Resource allocation and health financing

Vouchers for scaling up insecticide-treated nets in Tanzania: Methods for monitoring and evaluation of a national health system intervention
Hanson K, Nathan R, Marchant T, Mponda H, Jones C, Bruce J, Stephen G, Mulligan J, Mshinda H and Armstrong Schellenberg J: BMC Public Health 8(205), 10 June 2008

The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E). A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme. The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time. The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.

Vouchers for scaling up insecticide-treated nets in Tanzania: Methods for monitoring and evaluation of a national health system intervention
Hanson K, Nathan R, Marchant T, Mponda H, Jones C, Bruce J, Godlove Stephen, Mulligan J, Mshinda H and Armstrong Schellenberg J: BMC Public Health 8(205), June 2008

This study looked at the monitoring and evaluation (M&E) methods used to measure the equity, efficiency and sustainability of the Tanzania National Voucher Scheme (TNVS), which is used to deliver subsidised insecticide-treated mosquito nets (ITNs) to pregnant women and infants in Tanzania. The M&E focused on five key domains: ITN ownership and use among target groups, provision and use of reproductive and child health services, “leakage” of vouchers (use of vouchers by people not meant to benefit from the programme or use of vouchers to buy other things), availability of nets in the commercial ITN market and cost and cost-effectiveness of the scheme. The authors identify several successful features of this approach, namely, independence, breadth of scope, timely reporting with regular feedback, and sustainability - monitoring outcomes over time helps to identify lasting change.

W Cape health MEC takes aim at HIV shortage
IOL, 26 May 2006: Kassiem A

In a health budget that has received a R600-million boost, the Western Cape's drastic nursing shortage, HIV and Aids and tuberculosis are top of the list for the financial year, says Western Cape Health MEC Pierre Uys.

We are called the et cetera: experiences of the poor with health financing reforms that target them in Kenya
Kabia E; Mbau R; Oyando R; Oduor C; et al: International Journal for Equity in Health 18(98) 1-14, 2019

This study examined the experiences of poor people with health financing reforms that target them. The authors conducted a qualitative cross-sectional study in two purposively selected counties in Kenya, using focus group discussions and in-depth interviews with people in the lowest wealth quintile and health insurance subsidy programme beneficiaries. Health financing reforms reduced financial barriers and improved access to health services for poor people in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that health insurance subsidy programme beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among poor people.

WHA must draw up emergency plans to bridge health financing and health worker gaps in Africa
Richards T: World AIDS Campaign, 15 May 2007

In a statement ahead of the WHA meetings, APHRA coordinator Rotimi Sankore stated: “The World Health Assembly has in the past three years passed several resolutions on health financing and health worker shortages - yet there has been an overall increase in annual African deaths resulting from lack of sustainable health finance and health worker shortages. The worlds Health Ministers must now move from passing resolutions to effecting resolutions and emergency action to end the deaths of over 8 million Africans a year to preventable, treatable and manageable diseases, caused mainly by maternal mortality, child mortality, HIV/AIDS, TB and malaria.”

What Are Governments Spending on Health in East and Southern Africa?
Piatti-Fünfkirchen M; Lindelow M; Yoo K: Health Systems and Reform, doi: 10.1080/23288604.2018.1510287, 2018

This article reviews trends and patterns of government spending in the East and Southern Africa region. It points out methodological challenges with interpreting data from the World Health Organization’s (WHO) Global Health Expenditure Database (GHED) and other sources. Government expenditure for health has increased for most countries, albeit at a slower rate than gross domestic product (GDP). In most countries there has been a prioritization away from health in government budgets, putting the onus on the private sector and external funders to fill the gap. Reliance on external funding is important in the region but argued to be inconsistent with countries’ stated ambitions of universal health coverage. A number of methodological challenges with estimating health expenditures are identified. Capturing health expenditures adequately across agencies and levels of decentralization can be challenging, and off-budget funds and arrears are evasive. Measurement error can be significant because actual expenditure information can be hard to come by and is often dated and unreliable. Furthermore, how external financing is captured will affect government health expenditure estimates. These factors have contributed to differences in expenditure estimates between WHO and country-specific public expenditure reviews and complicate interpretation. The article concludes that it is critical to strengthen national data capacity and international efforts to promote quality and consistency of data.

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.

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?
D McIntyre, M Thiede, G Dahlgren, M Whitehead Social Science & Medicine, 62, 4 February 2006, 858-865

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households.

What can global health institutions do to help strengthen health systems in low-income countries?
Balabanova D, McKee M, Mills A, Walt G, Haines A: Health Research Policy and Systems 8(22), 29 June 2010

This paper argues that weaknesses in health systems have contributed to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programmes, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programmes that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.

What has tax got to do with development? A critical look at Mozambique’s and Zimbabwe’s tax systems
African Network on Debt and Development (AFRODAD): 14 July 2011

According to AFRODAD, tax revenues are, on average, lower in developing countries than in rich countries; the average revenue in African countries was approximately 15% of GDP in 2008. Hence the argument that if developing countries were able to collect sufficient tax revenues, they might be able to increase their independence, the provision of social protection, infrastructure and basic services such as education and health care which are crucial for development. The two reports on Mozambique and Zimbabwe reveal that mobilising domestic resources as a means to financing development has become an important development issue, a shift from the past emphasis on financing development from aid and external borrowing. For a long time mobilising domestic revenue has been neglected, despite being a better long-term option, AFRODAD argues. The reasons for this included the inherent pessimism about raising revenue, a prevalent ‘small-state’ ideology and a preference for foreign aid-led solutions. AFRODAD proposes that progressive taxation should play an important role in shaping the distribution of benefits from higher-income citizens to those most in need in a country. The reports also examine the various complexities surrounding taxation as a development finance mechanism in the two country cases including the current tax framework, the amount and extent of tax evasion and more specifically tax incentives and governance in various sectors of the economy. They conclude with policy and institutional recommendations to the governments of Mozambique and Zimbabwe – and civil society – to refine their tax systems.

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