Achieving the 2030 Agenda for Sustainable Development requires trillions of dollars annually. The authors indicate that global public and private investment would be sufficient – but only if financial resources were invested in and aligned with sustainable development. This requires a comprehensive approach, which mobilises public finance, sets appropriate public policies and regulatory frameworks, unlocks the transformative potential of people and the private sector, and incentivises changes in consumption, production and investment patterns in support of sustainable development. The Addis Ababa Action Agenda (AAAA) presents a policy framework that realigns financial flows with public goals. Official development assistance (ODA) remains crucial, particularly for countries most in need, but alone is not be sufficient. The AAAA addresses all sources of finance: public and private, domestic and international and stresses the importance of long-term investment, and the need for all financing to be aligned with sustainable development. It includes several new commitments by Governments: A new social compact to provide social protection and essential public services for all; A global infrastructure forum to bridge the infrastructure gap; An ‘LDC package’ to support the poorest countries; A Technology Facilitation Mechanism to advance to the SDGs; Enhanced international tax cooperation to assist in raising resources domestically; Mainstreaming women’s empowerment into financing for development. Additional cross-cutting issues include scaling up efforts to end hunger and malnutrition, promoting inclusive and sustainable industrialisation, full and productive employment and decent work for all, peaceful and inclusive societies, and protecting the ecosystem.
Resource allocation and health financing
Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.03–7.5 % in Kenya, with a statistically significant difference in the proportion of spending on SRH services across income quintiles. The poorest households in Kenya spent ten times more on seeking care than the least poor households. The most common coping mechanisms were receiving [money] from partner or household members and using own savings or regular income. Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings.
There is increasing interest in understanding how Results Based Financing (RBF) can improve efficiency, effectiveness and accountability in programming towards
Universal Health Coverage and improved health outcomes at scale. The Northern Uganda Health (NU Health) is a controlled implementation study to assess the costs and benefits of RBF relative to conventional Input Based Financing (IBF). The study design aimed to isolate the main effect of the financing modality in terms of quality and quantity of health service provision. Programme data and the results of an independent evaluation confirm a range of key findings. These include: A significant reduction in barriers to access and increase in health service utilisation; a three to eight fold improvement in adherence to standard treatment algorithms/quality of care for the major childhood killers: diarrhoea, malaria and pneumonia; and, particularly dramatic improvements in care and utilisation at the lowest level facilities, harbouring the promise of real progress toward Universal Health Coverage.
Africa has enjoyed a growth momentum since 2000 after the wasted years of the 1980s and much of the 1990s. However, eradicating poverty will require huge resources, which existing funding strategies will be unable to generate. Global commodity prices have fallen sharply; capacity to mobilise domestic revenues is waning; and aid has been insufficient in plugging funding gaps. Revenue bargains in which states extract revenues from citizens in exchange for investments that impact positively on well-being may be key to financing Africa’s development. They can substantially increase revenues, nurture effective state-citizen relations, force companies to pay correct taxes, push fragmented systems of service provision in the direction of universalism, improve policy space and make aid more effective.
How to finance progress towards universal health coverage in low-income and middle-income countries is a subject of intense debate. The authors investigated how alternative tax systems affect the breadth, depth, and height of health system coverage. The authors used cross-national longitudinal fixed effects models to assess the relationships between total and different types of tax revenue, health system coverage, and associated child and maternal health outcomes in 89 low-income and middle-income countries from 1995–2011. Tax revenue was a major statistical determinant of progress towards universal health coverage. Each US$100 per capita per year of additional tax revenues corresponded to a yearly increase in government health spending of $9·86, adjusted for GDP per capita. This association was strong for taxes on capital gains, profits, and income, but not for consumption taxes on goods and services. In countries with low tax revenues (<$1000 per capita per year), an additional $100 tax revenue per year substantially increased the proportion of births with a skilled attendant present by 6·74 percentage points and the extent of financial coverage by 11·4 percentage points. Consumption taxes, a more regressive form of taxation that might reduce the ability of the poor to afford essential goods, were associated with increased rates of post-neonatal mortality, infant mortality, and under-5 mortality rates. The authors did not detect these adverse associations with taxes on capital gains, profits, and income, which tend to be more progressive. Increasing domestic tax revenues is integral to achieving universal health coverage, particularly in countries with low tax bases. Pro-poor taxes on profits and capital gains seem to support expanding health coverage without the adverse associations with health outcomes observed for higher consumption taxes. Progressive tax policies within a pro-poor framework might accelerate progress toward achieving major international health goals.
