Resource allocation and health financing

Examining equity in health insurance coverage: an analysis of Ghana’s National Health Insurance Scheme
Dake F: International Journal for Equity in Health 17(85) 1-10; 2018

This paper examines equity in coverage under Ghana’s National Health Insurance Scheme. Secondary data from the 2008 Ghana Demographic and Health Survey based on an analytical sample of 4821 females and 4568 males were analysed using descriptive, bivariate and multivariate methods. As at 2008, more than 60% of Ghanaians aged 15–59 years were not covered under the National Health Insurance Scheme with slightly more females than males covered. Coverage was highest among the highly educated, professionals, those from households in the richest wealth quintile and urban residents. Lack of coverage was most concentrated among poor people. The author calls for deliberate action to enrol the poor under the National Health Insurance Scheme.

Saving lives, spending less: a strategic response to NCDs
World Health Organisation: WHO, Geneva, 2018

This report reveals the financing needs and returns on investment of WHO’s cost-effective and feasible “best buy” policies to protect people from noncommunicable diseases (NCDs), the world’s leading causes of ill health and death. It shows that for every US$1 invested in scaling up actions to address NCDs in low- and lower-middle-income countries (LLMICs), there will be a return to society of at least US$7 in increased employment, productivity and longer life. If all countries use these interventions, the world would move significantly closer to achieving Sustainable Development Goal 3.4 to reduce premature death from NCDs by one-third by 2030. Among the most cost-effective “best buy” interventions are increasing taxes on tobacco and alcohol, reducing salt intake through the reformulation of food products, administering drug therapy and counselling for people who have had a heart attack or stroke, vaccinating girls aged 9─13 years against human papillomavirus and screening women aged 30─49 years for cervical cancer. LLMICs currently bear the brunt of premature deaths from NCDs: almost half (7.2 million) of the 15 million people who die globally every year between the age of 30 and 70 are from the world’s poorest countries. Yet global financing for NCDs is severely limited, receiving less than 2% of all health funding. The report indicates that taking effective measures to prevent and control NCDs costs just an additional US$ 1.27 per person per year in LLMICs. The health gains from this investment will, in turn, generate US$350 billion through averted health costs and increased productivity by 2030, and save 8.2 million lives during the same period. Saving lives, spending less: a strategic response to NCDs issues a clear call for funding for scaling up the “best buy” policies which would save millions of lives.

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014
Obare F; Abuya T; Matanda D; et al.: International Journal for Equity in Health 17(65), doi: https://doi.org/10.1186/s12939-018-0774-4, May 2018

This paper examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys. In 2004, the Ministry of Health implemented the “10/20 policy” for maternal health services in public facilities, that removed user fees at the lowest levels of care. In 2007, the 10/20 policy was removed and a policy of no user fees for deliveries in public facilities was declared. However, no alternative source of funding was offered and the reality of informal fees remained in place for many service users. Government announced
free maternity services in all public health facilities in June 2013. Data was gathered from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy and a statistically significant increase in public facility deliveries among women from the two top quintiles, and a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time. The findings provided empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: a systematic review
Owusu-Addo E; Renzaho A; Smith B: Health Policy and Planning 33(5) 675–696, 2018

This paper synthesises the evidence on cash transfers (CTs) impacts on social determinants of health and health inequalities in sub-Saharan Africa, and to identify the barriers and facilitators of effective CTs. Twenty-one electronic databases and the websites of 14 key organizations were searched in addition to grey literature and hand searching of selected journals for quantitative and qualitative studies on CTs’ impacts on social determinants of health and health outcomes. Out of 182 full texts screened for eligibility, 79 reports that reported findings from 53 studies were included in the final review. The review found that CTs can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration. CTs modify intermediate determinants such as nutrition, dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage. In conjunction with their influence on social determinants of health, there is moderate evidence from the review that CTs impact on health and quality of life outcomes. Many factors relating to intervention design features, macro-economic stability, household dynamics and community acceptance of programs influence the effectiveness of CTs.

The financing gaps framework: using need, potential spending and expected spending to allocate development assistance for health
Haakenstad A; Templin T; Lim S: Health Policy and Planning 33(suppl_1), doi: https://doi.org/10.1093/heapol/czx165, 2018

As growth in development assistance for health levels off, development assistance partners must make allocation decisions within tighter budget constraints. In the ‘financing gaps framework’, the authors propose a new approach for harnessing information to make decisions about health aid. The framework was designed to be forward-looking, goal-oriented, versatile and customisable to a range of organisational contexts and health aims. The framework brings together expected health spending, potential health spending and spending need, to orient financing decisions around international health targets. As an example of how the framework could be applied, a case study is developed, focused on global goals for child health. The case study harnesses data from the Global Burden of Disease 2013 Study, Financing Global Health 2015, the WHO Global Health Observatory and National Health Accounts. Funding flows are tied to progress toward the Sustainable Development Goal’s target for reductions in under-five mortality. The flexibility and comprehensiveness of the framework makes it adaptable for use by a diverse set of governments, donors, policymakers and other stakeholders. The framework can be adapted to short‐ or long‐run time frames, cross‐country or subnational scales, and to a number of specific health focus areas. Depending on donor preferences, the framework can be deployed to incentivise local investments in health, ensuring the long-term sustainability of health systems in low- and middle-income countries, while also furnishing international support for progress toward global health goals.

