Resource allocation and health financing

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.

Financing A National Health Insurance for South Africa
The Davis Tax Committee: Ministry of Finance, South Africa, 2017

The Davis Tax Committee was established in 2013 by the Minister of Finance to inquire into the role of the tax system in promoting inclusive economic growth, employment creation, development and fiscal sustainability. This report concentrates on identifying long term financing principles – the specific operationalisation which will be informed by more detailed implementation and costing plans in order to manage the transition from the status quo to the financing regime envisaged in the National Health Insurance (NHI) in South Africa. This report examines the definition, rationale and design of the proposed NHI. It explores international experience in financing universal health coverage, with a focus on middle income developing countries and existing sources of health financing in South Africa are analysed. Cost estimates and potential macroeconomic impacts are discussed and the report concludes with an evaluation of options for NHI financing. The authors identify a number of factors in the design of NHI, as well as its implementation, all of which have an impact on its financing trajectory. These include parameters on risk pooling, on health care purchasing and on provision. Risk pooling decisions include whether there would be a single or multiple purchaser, the level of consolidation of risk pools and their coverage and composition as well as the nature of the resources allocation formula (evidence and needs based, risk equalisation etc.). The structure of purchasing encompasses, inter alia, the scope and pricing of the benefit package (which had not yet been defined in the White Paper), contractual arrangements with health care providers such as GPs and hospitals, quality management systems, payment and information systems.

A Political Economy Analysis of Domestic Resource Mobilization in Uganda
Kjær A; Ulriksen M; Kangave J; Katusiimeh M: United Nations Research Institute for Social Development WP 2017-8, Geneva, 2017

This synthesis paper brings together the research findings from four papers prepared by the Uganda team in the UNRISD Politics of Domestic Resource Mobilisation for Social Development project. It addresses three broad themes: bargaining and contestation, key relations, and institution building with regard to mobilising resources for social development. The authors analyse how political economy factors affect revenue raising and social spending priorities in Uganda. It applies a political settlement theory, exploring revenue bargaining or political negotiations that shape revenue mobilisation, revenue composition and policy priorities guiding revenue allocation. The authors focus on three instances of revenue bargains: legislative tax reform, institutional performance of the revenue agencies, and policy making. The first two instances relate to the actual mobilisation of resources, whereas the third example focuses on bargains over spending priorities within a given revenue base. The findings indicate that in Uganda, a low-income country with competing political factions, there are specific challenges to mobilising resources for social development. The need to maintain political power is argued by the authors to have led to reduced tax intakes as taxes levied on rural voters are abolished and tax exemptions introduced for powerful supporters. On the spending side, social development concerns are argued to compete with other public policy areas as well as the pressure to allocate resources for political purposes.

Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries
Stenberg K; Hanssen O; Edejer T; et al.: The Lancet Global Health 5(9), e875-e887, 2017

No estimates of the additional resources needed to strengthen comprehensive health service delivery towards the attainment of SDG 3 and universal health coverage in low-income and middle-income countries have been published. The authors developed a framework for health systems strengthening, within which population-level and individual-level health service coverage is gradually scaled up over time. They developed projections for 67 low-income and middle-income countries from 2016 to 2030, representing 95% of the total population in low-income and middle-income countries. The authors considered four service delivery platforms, and modeled two scenarios with differing levels of ambition: a progress scenario, in which countries' advancement towards global targets is constrained by their health system's assumed absorptive capacity, and an ambitious scenario, in which most countries attain the global targets. They estimated the associated costs and health effects, including reduced prevalence of illness, lives saved, and increases in life expectancy. They projected available funding by country and year, taking into account economic growth and anticipated allocation towards the health sector, to allow for an analysis of affordability and financial sustainability. The authors estimate that an additional $274 billion spending on health is needed per year by 2030 to make progress towards the SDG 3 targets (progress scenario), whereas US$371 billion would be needed to reach health system targets in the ambitious scenario—the equivalent of an additional $41 or $58 per person, respectively, by the final years of scale-up. In the ambitious scenario, total health-care spending would increase to a population-weighted mean of $271 per person across country contexts, and the share of gross domestic product spent on health would increase to a mean of 7.5%. Around 75% of costs are for health systems, with health workforce and infrastructure (including medical equipment) as the main cost drivers. Despite projected increases in health spending, a financing gap of $20–54 billion per year is projected. Should funds be made available and used as planned, the ambitious scenario would save 97 million lives and significantly increase life expectancy by 3.1–8.4 years, depending on the country profile. All countries will need to strengthen investments in health systems to expand service provision in order to reach SDG 3 health targets, but even the poorest can reach some level of universality. In view of anticipated resource constraints, each country will need to prioritise equitably, plan strategically, and cost realistically its own path towards SDG 3 and universal health coverage.