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.
Resource allocation and health financing
This paper examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys. In 2004, the Ministry of Health implemented the “10/20 policy” for maternal health services in public facilities, that removed user fees at the lowest levels of care. In 2007, the 10/20 policy was removed and a policy of no user fees for deliveries in public facilities was declared. However, no alternative source of funding was offered and the reality of informal fees remained in place for many service users. Government announced
free maternity services in all public health facilities in June 2013. Data was gathered from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy and a statistically significant increase in public facility deliveries among women from the two top quintiles, and a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time. The findings provided empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.
This study assessed the geographical distribution of comorbidity and its associated financial implications among commercially insured individuals in South Africa. The authors aggregated individual risk scores to determine the average risk score per district, also known as the comorbidity index, to describe the overall disease burden of each district The authors observed consistently high comorbidity index scores in districts of the Free State and KwaZulu-Natal provinces for all population groups before and after age adjustment. Some areas exhibited almost 30% higher healthcare utilization after age adjustment. Districts in the Northern Cape and Limpopo provinces had the lowest comorbidity index scores with 40% lower than expected healthcare utilization in some areas after age adjustment. The results show underlying disparities in the comorbidity index at national, provincial, and district levels.
This paper set out to explore whether adding a gender and HIV training programme to microfinance initiatives can lead to health and social benefits beyond those achieved by microfinance alone. Cross-sectional data was derived from three randomly selected matched clusters in rural South Africa. A total of 1,409 participants were enrolled, all female, with a median age of 45. After two years, both the microfinance-only group and the IMAGE group showed economic improvements relative to the control group. However, only the IMAGE group demonstrated consistent associations across all domains with regard to women’s empowerment, intimate partner violence and HIV risk behaviour. In conclusion, the addition of a training component to group-based microfinance programmes may be critical for achieving broader health benefits.
In this paper, the authors assessed Malawi’s sector-wide approach (SWAp) through its essential health package (EHP) in terms of coverage and choice of interventions. A review of the cost-effectiveness of 55 EHP interventions was undertaken to assess the appropriateness of each intervention used in the EHP, using WHO recommended protocols for burden of disease and performance and National Health Accounts data for cost. The authors found that 33 of the 55 EHP interventions were potentially cost-effective, while 12 were not so cost-effective, and cost-effective estimates were not available for 10 interventions. The paper suggests further areas of potentially high cost effectiveness for future inclusion in the EHP. Overall, the authors conclude that the SWAp had invested in some very cost-effective health interventions. In terms of numbers of patients treated, the EHP had delivered two-thirds of the services required, despite serious under-funding of the EHP, an increase in the population and shortage of staff. In conclusion, the identification of interventions of proven effectiveness and good value for money and earmarked funding through a SWAp process can produce measurable improvement in health service delivery at extremely low cost.
This report is from a study carried out by the Uganda Coalition for Access to Essential Medicines (UCAEM), to assess the implementation of the Global Fund to fight HIV/AIDS, Malaria and TB in Uganda. The study was specifically designed to offer an analysis of the implementation process and activities of the UGFATMP with the aim of establishing the involvement of key stakeholders particularly CSOs, identify the challenges, document beneficiary perspectives and make recommendations on key CSOs concerns about the process. Despite successes around the world this report reveals that there are still concerns at the country level in Uganda.
With United States (US) President Barack Obama's release of his 2012 foreign affairs budget and a Senate proposal to cut US international spending, the fight to sustain US aid abroad is intensifying, according to this article. Development and foreign policy analysts largely praised the administration's funding appeal for maximising returns by focusing spending on strategic areas such as global health, food security and climate change. Major funding hikes include an US$850 million (10.8%) raise for global health and child survival programmes, and a US$400 million (16%) raise for development assistance – which includes a US$1.1 billion boost to the Feed the Future Initiative and a US$651 million contribution to the Global Climate Change Initiative. But a proposal has been put forward to cut total spending for 2011 by US$100 billion, and conservative lawmakers are moving to lump the international budget with non-security accounts in a bid to make massive reductions possible. Their efforts emerge in the wake of Obama’s State of the Union speech in January 2011, where he pledged to freeze non-security funding for the next five years.
Uganda is experiencing an increase in nutrition-related non-communicable diseases (NCDs) including from overconsumption of sugar-sweetened beverages. Fiscal and taxation policies aim to address this, but make their adoption and implementation are constrained by political and economic challenges. The authors investigated the policy and political landscape related to this in Uganda, using a desk-based policy analysis and four key informant consultations. While nutrition-related NCDs were recognised as an emerging problem in Uganda and government has adopted a comprehensive approach to improve diets, its implementation is slow. There is limited recognition of the consumption of sugar and sugar-sweetened beverages as a contributor to these NCDs in policy documents, existing taxes on soft drinks are lower than the WHO recommended rate of 20% and do not target sugar content. The authors report that the soft drink industry has been influential in framing the taxation debate, with the Ministry of Finance reducing taxation of sugar-sweetened beverages to maintain competitiveness in a regional market. The Ministry of Health and other public health actors in civil society have been successful (albeit marginally) in countering reductions in taxation, and a platform for sugar-sweetened beverage taxation advocacy exists in Uganda. Compelling local research that explicitly links soft drink taxes to health goals is argued to be essential to advance sugar-sweetened beverage taxation.
Musgrove P, Zeramdini R. A summary description of health financing in WHO Member States(CMH Working Paper Series, Paper No. WG3: 3.
Analysed in this paper are national health accounts estimates for 191 WHO Member States for 1997, using simple comparisons and linear regressions to describe spending on health and how it is financed. The data cover all sources—out-of-pocket spending, social insurance contributions, financing from government general revenues and voluntary and employment-related private insurance — classified according to their completeness and reliability.
Rich countries should back their poorer neighbours in setting up free universal healthcare to help save thousands of lives, Hilary Benn, the minister for international development, will told public service workers in the UK in May.