Resource allocation and health financing

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.

Results-based financing in health: from evidence to implementation
McIsaac M: Kutzin J: Dale E; Soucat A: Bulletin of the World Health Organization 96(11), 729-796, 2018

Results-based financing for health programmes are being piloted in many low- and middle-income countries. While the term results-based financing refers to demand- and supply-side incentives to increase output – that is, improved access to and quality of health care – this editorial focuses on the incentives that target service providers, also referred to as performance-based financing or pay-for-performance. A study in Zambia concluded that the pay-for-performance intervention was cost–effective. However, cost–effectiveness is not the most interesting point of this study, as four policy relevant lessons emerge. First, any output-based provider payment method requires some method of verification. In Zambia, setting up verification mechanisms required new investments, as before the pilot, providers were paid based on inputs. The estimates of the costs of the programme in Zambia, although annualized, are based on only 2.3 years of experience. Given that it is a new programme, one would expect that pay-for-performance verification costs would decline over time. Second, approaching pay-for-performance as an either-or choice of financing is no longer the only frame of reference. The substantive question is how to integrate elements of performance into the mixed provider payment system. Third, as described in the overall evaluation of the project, the direct disbursement of funds to facility bank accounts in the pay-for-performance group was a key ingredient for ensuring better service delivery. Fourth, facility financial autonomy supported by pay-for-performance was found to be key for ensuring progress towards strategic purchasing in Zambia. If balanced with clear accountability for both good results and the use of funds, it should be promoted. In shifting towards mixed provider payment methods with timely disbursement of funds and greater financial autonomy by front-line providers, the budgeting processes need to be considered. In countries such as Zambia, where budgets are mainly formulated, approved and executed based on detailed input lines, the authors argue that shifting to payments based on performance could be challenging.

Willingness to Pay for Condoms in Five Countries Kenya, Nigeria, South Africa, Zambia, and Zimbabwe
Ramakrishnan G; Tuchman J; Hartel L: Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project, 2018

Though condom use is now higher than ever before, key gaps remain in countries and in certain populations, where use has stagnated or even decreased. This survey comprised five standalone national cross-sectional surveys carried out in randomly selected geographical areas. Quantitative data were collected from adult men who purchased or obtained a condom in the three months preceding the surveys. A minimum of 1,200 participants was enrolled for each country, with quotas for urban and rural respondents; and brand types that a user most often used (i.e., free, socially marketed (SM), and commercial). The AIDSFree team identified important differences in each of the countries’ condom markets. The team noted many overarching themes: Supplies of free condoms appear to significantly exceed use of such condoms; SM brands should set prices based ability-to-pay trends in country, rather than on trends in costs or available subsidies; It is not just price—brand appeal and availability are important factors in men’s choice of condom brands; Low-priced commercial condom brands are emerging, at the same or lower price than SM brands. However, lower awareness and availability appear to limit their market share.; Introducing a single pack of condom brands does not appear to change the market structure significantly.

HIV partner services in Kenya: a cost and budget impact analysis study
Cherutich P; Farquhar C; Wamuti B; et al: BMC Health Services Research 18(721) 1-11, 2018

This paper focuses on elicitation of contact information, notification and testing of sex partners of HIV infected patients (aPS). Using study data and time motion studies, the authors constructed an Excel-based tool to estimate costs and the budget impact of aPS in selected facilities in Kisumu County. The authors report the annual total and unit costs of HTS, incremental total and unit costs for aPS, and the budget impact of scaling up aPS over a 5-year horizon. The average unit costs for HIV testing among HIV-infected index clients was US$ 25.36 per client and US$ 17.86 per client using nurses and CHWs, respectively. The average incremental costs for providing enhanced aPS in Kisumu County were US$ 1 092 161 and US$ 753 547 per year, using nurses and CHWs, respectively. The average incremental cost of scaling up aPS over a five period was 45% higher when using nurses compared to using CHWs. Over the five years, the upper-bound budget impact of nurse-model was US$ 1,8mn, 63% and 35% of which were accounted for by aPS costs and ART costs, respectively. The CHW model incurred an upper-bound incremental cost of US$ 1,3mn which was 71% lower than the nurse-based model. The budget impact was sensitive to the level of aPS coverage and ranged from US$ 28 547 for 30% coverage using CHWs in 2014 to US$ 1,3mn for 80% coverage using nurses in 2018. Scaling aPS using nurses has minimal budget impact but not cost-saving over a five-year period. Targeting aPS to newly-diagnosed index cases and task-shifting to community health workers is recommended by the authors.

Uganda embarks on a journey to universal health cover
Asiimwe D: The East African, June 2018

Uganda has increased its allocation to the health sector from Ush1.8 trillion ( US $470.6 million) in the 2017/18 financial year to Ush2.3 trillion ($595.6 million), in what the author indicates that some see as an a response to a backlash in 2017 from external funders when the government reduced the nominal value of Ministry of Health’s funding by Ush6 billion ($1.5 million). Officials at the ministry note the increased allocation aims to support the country on a journey to universal health coverage and reduce dependence on external funding. In the 2018/19 financial year, Dr Sarah Byakika, the acting planning commissioner in the Ministry of Health, said the increased allocation will among other things target universal health coverage, recruit community health workers, cover recurrent expenditures at specific hospitals and for the national blood bank. Money is also being provided to avert the perennial strikes of interns and for the drafting of regulations for a new national health insurance law, with national health insurance seen as key for improved domestic financing.

Zimbabwe launches a Health Financing Policy and Strategy
World Health Organisation: WHO Zimbabwe, June 2018

Zimbabwe's Health Financing Policy and strategy launched in June 2018 was informed by WHO guidelines on health financing embedded in a health systems framework. The policy and strategy acknowledge that the way funds are raised and allocated and the way services are paid for influences how services are accessed by the population. It focuses on better use of available resources, and increased Government allocation to health leading to reduced direct out of pocket payments by households, which will in turn reduce financial barriers to access for the poor. It also brings in innovation in exploring more options to raise funding for health, and the creation of a pool of funds to ensure better management of health funds. Emphasis on achieving sustainable health financing is explicit in the Health Financing Strategy so that gains can be sustained. The financing seeks to ensure that the current National Health Strategy (2016-2020) is well financed and implemented to take steps towards financial risk protection and ultimately universal health coverage.

Zimbabwe: Realising the right to health for mothers and children, a mutli-donor Health Transition Fund helps to revitalise Zimbabwe’s health system
UNICEF: UNICEF and MoHCC Zimbabwe 2018

The Health Transition Fund (HTF) is a $435 million, five-year programme (2011-2015) that aimed to revitalize Zimbabwe’s health sector by improving the lives of children and women. It was funded by multiple external funders from the European Union, Canada, Ireland, Norway, the United Kingdom and SIDA Sweden, and managed by UNICEF in cooperation with the Zimbabwean Ministry of Health. It has four pillars: 1) Improvement of maternal, newborn and child health as well as nutrition, 2) Provision of essential medicines, vaccines and technologies, 3) Human resources including assistance with health worker management, training and retention, 4) Health policy, planning and finance. It aimed to reduce maternal mortality by three quarters and under-5 mortality by two thirds (as stated in the Millennium Development Goals) and eliminate user fees for children under the age of five and pregnant and lactating women by 2015. It sought to support the halving of the number of underweight children under five and combating, halting and reversing trends in HIV/AIDS, malaria and other diseases. A steering committee, chaired by the permanent secretary of the Ministry of Health, oversees and directs the rollout of the fund and defines priority interventions within each of the four thematic areas, while funders provide support to monitoring, evaluation and technical expertise.

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:, 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.