Resource allocation and health financing

Global funding trends for malaria research in sub-Saharan Africa: a systematic analysis
Head M: Lancet Global Health 5, doi: S2214-109X(17)30245-0, 2017

Total domestic and international funding for malaria is inadequate to achieve WHO global targets by 2030. The authors describe the trends of investments in malaria-related research in sub-Saharan Africa and compare investment with the national disease burden to identify areas of funding strength and potentially neglected populations, including that for malaria control. Research funding data related to malaria for 1997–2013 were sourced from existing datasets, from 13 major public and philanthropic global health funders, and from funding databases. Investments (reported in US$) were considered by geographical area and compared with data on parasite prevalence and populations at risk in sub Saharan Africa. 45 sub-Saharan African countries were ranked by amount of research funding received. The authors found 333 research awards totalling US$814.4 million. Public health research covered $308.1 million (37.8%) and clinical trials covered $275.2 million (33.8%). Tanzania ($107.8 million [13.2%]), Uganda ($97.9 million [12.0%]), and Kenya ($92.9 million [11.4%]) received the highest sum of research investment and the most research awards. Malawi, Tanzania, and Uganda remained highly ranked after adjusting for national gross domestic product. Countries with a reasonably high malaria burden that received little research investment or funding for malaria control included Central African Republic (ranked 40th) and Sierra Leone (ranked 35th). Congo (Brazzaville) and Guinea had reasonably high malaria mortality, yet received little investment. Some countries receive reasonably large investments in malaria-related research (Tanzania, Kenya, Uganda), whereas others receive little or no investments (Sierra Leone, Central African Republic). Research investments are typically highest in countries where funding for malaria control is also high. The authors suggest that investment strategies should consider more equitable research and operational investments across countries to include currently neglected and susceptible populations.

Seven key messages from the World Health Organisation meeting on Global Strategic Purchasing
Barasa E: Resilient & Responsive Health Systems (RESYST), London School of Hygiene and Tropical Medicine, June 2017

The purchasing function of health financing is gaining increasing attention and traction in global health systems and universal health coverage (UHC) debates, which have, in the past, focused predominantly on revenue collection and pooling. A recent workshop convened by the World Health Organisation on strategic purchasing. In the blog, the author summarises seven key messages from the workshop that are likely to feature in future discussions on strategic purchasing. Purchasing refers to the process by which funds are allocated to healthcare providers to obtain services on behalf of identified groups. Strategic purchasing is a continuous search for the best ways to maximise health system performance, by deciding which interventions should be purchased, how, and from whom. It is typically considered from the point of view of the purchaser. However, by looking at it from the perspective of healthcare facilities, a complex picture of multiple purchasers and funding flows emerges. A key responsibility of healthcare purchasers is in deciding what to include in the benefit package for health. However, decisions about priority setting are often neglected in this process. The governance boards of many purchasing organisations, such as social health insurers, include representatives from the government, employers (e.g. an umbrella employer association) and employees (labour unions). However, in most low and middle income countries, a significant proportion of the population work in the informal sector. They do not belong to the labour unions, and do not have formal employers to represent them on such boards. A further governance issue is the perennial problem regarding oversight of purchasers that are separate entities from the Ministry of health, such as social health insurers. Strategic purchasing cannot occur in the absence of good quality data. Often information systems are fragmented, presenting a partial view of the system. While it was appreciated that Results Based Financing (RBF) can contribute to strategic purchasing and act as a catalyst for health system reform, there is a need to ensure that RBF mechanisms are embedded and integrated within the wider health system. Strategic purchasing is argued to be not just a technical issue, but also a political issue.

WHO estimates cost of reaching global health targets by 2030
World Health Organisation: WHO, Geneva, 2017

The SDG Health Price Tag estimates the costs and benefits of progressively expanding health services in order to reach 16 Sustainable Development Goal (SDG) health targets in 67 low- and middle-income countries that account for 75% of the world’s population. The analysis shows that investments to expand services towards universal health coverage and the other SDG health targets could prevent 97 million premature deaths globally between now and 2030, and add as much as 8.4 years of life expectancy in some countries. While most countries can afford the investments needed, the poorest nations will need assistance to reach the targets. The SDG Health Price Tag models two scenarios: an “ambitious” scenario in which investments are sufficient for countries to attain the health targets in the SDGs by 2030, and a “progress” scenario in which countries get two thirds or more of the way to the targets. These investments would boost health spending as a proportion of gross domestic product across all 67 countries from an average of 5.6% to 7.5%. The global average for health spending as a proportion of GDP is 9.9%. Although higher spending does not necessarily translate to improved health, making the right investments at the right time can. The SDG Health Price Tag does not prescribe what countries should spend on health, but is intended as a tool to inform further research. It also highlights that achieving universal health coverage and the other health targets requires not only funding but political will and respect for human rights. WHO plans to update the estimates every five years and will include other health-related targets and diseases as more evidence becomes available.

