Resource allocation and health financing

Trends in national and provincial health and HIV/ AIDS budgeting and spending in South Africa
Centre for Economic Governance and AIDS in Africa (CEGAA): CEGAA Occasional Paper December 2013

This paper provides an analysis of trends in health and HIV/AIDS budgeting and spending, as well as trends in some related spending areas that are important for effective HIV and AIDS management in South Africa. The endless fight against HIV and AIDS would not have been possible without financial investment and rigorous research in the HIV and AIDS field. The recent procurement and distribution of the triple combination therapy for AIDS in South Africa depicts the commitment by government to intensify the fight against the pandemic and to enhance good adherence among those taking AIDS treatment.

12th BEMF meeting: How Do We Know If There is Enough Money to Provide For Delivery of Services?
Section 27: November 2013

The Budget and Expenditure Monitoring Forum (BEMF) in South Africa hosted a two-day workshop before the Minister of Finance Pravin Gordhan tabled the 2013 Medium Term Budget Policy Statement in Parliament. Under the theme “Reflections on the Medium Term Budget Policy Statement : How Do We Know If There is Enough Money to Provide For Delivery of Services?” numerous civil society organisations and representatives from organised labour, Parliament, the Auditor General’s office and academia came together to develop a deeper understanding of Government’s future medium term spending plans for 2014 – 2016. The workshop was opened by a presentation on what the National Development Plan (NDP) envisions for public service delivery and the implications of the NDP goals for the allocation of resources. An overview of South Africa’s macro-economic policy was provided illustrating the political choices made by Government to raise money for the delivery of services while promoting economic growth and curbing public debt. The workshop then turned to an assessment of the adequacy of the Education and Health budgets and analysis of the Social Development budgets for funding of Children’s Act services. The workshop also provided participants with an opportunity to be updated on the role of the Parliamentary Budget Office and the critical role that Parliament can and should be playing in exercising oversight of the Executive’s budget policy proposals. On the last day of the workshop participants were given an opportunity to hear about various budget and expenditure monitoring methodologies ranging from social audits to citizen journalism. A 2014 steering committee was established to guide the activities of the forum into 2014.The presentations given at the meeting are provided in the website.

Brazil-Africa technical cooperation in health: what’s its relevance to the post-Busan debate on ‘aid effectiveness’?
Russo G, Cabral L, and Ferrinho P: Globalization and Health 9 (2), 2013

Brazil is becoming an influential player in development cooperation, also thanks to its high-visibility health projects in Africa and Latin America. The 4th High-level Forum on Aid Effectiveness held in Busan in late 2011 marked a change in the way development cooperation is conceptualised. The present paper explores the issue of emerging donors’ contribution to the post-Busan debate on aid effectiveness by looking at Brazil’s health cooperation projects in Portuguese-speaking Africa. The authors first consider Brazil’s health technical cooperation within the country’s wider cooperation programme, aiming to identify its key characteristics, claimed principles and values, and analysing how these translate into concrete projects in Portuguese-speaking African countries. Then study discuss the extent to which the Busan conference has changed the way development cooperation is conceptualised, and how Brazil’s technical cooperation health projects fit within the new framework. The authors conclude that, by adopting new concepts on health cooperation and challenging established paradigms - in particular on health systems and HIV/AIDS fight - the Brazilian health experience has already contributed to shape the emerging consensus on development effectiveness. However, its impact on the field is still largely unscrutinised, and its projects seem to only selectively comply with some of the shared principles agreed upon in Busan. Although Brazilian cooperation is still a model in the making, not immune from contradictions and shortcomings, it should be seen as enriching the debate on development principles, thus offering alternative solutions to advance the discourse on cooperation effectiveness in health.

Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya
Mulupi S, Kirigia D and Chuma J: BMC Health Services Research 13:474, 12 November 2013

Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. This study contributes to this process by exploring through a cross sectional survey communities’ understanding and perceptions of health insurance and their preferred designs features. Kenyans should understand the implications of health financing reforms and their preferred design features considered to ensure acceptability and sustainability. About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance schemes but limited knowledge of how health insurance functions as well as understanding of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority.

