Resource allocation and health financing

Effects of payment for performance on accountability mechanisms: Evidence from Pwani, Tanzania
Mayumana I; Borghi J; Anselmi L; Mamdani M; Lange S: Social Science & Medicine 179, 61–73, 2017

Payment for Performance (P4P) aims to improve provider motivation to perform better, but little is known about the effects of P4P on accountability mechanisms. The authors examined the effect of P4P in Tanzania on internal and external accountability mechanisms. The authors carried out 93 individual in-depth interviews, 9 group interviews and 19 Focus Group Discussions in five intervention districts in three rounds of data collection between 2011 and 2013. The authors carried out surveys in 150 health facilities across Pwani region and four control districts, and interviewed 200 health workers, before the scheme was introduced and 13 months later. The authors examined the effects of P4P on internal accountability mechanisms including management changes, supervision, and priority setting, and external accountability mechanisms including provider responsiveness to patients, and engagement with Health Facility Governing Committees. P4P had some positive effects on internal accountability, with increased timeliness of supervision and the provision of feedback during supervision, but a lack of effect on supervision intensity. P4P reduced the interruption of service delivery due to broken equipment as well as drug stock-outs due to increased financial autonomy and responsiveness from managers. Management practices became less hierarchical, with less emphasis on bureaucratic procedures. Effects on external accountability were mixed, health workers treated pregnant women more kindly, but outreach activities did not increase. Facilities were more likely to have committees but their role was largely limited. P4P resulted in improvements in internal accountability measures through improved relations and communication between stakeholders that were incentivised at different levels of the system and enhanced provider autonomy over funds. P4P had more limited effects on external accountability, though attitudes towards patients appeared to improve, community engagement through health facility governing committees remained limited. Implementers should examine the lines of accountability when setting incentives and deciding who to incentivise in P4P schemes.

Interview: How do you quantify malaria’s economic damage?
China Global Television Network (CGTN) Africa, April 2017

Despite decades of interventions, malaria is still one of the biggest killer diseases in Africa continent. In 2015 alone, an estimated 429 000 people died of malaria according to the World Health Organisation, 90% of them in Africa. Beyond the lives lost, how much economic damage does malaria really do to sub-Saharan economies? That’s a question CGTN's Ramah Nyang explored in conversation with the CEO of the African Medical & Research Foundation.The drug RTSS prevents more than forty strains of malaria in toddlers. It is being rolled out to more than 300 000 children in Kenya, Ghana and Malawi in trials and more vaccines are being tested. It is unlikely that one vaccines will eradicate all malaria, but testing vaccines can significantly reduce the impact of malaria. Malaria was eradicated in Europe and America in the 1930s and many are asking why this cannot be done again in Africa.

Corporate taxation key to protecting human rights in the global economy
Centre for Economic and Social Rights: CESR, USA, 2017

In February 2017, the Committee on Economic, Social and Cultural Rights – a UN human rights body – held a discussion of its draft General Comment on State obligations in the context of business activities. This General Comment – as an authoritative interpretation of States’ duties under the International Covenant on Economic, Social and Cultural Rights (ICESCR) – will fill an important gap in applying human rights law to situations of business-related abuses of these rights occurring within States’ territory as well as overseas. Corporate taxation remains an under-explored yet critical piece of the business and human rights puzzle, as confirmed by various participants in the discussion. Alongside the more direct ways businesses can adversely impact human rights (such as labor abuses, water pollution, etc.), the amount of tax corporations pay, and where they pay them, has profound human rights implications. As detailed in a factsheet co-authored by CESR, tax dodging by multinational copper firms in Zambia are estimated to amount to as much as $326 million annually, equivalent for example to about 60 percent of the country’s health budget. This raises governments’ responsibilities as State parties to international human rights treaties such as the ICESCR, and the phenomenon of tax avoidance and evasion. The ICESR General Comment early draft states that raising revenue through corporate taxation is an important part of the State’s duty to fulfil ESCR in its territory as the realisation of ESCR is dependent upon public resources that can, for example, pay for hospitals, schools and water systems. These resources will be raised from a variety of sources (including aid in some countries), but in all contexts progressive taxation is a lynchpin of public revenue raising. The report argues that those who can most afford to pay (including profitable multinational corporations and their executives and shareholders) must pay their fair share, and loopholes which allow them to escape tax should be closed.