The paper reports on work to collect, compile and evaluate publicly available national health accounts (NHA) reports produced worldwide between 1996 and 2010. The authors compiled data in the four main types used in these reports: (i) financing source; (ii) financing agent; (iii) health function; and (iv) health provider. The authors identified 872 NHA reports from 117 countries containing a total of 2936 matrices for the four data types. Most countries did not provide complete health expenditure data: only 252 of the 872 reports contained data in all four types. Some countries reported substantial year-on-year changes in both the level and composition of health expenditure that were probably produced by data-generation processes. All study data are publicly available at http://vizhub.healthdata.org/nha/. Data from NHA reports on health expenditure are often incomplete and, in some cases, of questionable quality. Better data would help finance ministries allocate resources to health systems, assist health ministries in allocating capital within the health sector and enable researchers to make accurate comparisons between health systems.
With 3.1 million people on antiretrovirals (ARV), South Africa has the world’s largest ARV programme. Sustaining it – and the HIV response – is argued to more than double in cost in the next two decades, according to new research. The research reported in this paper modelled the cost of county’s HIV response and what it will take to meet ambitious international development targets adopted by the country in 2014. The research found that South Africa’s HIV programme will cost about R40 billion each year by 2033 – more than double the R21 billion budgeted for the programme in the next financial year. The analysis also revealed the top 18 most cost-effective ways South Africa can tackle its epidemic. Top of the list was increasing condom distribution, medical male circumcision and mass communication campaigns promoting safer sex among teens.
In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, the authors consider inequalities in access to the DG for patients on ART and implications of DG access for on-going access to healthcare. Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. Grant recipients were comparatively worse off than non-recipients in terms of employment and wealth. The regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed. Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG. The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.
South Africa's proposed National Health Insurance (NHI) scheme, is many years away, but many of the country’s 10 pilot sites are reported to be making progress. Of the 10 NHI pilot districts Health e-news investigated all – with the exception of OR Tambo in the Eastern Cape – are making reasonable progress in improving public health. The pilot districts, covering 20 percent of the population, were set up almost five years previously after Health Minister Aaron Motsoaledi announced the NHI as government policy. Negative patient experiences in public health facilities led government to concentrate on cleaning its own house before attempting any engagement of the NHI with the private sector.
The Ebola crisis exposed the weaknesses of healthcare systems in low- and middle-income countries created mainly by insufficient funding. Given the global community’s commitment to universal health coverage (UHC), the Ebola outbreak has prompted serious reflection among health policy decision-makers. One of the central features of this debate is financing: how can relatively poor countries find the money to pay for universal health coverage? To date, low- and middle-income countries have been growing toward UHC through social health insurance systems funded through employment. Yet, progress has been slow and uneven leaving people in the informal sector, who are the majority of the population, out was insurance schemes. Rather than seeking innovative solutions to this old problem, this blog outlines how Aaron Reeves argues that what is needed is a renewed commitment to an old solution: tax-based financing. Using data from low- and middle-income countries my colleagues and I examined the association between tax revenues and health spending. We found that tax revenue was a major statistical determinant of progress towards UHC. Each $10 per-capita increase in tax revenue was associated with an additional $1 of public health spending per capita. Whereas each $10 increase in GDP per capita was associated with an increase of $0.10. Crucially, tax revenues sit on the pathway between economic growth and health spending. In short, tax financing is an efficient way of translating economic growth into health spending. Countries with more tax revenues have also made more progress on other indicators of UHC, even after adjusting for economic activity in the country. Among tax poor countries, greater tax revenues are associated with more women being attended by a skilled healthcare worker during pregnancy and greater access to healthcare for all people.