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.
Resource allocation and health financing
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).
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.
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.
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 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.
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.
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.
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.