Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20–64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005–2010) for RMNH expenditures (2005–2010) and 165 % for CH expenditures (2005–2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals.
Resource allocation and health financing
This research explored health financing policies for universal health coverage to identify issues that need to be addressed and approaches that can fruitfully be pursued in future policy design. The authors systematically searched the following databases: PubMed, SCOPUS, and COCHRANE up to January 2016 and included health financing policy assessment toward universal health coverage followed by a thematic and descriptive synthesis of data. Twenty three papers were included. The authors categorised dimensions that were important in health financing assessment to achieve UHC into nine groups as follows: stewardship, raising revenues and contribution methods, risk pooling and financial protection, resource allocation purchasing, human resources, policy stakeholders, policy content, policy context, and policy process. As countries commit to expand universal health coverage, the authors argue that these dimensions identified from the literature can help policy makers to prioritise competing demands, make rational choices, and adapt their approaches.
The International AIDS Economics Network (IAEN) Preconference in Durban in July 2016 demonstrated the strong political will to prioritise financing and harness economics to sustain the global HIV response and end AIDS, with high-level participation by ministers of health from Lesotho, Namibia, Botswana, Uganda, and Zimbabwe, along with the heads of UNAIDS and PEPFAR and experts from the CDC and the World Bank. At the policy level, a high-level panel discussed how evidence generated by economists can help facilitate engagement between the ministries of health and treasury and with civil society to keep health and HIV as a top priority in many countries. They also argued that investment cases should be made alongside human rights cases. These messages were echoed throughout the main conference. The face of HIV economics has changed, with young researchers from low- and middle-income countries making most of the presentations. The community’s focus has also changed in other promising ways. In 2000 health economists were just starting to explain why it makes economic sense to introduce antiretroviral (ARV) medicines into low-resource settings, and responsibility for financing HIV programs was seen to lie squarely in the hands of rich countries. In contrast, today energy is channeled towards sustaining the response and striving toward the 90-90-90 targets as efficiently as possible. Critically, the International AIDS Economics Network are supporting countries to mobilize ever more domestic resources and take ownership of their national programs.
The author of this article suggests that the individual multi-billionaire philanthropists who control and define the work of their foundations are able to exert massive influence in public policy and political agendas far beyond the average citizen. He questions this significant entitlement that money gives to a few people to influence global health, environment, education, food, medical, housing policies, whilst benefiting from global and economic inequality, including from the tax exemption they obtain. He cautions on the regression of the power of the state that this may imply, and calls for the legacy of the liberation struggle to be redeemed by building countervailing options and influence that increase citizen voice and engagement.
Return on investment (ROI) is an economic measure used to indicate how much economic benefit is derived from a program in relation to its costs. Interest in the use of ROI in public health has grown substantially over recent years. Given its potential influence on resource allocation, it is crucial to understand the benefits and the risks of using ROI to defend public health programs. In this paper, the authors explore those benefits and risks. They present two recent examples of ROI use in public health and conclude with a series of proposals to minimise the risks associated with using ROI to defend public health interventions. ROIs are increasingly being calculated to demonstrate the value of investments and ultimately to reinforce funding. Consequently, they argue that careful reflection is needed on how their use influences allocation decisions, especially given their role as an advocacy tool in the political arena. It is therefore crucial to understand the basics of how ROIs are calculated and to know their limitations and risks, rather than blindly accepting black-box numbers.
The author argues that the key to sustainable, adequate and predictable financing of Africa’s development no longer lies in the delivery of aid from traditional donors but largely in unlocking the domestic resource potential, so that the continent can harness more of its own revenue for development. Africa’s much celebrated growth over the last two decades has benefited in large part from public revenues derived from the sale of natural resources. While the tax base remains narrow, and tax compliance levels low on the continent, revenues from tax collection continue to increase, rising from USD 259.3 billion in 2005 to USD 527.3 billion in 2012. A 2013 study by NEPAD and UNECA shows that the fundamentals and resource potential exist for the continent to raise more financial resources domestically to implement its development programmes and finance its own institutions. At the same time, South-South Cooperation in Africa is increasing, with more public finances being channelled from emerging economies to Africa via various bilateral and multi-lateral arrangements. In contrast, there is clear evidence that Official Development Assistance (ODA) from traditional donors is dwindling – falling from 38% as a proportion of all external financial flows to Africa in 2000 to 27% in 2014. Africa’s reliance on aid and the sale of natural resources, as opposed to broad-based tax collection, for example, is argued to have distorted accountability over public expenditure, with governments incentivised to meet the needs of the extractive and commodity private sector corporations and the priorities of external funders, as opposed to those of their citizens. The author suggests that aid will achieve its best outcomes when it is used in ways that complement and bolster domestic financing, support other financing mechanisms and help African countries to better manage revenues for their citizens’ development.