Ghana’s National Health Insurance Scheme: a national level investigation of members’ perceptions of service provision
Dixon J, Tenkorang EY and Luginaah I: BMC International Health and Human Rights 13(35): 2013

Ghana’s National Health Insurance Scheme (NHIS) was established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing. This study analyses NHIS members’ perceptions of service provision at the national level using data from the 2008 Ghana Demographic Health Survey. Results demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, the study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. The authors conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate.

Obstacles to Increasing Tax Revenues in Low Income Countries
Moore M: ICTD Working Paper 15, UNRISD, December 2013

This paper is focused on the question: why do the governments of low income countries not raise more tax revenues? Two different but complementary approaches are used to answer it. The first approach is comparisons: among countries today, and within countries over time. This approach tends to generate relatively conservative answers to the central question. It leads to an emphasis on the ‘sticky’ nature of the taxation. For any individual country in ‘normal times’ – i.e. excluding situations of war, major internal conflict, the collapse or rapid reconstruction of state power - revenue collections, measured as a proportion of GDP, do not change much from year to year. This is partly because effective taxation systems require a great deal of coordination and cooperation between revenue agencies and other organisations, both inside and outside the public sector. It is hard quickly to improve the effectiveness of a complex organisational network. The ‘stickiness’ of tax collections also reflects the fact that the overall tax take – i.e. the proportion of GDP raised as public revenue – is to a significant degree determined by the structure of national economies. For logistical reasons, it is much easier to raise revenue from economies (a) that are high income, urban and non-agricultural and (b) where the ratio of international trade to GDP is high. The government of the average low income country raises less than 20 per cent of GDP in revenue. The author argues that this weakens the ability of such governments to aim to match OECD tax takes of 30-45 per cent of GDP.

Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya
Mulupi S, Kirigia D and Chuma J: BMC Health Services Research 13: 474, 12 November 2013

Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. This study contributes to this process by exploring communities' understanding and perceptions of health insurance and their preferred designs features. Data collection methods included a cross-sectional household survey and focus group discussions. About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance but limited knowledge of how it functions or of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority.

Does investment in the health sector promote or inhibit economic growth?
Reeves A, Basu S, McKee M, Meissner C, Stuckler D: Globalization and Health 2013, 9:43

In this study, the authors evaluate the economic effects of alternative types of government spending by estimating “fiscal multipliers” (the return on investment for each $1 dollar of government spending). While the study is implemented using data from Europe the findings may have wider relevance: they indicate that government spending on health may have short-term effects that make recovery more likely.

Health technology assessments as a mechanism for increased value for money: Recommendations to the Global Fund
Teerawattananon Y, McQueston K, Glassman A, Yothasamut J and Myint CY: Globalization and Health 9(35), 21 August 2013

The Global Fund is experiencing increased pressure to optimise results and improve its impact per dollar spent, according to this study. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. The authors assess the efficacy of current Global Fund investment and examine how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidised by the Global Fund. In addition, they identify areas where the application of HTAs can exert the greatest impact and propose ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, they address the challenges facing the Global Fund in realising the full potential of HTAs.

The 2013 DATA Report: Financing the Fight for Africa’s Transformation
One.org: Berlin, 2013

The world has officially entered the final leg of its 15-year journey to halve extreme poverty and reduce child mortality by two-thirds, reverse the tide against HIV/AIDS and malaria, and ensure that more people have access to basic services, such as primary education and safe drinking water. Despite a challenging global economic environment, many low and middle-income countries are making dramatic progress towards the highly ambitious MDG targets. ONE’s 2013 DATA Report examines the recent progress of individual countries against eight MDG targets, focusing particular attention on sub-Saharan Africa, and compares that progress against African government and donor spending in three key poverty-reducing sectors: health, education, and agriculture.

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