Resource allocation and health financing

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:, 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:, 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:, 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:, 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.

Can cash break the cycle of educational risks for young children in high HIV–affected communities? A cross–sectional study in South Africa and Malawi
Sherr L; Tomlinson M; Macedo A; et al.: Journal of Global Health 7(1), doi: 10.7189/jogh.07.010409, 2017

This study describes the impact of cash grants and parenting quality on 854 children aged 5–15 in South African and Malawi on educational outcomes including enrollment, regular attendance, correct class for age and school progress, controlling for cognitive performance. Consecutive attenders at randomly selected Community based organisations were recruited. The effects of cash plus good parenting, HIV status and gender were examined. Overall 73.1% received a grant – significantly less children with HIV (57.3% vs 75.6%). Controlling for cognitive ability, grant receipt was associated with higher odds of being in the correct grade, higher odds of attending school regularly, and much higher odds of having missed less than a week of school recently. Grant receipt was not associated with how well children performed in school compared to their classmates or with school enrollment. Grant receipt was associated with a significant reduction in educational risk for girls.

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme
Goudge J; Olufunke A; Govender V; et al: International Journal for Equity in Health 17(1), doi:, 2018

The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper, the authors ask whether the scheme has assisted in efforts to move towards UHC. Using a cross-sectional survey across four of South Africa’s nine provinces, the authors interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. A quarter of respondents remained uninsured, even higher among 20–29 year olds (46%) and lower-skilled employees (58%). The scheme generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having one outpatient visits/month compared to 0.6/month with lowest benefits. By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The authors observe that the inequities generated by the scheme have been institutionalised within the country’s financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.

Who benefits from increased service utilisation? Examining the distributional effects of payment for performance in Tanzania
Binyaruka P; Robberstad B; Torsvik G; et al: International Journal for Equity in Health 17(14), doi:, 2018

The authors examined pay for performance (P4P) effects on service utilisation across different population subgroups in Tanzania. About 3000 households were surveyed of women who delivered in the last 12 months prior to the interview from seven intervention and four comparison districts in January 2012 and a similar number of households in 13 months later. The household data were used to generate the population subgroups and to measure the incentivised service utilisation outcomes, with a focus on the institutional delivery rate and the uptake of antimalarials for pregnant women. P4P led to a significant increase in the rate of institutional deliveries among women in poorest and in middle wealth status households, but not among women in least poor households. The differential effect was marginally greater among women in the middle wealth households compared to women in the least poor households. The effect of P4P on institutional deliveries was also significantly higher among women in rural districts compared to women in urban districts, and among uninsured women than insured women. The effect of P4P on the uptake of antimalarials was equally distributed across population subgroups. The authors suggest that P4P can enhance equitable healthcare access and use especially when the demand-side barriers to access care such as user fees associated with drug purchase due to stock-outs have been reduced.