africa had a significant problem with obesity but while academics praised the tax, industry players pleaded for other measures. Treasury has proposed a tax of 2.29c per gram of sugar on soft drinks, which would work out to be about a 20% tax on a Coca Cola.

The influence of power and actor relations on priority setting and resource allocation practices at the hospital level in Kenya: a case study
Barasa E; Cleary S; Molyneux S; English M: BMC Health Services Research, 2016, doi: 10.1186/s12913-016-1796-5

Priority setting and resource allocation in healthcare organisations often involves the balancing of competing interests and values in the context of hierarchical and politically complex settings with multiple interacting actor relationships. Despite this, few studies have examined the influence of actor and power dynamics on priority setting practices in healthcare organisations. This paper examines the influence of power relations among different actors on the implementation of priority setting and resource allocation processes in public hospitals in Kenya. The authors used a qualitative case study approach to examine priority setting and resource allocation practices in two public hospitals in coastal Kenya. They collected data by a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations in case study hospitals over a period of 7 months. The authors applied a combination of two frameworks, Norman Long’s actor interface analysis and VeneKlasen and Miller’s expressions of power framework to examine and interpret findings. The interactions of actors in the case study hospitals resulted in socially constructed interfaces between: 1) senior managers and middle level managers 2) non-clinical managers and clinicians, and 3) hospital managers and the community. Power imbalances resulted in the exclusion of middle level managers (in one of the hospitals) and clinicians and the community (in both hospitals) from decision making processes. This resulted in, amongst others, perceptions of unfairness, and reduced motivation in hospital staff. It also puts to question the legitimacy of priority setting processes in these hospitals. The authors suggest that designing hospital decision making structures to strengthen participation and inclusion of relevant stakeholders could improve priority setting practices. This should however, be accompanied by measures to empower stakeholders to contribute to decision making. They also suggest that strengthening soft leadership skills of hospital managers could also contribute to managing the power dynamics among actors in hospital priority setting processes.

Financing the HIV response in sub-Saharan Africa from domestic sources: Moving beyond a normative approach
Remme M; Siapka M; Sterck O; Ncube M; Watts C; Vassalla A: Social Science & Medicine 169, 66–76, 2016

This paper examines the potential to expand public HIV financing, and the extent to which governments have been utilising these options. First, with data from the 14 most HIV-affected countries in sub-Saharan Africa, the authors estimate the potential increase in public HIV financing from economic growth, increased general revenue generation, greater health and HIV prioritisation, as well as from more unconventional and innovative sources, including borrowing, health-earmarked resources, efficiency gains, and complementary non-HIV investments. The authors then adopt a novel empirical approach to explore which options are most likely to translate into tangible public financing, based on cross-sectional econometric analyses of 92 low and middle-income country governments' most recent HIV expenditure between 2008 and 2012. If all fiscal sources were simultaneously leveraged in the next five years, public HIV spending in these 14 countries could, it is estimated, increase from US$3.04 to US$10.84 billion per year. This could cover resource requirements in South Africa, Botswana, Namibia, Kenya, Nigeria, Ethiopia, and Swaziland, but not even half the requirements in the remaining countries. The empirical results suggest that, in reality, even less fiscal space could be created (a reduction by over half) and only from more conventional sources. International financing may also crowd in public financing. The authors observe that most HIV-affected lower-income countries in sub-Saharan Africa will not be able to generate sufficient public resources for HIV in the medium-term, even if they take very bold measures. Considerable international financing will be required for years to come. HIV funders will need to engage with broader health and development financing to improve government revenue-raising and efficiencies

Improving priority setting practices in Kenya's hospitals: Recommendations for county decision-makers and hospital managers
Barasa E; English M: Kemri Wellcome Trust, Kenya, 2016

