Resource allocation and health financing

What healthcare financing changes are needed to reach universal coverage in South Africa?
McIntyre D: South African Medical Journal 102(6), June 2012

Moving towards a predominantly publicly funded health system with a specified role for private voluntary health insurance will take time, according to this article. What is required in the short term is for Treasury to be responsive to submissions to gradually increase the allocations to the health sector from general tax revenue, to enable the Department of Health to implement its plans to strengthen substantially both primary healthcare and hospital services, as outlined in the National Health Insurance (NHI) Green Paper and other recent policy documents. It is likely that it will be necessary to supplement this with additional taxes dedicated to the health sector, such as an income tax surcharge, payroll tax on employers and/or ‘sin taxes’ on tobacco and alcohol, which can be phased in after initial improvements to the public health system have been achieved. The author argues that when universal entitlements to specified services are formalised in legislation, it will be important to specify the complementary role of private voluntary insurance. Through this overall process, the relative distribution of healthcare funding across different financing mechanisms will, it is argued, shift gradually to the pattern seen in countries that have already achieved universal coverage.

What mothers do: responses to childhood fever on the Kenyan Coast

Do rural and urban mothers differ in their choice of health providers when their children are ill? How does proximity to different health facilities affect a mother's decision? These questions are important for health planners responding to rising urban poverty and ill health, as sub-Saharan Africa has the highest rates of urbanisation in the developing world.

When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi
Pot H; de Kok B; Finyiza G: Reproductive Health Matters, 26(54) 126-136, 2018

This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world’s highest burdens of maternal mortality. The authors analysed Malawi’s recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of external funding, a shift in political leadership and priorities and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. The authors report that different actors are frustrated about user fees and their impact on poor people, especially because in Malawi non-institutional deliveries have become strongly associated with maternal deaths. This especially affects women in rural areas, where access to care is already minimal. In addition, the poorest rural women struggle most to pay user-fees, and would have to travel to the district hospital. User-fees eroded trust between women and health workers. The authors indicate that the fact that local maternity services excluded of the most vulnerable rural women from care rather than address higher level sources reflect the power dynamics involved in this issue.

Where did all the aid go? An in-depth analysis of increased health aid flows over the past ten years
Piva P and Dodd R: Bulletin of the World Health Organization 87: 930–939, December 2009

This study set out to examine how health aid is spent and channelled, including the distribution of resources across countries and between subsectors. It aimed to complement the many qualitative critiques of health aid with a quantitative review and to provide insights on the level of development assistance available to recipient countries to address their health and health development needs. A quantitative analysis of data from the Aggregate Aid Statistics and Creditor Reporting System databases of the Organisation for Economic Co-operation and Development was carried out. The analysis shows that while health official development assistance (ODA) is rising and capturing a larger share of total ODA, there are significant imbalances in the allocation of health aid, which run counter to internationally recognised principles of ‘effective aid’. Countries with comparable levels of poverty and health need receive remarkably different levels of aid. Although political momentum towards aid effectiveness is increasing at global level, some very real aid management challenges remain at country level.

Where is the Paris Agenda heading? Changing relations in Tanzania, Zambia and Mozambique
Odén B and Wohlgemuth L: European Centre for Development Policy Management Briefing Note 21, February 2011

How has the Paris Declaration has been translated into action in Mozambique, Tanzania and Zambia? The authors of this study found that, despite some positive developments, the dialogue between donor and recipient governments is breaking down. External funders are becoming increasingly concerned with governance issues in recipient countries, so the dialogue has become more political in nature. At some point in the past, all three countries have had their general budget support temporarily suspended or permanently stopped due to corruption disputes. The authors argue that the dialogue structure developed so far by external funders has become too complex for the three recipient countries, which have insufficient capacity and lack funds for higher-than-expected transaction costs. In conclusion, the authors recommend that stakeholders must try to deal with the inherent contradictions between aid partners: on the external funders’ side there is increasing concentration on short term quantifiable results, a continuous tendency for micro-management and over-optimistic expectations on the speed of agreed reforms, while on the recipients’ side, a lack of visible improvements in governance has undermined the necessary trust needed for increased alignment and programme-based forms of aid.