Quality of Care in Performance-Based Financing: How It Is Incorporated in 32 Programs Across 28 Countries
Gergen J; Josephson E; Coe M; Ski S; Madhavan S; Bauhoff S: Global Health: Science and Practice 5(1) 90-107, 2017

This study describe how quality of care is incorporated into performance-based financing (PBF) programmes, what quality indicators are being used, and how these indicators are measured and verified. An exploratory scoping methodology was used to characterise the full range of quality components in 32 PBF programmes, initiated between 2008 and 2015 in 28 low- and middle-income countries, totalling 68 quality tools and 8,490 quality indicators. The programmes were identified through a review of the peer-reviewed and grey literature as well as through expert consultation with key funder representatives. Most of the PBF programmes were implemented in sub-Saharan Africa and most were funded primarily by the World Bank. On average, PBF quality tools contained 125 indicators predominately assessing maternal, newborn, and child health and facility management and infrastructure. Indicators were primarily measured via checklists which largely (over 90%) measured structural aspects of quality, such as equipment, beds, and infrastructure. Of the most common indicators across checklists, 74% measured structural aspects and 24% measured processes of clinical care. The quality portion of the payment formulas were in the form of bonuses (59%), penalties (27%), or both (hybrid) (14%). The median percentage (of a performance payment) allocated to health facilities was 60%, ranging from 10% to 100%, while the median percentage allocated to health care providers was 55%, ranging from 20% to 80%. Nearly all of the programmes included in the analysis (91%) verified quality scores quarterly (every 3 months), typically by regional government teams. PBF is argued by the authors to be a potentially appealing instrument to link verified performance measurement with strategic incentives and could ultimately help meet policy priorities. They also raise substantial variation and complexity in how PBF programmes incorporate quality of care considerations suggesting a need to further examine whether differences in design are associated with differential programme impacts.

The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms
Okungu V; Chuma J; McIntyre D: International Journal for Health in Equity 16(1), 2017, doi: 10.1186/s12939-017-0535-9

In many developing countries where the majority of the population works in the informal sector, there are critical debates over the best financing mechanisms to progress towards UHC. In Kenya, government health policy has prioritized a contributory financing strategy (social health insurance) as the main financing mechanism for UHC. However, there are currently no studies that have assessed the cost of either social health insurance (SHI) as the contributory approach or an alternative financing mechanism involving non-contributory (general tax funding) approaches to UHC in Kenya. This study critically assessed the financial requirements of both contributory and non-contributory mechanisms to financing UHC in Kenya in the context of large informal sector populations, to provide estimates of financial resource needs for UHC over a 17-year period (2013-2030). The 17-year period was necessary because the Government of Kenya aims to achieve UHC by 2030. The results show that SHI is financially sustainable (that is expenditure does not outstrip revenue) within the first five years of implementation, but it becomes less sustainable with time. Modelling for a non-contributory scenario, on the other hand, showed greater sustainability both in the short- and long-term. The financial resource requirements for universal access to health care through general government revenue are compared with a contributory health insurance scheme approach. Although both funding options would require considerable government subsidies, given the magnitude of the informal sector in Kenya and their limited financial capacity, a tax-funded system would be less costly and more sustainable in the long-term than an insurance scheme approach. However, more innovative financing for health care as well as giving the health sector higher priority in government expenditure will be required to make the non-contributory financing mechanism more sustainable.

The imperative for systems thinking to promote access to medicines, efficient delivery, and cost-effectiveness when implementing health financing reforms: a qualitative study
Achoki T; Lesego A: International Journal for Equity in Health 16(53) 2017 doi: 10.1186/s12939-017-0550-x

Health systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. Expansion of health insurance is being promoted in the quest for sustainable healthcare financing for many of the health systems in the region. However, the broader policy implications of expanding health insurance coverage have not been fully investigated and contextualised to many African health systems. The authors interviewed 37 key informants drawn from public, private and civil society organisations involved in health service delivery in Botswana. They aimed to determine the potential health system impacts that would result from expanding the health insurance scheme covering public sector employees. Study participants were selected through purposeful sampling, stakeholder mapping, and snowballing. The authors thematically synthesised their views, focusing on the key health system areas of access to medicines, efficiency and cost-effectiveness, as intermediate milestones towards universal health coverage. Participants suggested that expansion of health insurance would be characterised by increased financial resources for health and catalyse an upsurge in utilisation of health services particularly among those with health insurance cover. As a result, the health system, particularly within the private sector, would be expected to see higher demand for medicines and other health technologies. However, majority of the respondents cautioned that, realising the full benefits of improved population health, equitable distribution and financial risk protection, would be wholly dependent on having sound policies, regulations and functional accountability systems in place. It was recommended that, health system stewards should embrace efficient and cost-effective delivery, in order to make progress towards universal health coverage. Despite the prospects of increasing financial resources available for health service delivery, expansion of health insurance is reported to come with many challenges. They argue that decision-makers keen to achieve universal health coverage, must view health financing reform through the holistic lens of the health system and its interactions with the population, in order to anticipate its potential benefits and risks. Failure to embrace this comprehensive approach, would potentially lead to counterproductive results.