KEMRI-Wellcome Trust has conducted research to understand how county hospitals in Coastal Kenya set priorities and allocate resources between services. Data was collected in 2012 and 2013. This brief presents the key findings from the research, showing how hospital managers set priorities and the reasons behind their decisions. Even though the study was conducted pre-devolution, findings remain relevant post-devolution, especially in counties where hospitals still enjoy financial autonomy and as they plan ways to structure hospital financing and priority setting. The brief provides recommendations for county departments of health to improve hospital financing and budgeting, and for hospital managers to improve priority setting and ensure a fair allocation of resources between services. Key messages from the report included that hospitals lack explicit processes for setting healthcare priorities; this provides room for the use of inappropriate priority setting criteria such as lobbying and favouritism. Evidence is not used in decision- making. Hospitals are severely under-resourced and depend on user fee revenues. This has turned hospitals into revenue-maximisers whereby managers prioritise services that generate revenue through user-fees and overlook services with limited moneymaking potential, including those for young children and disabled people. Many key stakeholders including middle level managers, clinicians and community members, are not included in priority setting processes. It is important for hospital managers to institute clearly defined procedures and ensure that priority setting is inclusive. Hospital managers are often clinicians with limited training and skills in management and leadership. Many did not choose to become leaders. Educational institutions and county departments of health both have a role to play in strengthening management and leadership capacity, as well as incentivising hospital managers.

Setting healthcare priorities: a description and evaluation of the budgeting and planning process in county hospitals in Kenya
Barasa E; Cleary S; Molyneux S; English M: Health Policy and Planning, 2016, doi: 10.1093/heapol/czw132

This paper describes and evaluates the budgeting and planning processes in public hospitals in Kenya. The authors used a qualitative case study approach to examine these processes in two hospitals in Kenya and collected data by in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), by a review of documents, and non-participant observations within the hospitals over a 7 month period. The budgeting and planning process in the case study hospitals was characterized by lack of alignment, inadequate role clarity and the use of informal priority-setting criteria. The hospitals incorporated economic criteria by considering the affordability of alternatives, but rarely considered the equity of allocative decisions. In the first hospital, stakeholders were aware of - and somewhat satisfied with - the budgeting and planning process, while in the second hospital they were not. Decision making in both hospitals did not result in reallocation of resources. With regard to procedures, the budgeting and planning process in the first hospital was more inclusive and transparent, with the stakeholders more empowered compared to the second hospital. In both hospitals, decisions were not based on evidence, implementation of decisions was poor and the community was not included. There were no mechanisms for appeals or to ensure that the procedures were met in both hospitals. Public hospitals in Kenya could improve their budgeting and planning processes by harmonising these processes, improving role clarity, using explicit priority-setting criteria, and by incorporating both consequences (efficiency, equity, stakeholder satisfaction and understanding, shifted priorities, implementation of decisions), and procedures (stakeholder engagement and empowerment, transparency, use of evidence, revisions, enforcement, and incorporating community values).

The effects of Maternal and Child Health insurance cards on improving equity in access and use of maternal and child health care services in Tanzania: a mixed methods analysis.
Kuwawenaruwa A; Mtei G; Baraka J; Tani K: Journal of Health, Population and Nutrition 35(37), 2016

Inequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services. A mixed methods approach was used in Rungwe district where maternal and child health insurance cards had been implemented. To assess equity, three categories of beneficiaries’ education levels were used and were compared to that of women of reproductive age in the region from previous surveys. To explore factors influencing women’s decisions on delivery site and use of the maternal and child health insurance card and attitudes towards the birth experience itself, a qualitative assessment was conducted at representative facilities at the district, ward, facility, and community level. A total of 31 in-depth interviews were conducted on women who delivered during the previous year and other key informants. Women with low educational attainment were under-represented amongst those who reported having received the maternal and child health insurance card and used it for facility delivery. Qualitative findings revealed that problems during the current pregnancy served as both a motivator and a barrier for choosing a facility-based delivery. Decision about delivery site was also influenced by having experienced or witnessed problems during previous birth delivery and by other individual, financial, and health system factors, including fines levied on women who delivered at home. To improve equity in access to facility-based delivery care using strategies such as maternal and child health insurance cards it is necessary to ensure beneficiaries and other stakeholders are well informed of the programme, as only giving women insurance cards does not guarantee their access to facility-based delivery.

A victory today for Universal Health Coverage - Statement from Oxfam
Kamal-Yanni M: Global Health Check, November 2016

Oxfam have announced that it is now possible to count the cost of paying for healthcare for households around the world. A group of experts tasked with developing the indicator framework to measure progress towards the Sustainable Development Goals (SDGs), have agreed to measure financial risk protection of universal health coverage by ‘’proportion of the population with large household expenditures on health as a share of total household expenditure or income”. This signals a great shift in from the previous dangerous indicator that would just measure population with access to health insurance or a public health system. The previous indicator was flawed because it did not measure whether or not people were actually financially protected against potentially catastrophic costs for health care. It would have also failed to measure progress across different income groups or by gender. It was also dangerous as it sent a signal to governments around the world that health insurance was the route to achieving Universal Health Coverage despite robust and scientific evidence that many voluntary health insurance schemes have exacerbated inequality. The change to the new indicator that ‘measures what matters’ was advocated for civil society organisations, academics, development agencies and statistical authorities expressed their deep concerns through letters, lobbying and public statements.