A more progressive tax regime is a viable and better alternative to addressing revenue shortfalls, civil society organisations tell Parliament
NGOpulse: SANGONeT, South Africa, March 2018

In February, a broad cross-section of South African civil society organisations (CSOs) called on Parliament to halt the proposed increase in value-added tax (VAT), demonstrating that such a move for general revenue collection would make the tax regime more regressive, potentially violate the equality clause in the Constitution, and worsen already unacceptably high levels of poverty and inequality. They illustrated that more progressive alternatives exist. The organisations argued that a reconsideration of the tax regime was not to be taken lightly and therefore not something National Treasury could unilaterally decide on, without proper public consultation. The CSOs highlighted that tax can and must play a redistributive role in the economy, while ensuring sufficient revenue collection for pressing social needs. Yet the proposed 2018 budget not only increases the fuel levy and VAT, the least progressive tax instruments, but also opts to cut down on social spending in areas such as basic education, health care, housing, municipal infrastructure, informal settlement upgrading and transport. They argue that the VAT increase for general revenue (and not specifically for health), will have negative consequences for service delivery and affect poor and working class communities the most.

Evaluation of results-based financing in the Republic of the Congo: a comparison group pre–post study
Zeng W; Shepard D; de Dieu Rusatira J; et al: Health Policy and Planning 33(3) 392–400, 2018

In this study on a pilot results based financing (RBF) in the Republic of the Congo from 2012 to 2014, the authors conducted pre- and post-household surveys and gathered health facility services data from both intervention and comparison groups. Using a difference-in-differences approach, the study evaluated the impact of RBF on maternal and child health services. The household survey found statistically significant improvements in quality of services regarding the availability of medicines, perceived quality of care, hygiene of health facilities and being respected at the reception desk. The health facility survey showed no adverse effects and significantly favourable impacts on: curative visits, patient referral, children receiving vitamin A, HIV testing of pregnant women and assisted deliveries. These improvements, in relative terms, ranged from 42% to 155%. However, the household survey found no statistically significant impacts on the five indicators measuring the use of maternal health services, including the percentage of pregnant women using prenatal care, 3+ prenatal care, postnatal care, assisted delivery, and family planning. Surprisingly, RBF was found to be associated with a reduction of coverage of the third diphtheria, pertussis, and tetanus immunization among children in the household survey. From the health facility survey, no association was found between RBF and full immunization among children.

Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy
Okungu V; Chuma J; Mulupi S; et al: BMC Health Services Research 18(37), doi: https://doi.org/10.1186/s12913-017-2805-z, 2018

This study documented the views of informal sector workers regarding different prepayment mechanisms, to inform the design and policy implications of financing Universal health coverage in Kenya. This was part of larger study which involved a mixed-methods approach. Data was collected from informal sector workers: focus group discussions, individual in-depth and a questionnaire survey. The findings showed that informal sector workers in rural and urban areas prefer different prepayment systems for financing Universal health coverage. Preference for a non-contributory system of financing Universal health coverage was particularly strong in the urban study site. Over 70% in the rural area preferred a contributory mechanism in financing Universal health coverage. The main concern for informal sector workers regardless of the overall design of the financing approach to Universal health coverage included a poor governance culture, especially one that does not punish corruption. Other reasons especially with regard to the contributory financing approach included high premium costs and inability to enforce contributions from informal sector. On average 47% of all study participants, the largest single majority, are in favour of a non-contributory financing mechanism. Strong evidence from existing literature indicates difficulties in implementing social contributions as the primary financing mechanism for Universal health coverage in contexts with large informal sector populations. The authors argue that non-contributory financing should be strongly recommended to policymakers to be the primary financing mechanism, supplemented by social contributions.

The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique
Warren A; Cordon R; Told M; et al: Globalisation and Health 13(89) doi: https://doi.org/10.1186/s12992-017-0308-7, 2017

The Global Fund is one of the largest actors in global health, disbursing in 2015 close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients’ misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. The authors conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing. Analysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund’s structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. While decision-makers in Geneva recognize in-country coordination as vital to successful implementation, to date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique’s in-country coordination groups. In-country partners provide much needed support for Global Fund recipients, but the authors argue that roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership.

The unfunded priorities: an evaluation of priority setting for noncommunicable disease control in Uganda
Essue B; Kapiriri L: Globalization and Health 14(22), doi: https://doi.org/10.1186/s12992-018-0324-2, 2018

This paper examined the influence of national, sub-national and global factors on priority setting for noncommunicable disease control in Uganda. A mixed methods design that used the Kapiriri Martin framework for evaluating priority setting in low income countries and the evaluation period was 2005–2015. Priority setting for noncommunicable diseases was not entirely fair nor successful. While there were explicit processes that incorporated relevant criteria, evidence and wide stakeholder involvement, these criteria were not used systematically or consistently in the contemplation of noncommunicable diseases. There were insufficient resources for noncommunicable diseases, despite being a priority area. There were weaknesses in the priority setting institutions, and insufficient mechanisms to ensure accountability for decision-making. Priority setting was influenced by the priorities of major stakeholders, such as development assistance partners, which were not always aligned with national priorities. There were major delays in the implementation of noncommunicable disease-related priorities and in many cases, a failure to implement. This evaluation revealed the challenges that low income countries are grappling with in prioritizing noncommunicable diseases in the context of a double disease burden with limited resources. The authors propose that strengthening local capacity for priority setting would help to support the development of sustainable and implementable noncommunicable disease-related priorities and that global support to low income countries for noncommunicable diseases must catch up to align with NCDs as a global health priority.

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