Adapting global health aid in the face of climate change
Gupta V, Mason-Sharma A, Caty S, KerryV: Lancet Global health Volume 5, No. 2, e133–e134, 2017

WHO estimates an additional 250 000 mortalities between 2030 and 2050 will be attributable to climate-associated increases in malnutrition, malaria, diarrhoea, respiratory disease, water inaccessibility, and heat stress. Spillover effects on state and regional security are argued to be inevitable. The World Economic Forum has identified climate change as the single greatest threat to global stability because of its considerable consequences on the health and stability of developing nations. The complex interaction between climate change, health system burdens, and poor health outcomes, and their subsequent impact on politics, security, and society can be captured within the concept of a so-called climate-health-security nexus. Many of the world's poorest and most politically fragile nations lie at the centre of this nexus. Within this nexus, poverty, state fragility, poor pre-existing health outcomes, and high susceptibility to climate change converge to amplify the effects of future famines, droughts, and neglected tropical diseases. This amplification subsequently leads to worsened economies, social instability, and reliance on external support. The nations most at risk for climate-triggered health crises are primarily scattered throughout sub-Saharan Africa and south Asia and are already afflicted by the highest rates of disease burden globally (table, appendix). Notably, most of these countries are low-income nations without the resources to adequately contend with climate-related challenges.

Incentives to change: effects of performance-based financing on health workers in Zambia
Shen G; Nguyen H; Das A; Sachingongu N; Chansa C; Qamruddin J; Friedman J: Human Resources for Health 15(20), 2017, doi: 10.1186/s12960-017-0179-2

Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers’ job satisfaction, motivation, and attrition in Zambia. It uses a randomised intervention/control design to evaluate before–after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. Mixed methods were employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion sought to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centres were staffed with qualified personnel and the personnel had role clarity. In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.

Is it all about the money? A qualitative exploration of the effects of performance-based financial incentives on Zimbabwe's voluntary male medical circumcision program
Feldacker C; Bochner A; Herman-Roloff A et al.: PLoS ONE 12(3), 2017, doi:10.1371/journal.pone.0174047

In 2013, Zimbabwe’s voluntary medical male circumcision (VMMC) program adopted performance-based financing (PBF) to speed progress towards ambitious VMMC targets. The PBF intended to encourage low-paid healthcare workers to remain in the public sector and to strengthen the public healthcare system. The majority of the incentive supports healthcare workers who perform VMMC alongside other routine services; a small portion supports province, district, and facility levels. This qualitative study assessed the effect of the PBF on healthcare worker motivation, satisfaction, and professional relationships. The study objectives were to: 1) Gain understanding of the advantages and disadvantages of PBF at the healthcare worker level; 2) Gain understanding of the advantages and disadvantages of PBF at the site level; and 3) Inform scale up, modification, or discontinuation of PBF for the national VMMC program. Sixteen focus groups were conducted: eight with healthcare workers who received PBF for VMMC and eight with healthcare workers in the same clinics who did not work in VMMC and, therefore, did not receive PBF. Fourteen key informant interviews ascertained administrator opinion. Findings suggest that PBF appreciably increased motivation among VMMC teams and helped improve facilities where VMMC services are provided. However, PBF appears to contribute to antagonism at the workplace, creating divisiveness that may reach beyond VMMC. PBF may also cause distortion in the healthcare system: Healthcare workers prioritised incentivised VMMC services over other routine duties. To reduce workplace tension and improve the VMMC program, participants suggested increasing healthcare worker training in VMMC to expand PBF beneficiaries and strengthening integration of VMMC services into routine care. In the low-resource, short-staffed context of Zimbabwe, PBF enabled rapid VMMC scale up and achievement of ambitious targets; however, side effects make PBF less advantageous and sustainable than envisioned. Careful consideration is warranted in choosing whether, and how, to implement PBF to prioritise a public health program.

Assessing fiscal space for health expansion in low- and middle-income countries: a review of the evidence
Barroy H; Sparkes S; Dale E: Working Paper, World Health Organisation, WHO/HIS/HGF/HF Working Paper/16.3, 2016

Despite the proliferation of the term ‘fiscal space for health’ in recent years, there has been no comprehensive review of how the concept can be applied to assess and support the expansion of resources for the health sector. There is also a certain amount of confusion regarding the conceptual underpinnings and application of fiscal space for health analysis, notably regarding the way in which such analysis can help countries realise potential fiscal space for health expansion. In this paper, a qualitative review of 35 studies was undertaken in four stages to identify all fiscal space for health studies and to systematically assess their findings and methods. These four stages involved a literature search, crowd-sourcing techniques, data extraction, and comprehensive qualitative analysis. The study shows that economic growth, budget re-prioritisation and efficiency improving measures are the main drivers of fiscal space for health expansion. There is scarce evidence regarding the prospective role of earmarked funds, and development assistance for health in expanding fiscal space for the sector. The lack of standardised methods and metrics to systematically assess fiscal space for health results in variations in the analytical approaches used, and limits study relevance and applicability for policy reform. The paper concludes that a more contextualised approach to fiscal space analysis is required, which focuses on key sources of fiscal space for health expansion and includes efficiency enhancements. Fiscal space analysis should be systematically embedded in domestic budgeting processes and explicitly consider both technical and political feasibility of assessed options. Adopting this approach could offer considerable potential for optimising government budget and expenditure decisions and more effectively support progress toward UHC.

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