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 L; Hanssen O; Edejer T; et al.: The Lancet Global Health, Doi: S2214-109X(17)30263-2, 2017

The ambitious development agenda of the Sustainable Development Goals (SDGs) requires substantial investments across several sectors, including for SDG 3 (healthy lives and wellbeing). 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 and calculated projections for 67 low-income and middle-income countries from 2016 to 2030. The authors estimated 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.

Implementation research to improve quality of maternal and newborn health care, Malawi
Brenner S; Wilhelm D; Lohmann J; Kambala C; Chinkhumba J; Muula A; Allegri M: Bulletin of World Health Organisation 95(7), 491–502, 2017

This study evaluated the impact of a performance-based financing scheme on maternal and neonatal health service quality in Malawi. The authors conducted a non-randomised controlled before and after study to evaluate the effects of district- and facility-level performance incentives for health workers and management teams. The authors assessed changes in the facilities’ essential drug stocks, equipment maintenance and clinical obstetric care processes. The authors observed 33 health facilities, 23 intervention facilities and 10 control facilities and 401 pregnant women across four districts. The scheme improved the availability of both functional equipment and essential drug stocks in the intervention facilities. The authors observed positive effects in respect to drug procurement and clinical care activities at non-intervention facilities, likely in response to improved district management performance. Birth assistants’ adherence to clinical protocols improved across all studied facilities as district health managers supervised and coached clinical staff more actively. Despite nation-wide stock-outs and extreme health worker shortages, facilities in the study districts managed to improve maternal and neonatal health service quality by overcoming bottlenecks related to supply procurement, equipment maintenance and clinical performance. To strengthen and reform health management structures, performance-based financing may be a promising approach to sustainable improvements in quality of health care.

Sub-national assessment of aid effectiveness: A case study of post-conflict districts in Uganda
Ssengooba F; Namakula J; Kawooya V; Fustukian S: Globalisation and Health 13(32), doi: 10.1186/s12992-017-0251-7, 2017

In post-conflict settings, many state and non-state actors interact at the sub-national levels in rebuilding health systems by providing funds, delivering vital interventions and building capacity of local governments to shoulder their roles. Aid relationships among actors at sub-national level represent a vital lever for health system development. This study was undertaken to assess the aid-effectiveness in post-conflict districts of northern Uganda. This was a three district cross sectional study conducted from January to April 2013. Managers of organisations involved in service delivery were interviewed and asked to list the external organisations that contribute to three key services. For each inter-organisational relationship a custom-made tool designed to reflect the aid-effectiveness in the Paris Declaration was used. Three hundred eighty four relational ties between the organisations were generated from a total of 85 organisations interviewed. Satisfaction with aid relationships was mostly determined firstly by the extent managers were able to negotiate own priorities, by their awareness of expected results, and thirdly on the provision of feedback about their performance. Provider satisfaction was mostly determined by awareness of expected results and feedback on performance. These findings illustrate the focus on “results” domain and less on “ownership” and “resourcing” domains. The capacity and space for sub-national level authorities to negotiate local priorities requires more attention especially for health system development in post-conflict settings.

Current and future availability of and need for human resources for sexual, reproductive, maternal and newborn health in 41 countries in Sub-Saharan Africa
Guerra A; Nove A; Michel-Schuldt M; de Bernis L: International Journal of Equity Health 16(1) 69, 2017

The World Health Organisation African region, covering the majority of Sub-Saharan Africa, faces the highest rates of maternal and neonatal mortality in the world. This study uses data from the State of the World's Midwifery 2014 survey to cast a spotlight on the World Health Organisation African region, highlight the specific characteristics of its sexual, reproductive, maternal and newborn health (SRMNH) workforce and describe and compare countries' different trajectories in terms of meeting the population need for services. Using data from 41 African countries, this study used a mathematical model to estimate potential met need for SRMNH services, defined as "the percentage of a universal SRMNH package that could potentially be obtained by women and newborns given the composition, competencies and available working time of the SRMNH workforce." The model defined the 46 key interventions included in this universal SRMNH package and allocated them to the available health worker time and skill set in each country to estimate the potential met need. Based on the current and projected potential met need in the future, the countries were grouped into three categories: (1) 'making or maintaining progress' (expected to meet more, or the same level, of the need in the future than currently): 14 countries including Ghana, Senegal and South Africa, (2) 'at risk' (currently performing relatively well but expected to deteriorate due to the health workforce not keeping pace with population growth): 6 countries including Gabon, Rwanda and Zambia, and (3) 'low performing' (not performing well and not expected to improve): 21 countries including Burkina Faso, Eritrea and Sierra Leone. The three groups face different challenges, and the authors argue that policy solutions to increasing met need should be tailored to the specific context of the country and that national health workforce accounts be strengthened so that workforce planning can be evidence-informed.

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.