Resource allocation and health financing

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.

Free maternity services in Kenya: How can the policy be improved going forward?
RESYST, London School of Hygiene & Tropical Medicine, 2017

In order to increase access to and use of maternal health services, in June 2013, the President of Kenya announced a policy offering free care for all women giving birth in a public health facility. This policy brief highlights both the positive and negative effects of the Free Maternity Services Policy based on research conducted in health facilities in three counties in Kenya. It outlines the challenges to implementing the policy and suggests how the Ministry of Health can make improvements going forward. The policy appears to have increased use of maternity services and provided additional funding for some facilities; however, its hurried implementation led to confusion about what services were included, and some clients were still required to pay for services. The policy was not accompanied by any supportive interventions to increase the capacity of health facilities. As a result, increased demand for services put a strain on health workers and compromised quality of care. The implementation of the Free Maternity Services Policy highlights the need for whole system change as opposed to isolated policy interventions. Going forward, the authors argue that the national Ministry of Health must provide clear guidelines as to what the policy covers and communicate these effectively to health facilities and providers. The county governments should strengthen the capacity of health facilities to cope with additional demand.

From blockchain technology to global health equity: can cryptocurrencies finance universal health coverage?
Till B; Peters A; Afshar S; Meara J: BMJ Global Health 2(4), doi:,, 2017

Blockchain technology and cryptocurrencies could remake global health financing and usher in an era global health equity and universal health coverage. The authors outline and provide examples for at least four important ways in which this potential disruption of traditional global health funding mechanisms could occur: universal access to financing through direct transactions without third parties; novel new multilateral financing mechanisms; increased security and reduced fraud and corruption; and the opportunity for open markets for healthcare data that drive discovery and innovation. The authors present these issues as a paramount to the delivery of healthcare worldwide and relevant for payers and providers of healthcare at state, national and global levels; for government and non-governmental organisations; and for global aid and intergovernmental organisations.

How the introduction of a human resources information system helped the Democratic Republic of Congo to mobilise domestic resources for an improved health workforce
Esanga J; Viadro C; McManus L; et al: Health Policy and Planning 32(Suppl 3) iii25–iii31, 2017

In the Democratic Republic of Congo, recognising the need for reliable health workforce information, the government has worked to implement iHRIS, an open source human resources information system that facilitates health workforce management. In Kasaï Central and Kasaï Provinces, health workers brought relevant documentation to data collection points, where trained teams interviewed them and entered contact information, identification, photo, current job, and employment and education history into iHRIS on laptops. After uploading the data, the Ministry of Public Health used the database of over 11 500 verified health worker records to analyse health worker characteristics, density, compensation, and payroll. Both provinces had less than one physician per 10 000 population and a higher urban versus rural health worker density. Most iHRIS-registered health workers (57% in Kasaï Central and 73% in Kasaï) reported receiving no regular government pay of any kind (salaries or risk allowances). Payroll analysis showed that 27% of the health workers listed as salary recipients in the electronic payroll system were ghost workers, as were 42% of risk allowance recipients. As a result, the Ministries of Public Health, Public Service, and Finance reallocated funds away from ghost workers to cover salaries and risk allowances for thousands of health workers who were previously under- or uncompensated due to lack of funds. The reallocation prioritised previously under- or uncompensated mid-level health workers, with 49% of those receiving salaries and 68% of those receiving risk allowances representing cadres such as nurses, laboratory technicians, and midwifery cadres. The authors observe that assembling accurate health worker records can help governments understand health workforce characteristics and use data to direct scarce domestic resources to where they are most needed.

Taxing the ill - How user fees are blocking universal health coverage
Médecins Sans Frontières: Belgium, December 2017

Direct payments by patients at the point of health care delivery, commonly known as user fees, lead to low utilisation of or exclusion from available health care services and impoverish households. Vulnerable groups are particularly affected. Over the past decade, many countries transitioned away from their user fee policies in favour of health care free at point of care for all or for specific population groups, such as pregnant women, children, and people with certain illnesses. Médecins Sans Frontières teams report in this paper witnessing evidence which starkly contrasts the discourse around UHC. Instead of improved access to care, they report a trend towards the reintroduction of user fees and other direct payments within national health financing strategies. They also report a lack of commitment and support to implement free care policies that secure access and sufficient coverage for the population’s health needs. The authors argue that if the global health community is serious about making UHC a reality and ‘leave no one behind’, removal of user fees for essential medicines and services must be tackled as a priority.