Resource allocation and health financing

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.

Countdown to 2015 country case studies: what can analysis of national health financing contribute to understanding MDG 4 and 5 progress?
Mann C; Ng C; Akseer N; Bhutta Z; et al.: BMC Public Health 16(Suppl 2) (792), 2016, doi: 10.1186/s12889-016-3403-4

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.

Health Financing Assessment and Policy Analysis toward Universal Health Coverage: A Systematic Review of Qualitative Research
Sakha M; Rashidian A; Bazyar M; Sari A; Yazdani S; Moghadam A: Global Journal of Health Science 9(5) 2016, doi:

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.

Economics, financing and HIV: Reflections from the 2016 International AIDS Economics Network Preconference
Forsythe S; Barker C; Chaitkin M: Results for Development, August 2016

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.

Mega-philanthropy: Charitable deeds or monopoly tyranny?
Pheko L: Pambazuka News, 28 July 2016

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.

What are the benefits and risks of using return on investment to defend public health programs?
Broussellea A; Benmarhniab T; Benhadjc L: Preventive Medicine Reports 3, 135-135, 2016

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.

Making aid and domestic public finance work for Africa and its people
Chagutah T: Pambazuka News, June 2016

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.

Podcast: Sustainable funding for Africa’s cities
African Research Institute, July 2016

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.