Male involvement in the National Health Insurance Fund (NHIF/KfW) prepaid insurance card for pregnant women in Pangani District, Tanzania
Kassimu T: Resilient and responsive health systems (RESYST) blog, Muhimbili University of Health and Allied Sciences, Tanzania, September 2016

In Tanzania, reasons for low use of maternal care are complex, including shortage of resources, long distances to services, high costs and low capacity to provide services. ‘Gender exclusion’, in this case the exclusion of men in planning or implementing interventions, is also identified to be a major barrier to achieving improved maternal and child health. The author reports that men were involved in the implementation of Tanzania's NHIF/KfW prepaid health insurance card scheme in various ways: during its design; inauguration; registration; and in community sensitisation at the village level and health facilities. At the health care facilities, women are encouraged to attend with their partners during antenatal visits. This is to ensure they are all tested together for HIV, as well as educated on how to take care of the pregnancy and prepare for delivery. This encouraged male involvement and payment of because of any costs of using services. Women had a different views with regard to men’s involvement in the provision of reproductive and child health care services. Participants identified strategies to improve male involvement in the implementation of NHIF/KfW prepaid insurance card in Pangani District. Communication between partners was one of the ways to increase their men’s involvement. In the villages, there are routine meetings every three months. During the meeting, participants discussed various topics and made decisions together for the betterment of the whole community. Men pointed out that giving them more knowledge about health care services and facility practices would enhance their participation in care. The author argues that improvement in the health care provision and community sensitisation of the importance of male partner involvement in the implementation of maternal and child health care programmes needs to be prioritised in order to improve their participation and mitigate the effect of socio-economic and cultural barriers to access.

South African National Department of Health (NDoH) Finalising Draft of National Health Insurance Financing Models
Hlabangane S: EHealth News, South Africa, September 2016

South African Health Minister, Dr Aaron Motsoaledi, announced that a draft set of the National Health Insurance (NHI) ‘financing scenarios’ are ready for provincial health Members of Executive Councils (MECs) in October 2016. According to the legal brief Policy Watch, the Minister said that – in finalising government policy on universal healthcare – the department will consider each scenario and carefully reflect on the ”very useful suggestions” received from stakeholders following the release of a draft White Paper in December 2015 for comment. Noting that the costs associated with implementing universal healthcare are ”influenced by many factors, including design elements and the pace of implementation,” Dr Motsoaledi emphasised the importance of focusing on the implications of each funding scenario for incrementally introducing the necessary reforms. With that in mind, the draft scenarios will be informed by an “estimation framework” based on “configurations” of projected service demand, service delivery and associated costs ‘at each level of care. There are views that there are many uncertainties and unaddressed issues in the White Paper, including in the funding model. Meanwhile, the Treasury has allocated South African Rand 4.5bn to renovate healthcare facilities across 11 NHI pilot projects and allocated SAR300 million on developing a national electronic medicine stock management system, a key element for NHI outlined in the White paper.

Universal Health Coverage in Africa: A framework for action. Joint UHC working paper
World Bank: World Bank Group, August 2016

Africa’s population is estimated to reach 2.5 billion by 2050, raising a challenge for progress toward Universal Health Coverage (UHC), the principle that everyone receives needed health services without financial hardship. The primary reason for investing in UHC is argued to be a moral one: it is not acceptable that some members of society should face death, disability, ill health or impoverishment for reasons that could be addressed at limited cost. However, UHC is also argued to be a good investment. Prevention of malnutrition and ill health is likely to have enormous benefits in terms of longer and more productive lives, higher earnings, and averted care costs. Effectively meeting demand for family planning will accelerate the fertility transition, which in turn will result in higher rates of economic growth and more rapid poverty reduction. And strong health and disease surveillance systems halt epidemics that take lives and disrupt economies. The authors report for example that In 2015, the forgone economic growth due to Ebola amounted to more than a billion US dollars in the three countries hit by the epidemic.

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