Which Patients First? Setting Priorities for Antiretroviral Therapy Where Resources Are Limited
July 2005, Vol 95, No. 7, American Journal of Public Health

The availability of limited funds from international agencies for the purchase of antiretroviral (ARV) treatment in developing countries presents challenges, especially in prioritizing who should receive therapy. Public input and the protection of human rights are crucial in making treatment programs equitable and accountable. By examining historical precedents of resource allocation, we aim to provoke and inform debate about current ARV programs.

White paper on China's foreign aid
The People's Republic of China: April 2011

In their white paper on foreign aid, the Chinese government notes that, currently, the environment for global development is not favourable. With the repercussions of the international financial crisis continuing to linger, global concerns such as climate change, food crisis, energy and resource security, and epidemic of diseases have brought new challenges to developing countries, aggravating the imbalance in the development of the global economy, and widening the gap between North and South, rich and poor. The international community should strengthen co-operation and jointly rise to the challenges facing development, according to the paper. Against this background, China has a long way to go in providing foreign aid. The Chinese government will make efforts to optimise the country's foreign aid structure, improve the quality of foreign aid, further increase recipient countries' capacity in independent development, and improve the pertinence and effectiveness of foreign aid. China further pledges to continue to promote South-South co-operation, gradually increase its foreign aid input on the basis of the continuous development of its economy and promote the realisation of the UN Millennium Development Goals.

White paper: National Health Insurance for South Africa
Department of Health, Republic of South Africa, December 2015

This white paper outlines South Africa’s path to universal health coverage over 14 years and proposes dramatic changes in the role of private medical aid among others. Released on the 10th of December 2015, the long awaited white paper begins by providing the background and justification of the country’s moves to join other countries like the Brazil, the United Kingdom and Thailand in introducing universal healthcare coverage. The document notes that healthcare in South Africa is comprised of a two-tiered system divided along socio-economic lines. The private medical aid sector is comprised of 83 medical aid schemes that fund healthcare services for about 16 percent of the population. The paper noted that spending through medical schemes in South Africa is the highest in the world and is six times higher than in Organisation for Economic Co-operation and Development (OECD) countries. The paper argues that this two-tiered system has led to fragmented funding and risk pools in healthcare and posits that the creation of a National Health Insurance (NHI) will improve healthcare equity by combining fragmented private and public health funding pools and eliminating out-of-pocket payments.The paper notes that the NHI will ultimately deliver a comprehensive package of health services that include services such as rehabilitation and palliative care, mental health care including that related to substance abuse and maternal and child health care. The paper is made available to call for stakeholder feedback.

Whither EC Aid? WECA Compendium
Corre G (ed) and European Centre for Development Policy Management (ECDPM): 2009

In 2005, the Paris Declaration formulated a number of challenges facing development cooperation. While the principles of the Declaration were broadly accepted, there seemed to be a lack of shared understanding of key underlying issues shaping the debate of EU aid effectiveness. This publication archives all the outputs generated through Whither EC Aid (WECA), from the Initial Discussion Note to the reports of the dozen roundtables held and the thematic Briefing Notes. A year after the adoption of the Accra Agenda for Action, it looks back on the perceptions of various group of stakeholders about the aid effectiveness agenda, to see to what extent the different points of view shared during the WECA process find an echo today in the international agenda on aid. The WECA Compendium is the final stage of a joint ECDPM-Action Aid project initiated in mid-2007.

Who benefits from health care in South Africa?
University of Cape Town Health Economics Unit Information Sheet

This information sheet presents evidence on the distribution of benefit of health services in South Africa. Within the public sector, the poor benefit relatively more than the rich from outpatient services at lower levels of care. The rich benefit considerably more than the poor from regional and central hospital services (both outpatient and inpatient services) and also benefit more from public sector inpatient services overall. The rich benefit far more from private sector services than the poor; the richest 40% of the population receive about 70% of the benefits of private outpatient services (from general practitioners, specialists, dentists and retail pharmacies) and nearly 80% of the benefits of inpatient care in private hospitals. Overall, health care benefits in South Africa are very ‘pro-rich’, with the richest 20% of the population receiving more than a third of total benefits while the poorest 20% receive less than 13% of the benefits, despite poor people bearing a much greater share of the burden of ill-health than rich people.

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