Governments are being overwhelmed by the rapid growth of Africa’s cities. Strategic planning has been insufficient and the provision of basic services is worsening. Since the 1990s, widespread devolution has substantially shifted responsibility for coping with urbanisation to local authorities, yet municipal governments across Africa receive a paltry share of national income with which to discharge their responsibilities. Responsible city authorities are examining how to improve revenue generation and diversify their sources of finance. Following the creation of a sustainable development goal for cities (SDG 11), and ahead of the Habitat III summit in October 2016, this Africa Research Institute event examined some of the financing options and the urgent need for a proactive approach on the part of national and municipal governments. The speakers in the podcast include, Professor Susan Parnell Department of Environmental and Geographical Sciences, Jeremy Gorelick, Lead technical adviser, Dakar Municipal Finance Program and Dr Beacon Mbiba, Senior Lecturer, Urban Policy and International Development.
This research project investigates how governments can generate more of their own national resources for health and reduce their dependence on donor funding, which can be both unstable and unsustainable. Case studies in Nigeria, South Africa and Kenya, document country experiences of increasing the effectiveness of their tax collection services and investigate how this has contributed to increased health sector spending. Governments in Kenya, Lagos State (Nigeria) and South Africa have increased domestic tax revenue by expanding the tax base and improving the efficiency of tax collection systems. Specific efforts have been made to reach the informal sector by taxing businesses (in Kenya) and reaching informal trade associations (in Nigeria). Political support to tax policy reforms and the tax collection agencies led to additional funding for their operations and strengthened human resource capacity. Despite achievements in raising tax revenue, the share of government spending allocated to the health sector has not increased. A critical challenge for Ministries of Health is to make a better case for health during budget negotiations, and to demonstrate the social and economic benefits of health investments.
This paper argues that there are useful lessons for South Africa (and other countries in putting into place the legal and institutional frameworks system and systems for implementation of universal health coverage (UHC). Thailand has received widespread international recognition as one of several middle-income countries that have made enormous progress in building a UHC system and in achieving ‘good health at low cost. Thailand has a strong national fund called the Universal Coverage (UC) Fund, which covers 75% of its population, the rest being covered by social health insurance and the Civil Servant Medical Benefit Scheme. Thailand has a well-developed purchaser-provider split, with the independent UC Fund established by legislation, with a multi-stakeholder governing body including private and civil society representatives. Its internal structure, operating systems, procedures and information technology are firmly established, accessible and affordable in the middle-income country context. It uses capitation purchasing, with a focus on primary care systems. The National Health Security Office (NHSO), which manages the UC Fund, concentrates on pooling and strategic purchasing; it has no revenue collection function, as the scheme is financed through an annual budget. The NHSO manages the disease prevention and health promotion budget for all Thai citizens, thus assisting the other schemes and providing a strong focus on prevention and promotion. The article discusses these and other positive features and the challenges as learning for South Africa and other countries financing UHC.
The author observes that insufficient, ineffective and inequitable public spending on child-focused sectors and programmes stands as the biggest barrier to enjoyment of rights by all children. To date, only 7 countries in Africa have at some point in time met the Abuja target for African governments to allocate at least 15% of their budgets to health. Furthermore, no African country has so far met the Dakar Commitment on Education for All to allocate at least 7% of its GDP to education, which should have increased to 9% in 2010. In 2014, with the exception of Malawi, Niger and South Africa, who have come close by spending between 5.5-7%, the rest of African states are spending below 5% of their GDP on education, well below the Dakar Commitment. The author asks: What then are some of the concrete actions that African states should undertake to ensure sufficient, equitable, sustainable and effective public investments in children? Domestic revenue from effective and progressive taxation will continue to be the most significant and sustainable source of revenue for states to finance investments in children. He argues that, in line with the overarching SDG focus on ‘leaving no one behind’, African governments should develop and implement fiscal policies and budgets that promote equity. In line with the spirit of SDGs and of the African Charter on the Rights and Welfare of the Child, African states should create formal platforms and opportunities for children and their representatives to meaningfully participate in planning and public budgeting, including to hold duty bearers to account for their commitments to children.