Health Systems & Reform ISSN: 2328-8604 (Print) 2328-8620 (Online) Journal homepage: http://www.tandfonline.com/loi/khsr20 Introduction to Special Issue on Health Financing in East and Southern Africa Pia Schneider, Abdo S. Yazbeck & Magnus Lindelow To cite this article: Pia Schneider, Abdo S. Yazbeck & Magnus Lindelow (2018) Introduction to Special Issue on Health Financing in East and Southern Africa, Health Systems & Reform, 4:4, 267-271, DOI: 10.1080/23288604.2018.1514481 To link to this article: https://doi.org/10.1080/23288604.2018.1514481 Published with license by Taylor & Francis Group, LLC© 2018 International Bank for Reconstruction and Development / The World Bank Accepted author version posted online: 24 Sep 2018. Published online: 24 Sep 2018. Submit your article to this journal Article views: 344 View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=khsr20 Health Systems & Reform, 4(4):267–271, 2018 Published with license by Taylor & Francis Group, LLC ISSN: 2328-8604 print / 2328-8620 online DOI: 10.1080/23288604.2018.1514481 Commentary Introduction to Special Issue on Health Financing in East and Southern Africa Pia Schneidera,*, Abdo S. Yazbeckb, and Magnus Lindelowa a Health Nutrition and Population Global Practice, The World Bank Group, Washington, DC, USA b International Health Department, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA CONTENTS WHY A SPECIAL ISSUE ON HEALTH FINANCING IN EAST AND SOUTHERN AFRICA? Why a Special Issue on Health Financing in East and This special issue on health financing in East and Sothern Southern Africa? Africa comes at an opportune time. Economic growth in the Health Financing at the World Bank region is contributing to a changing lifestyle and an increasing This Special Issue burden of noncommunicable diseases, such as diabetes, which Concluding Remarks are costlier to treat. Coupled with the unfinished health agenda References of communicable diseases and maternal and child health, demand for health care is increasing rapidly and putting finan- cial pressure on governments. A risky response in a resource- constrained setting is governments reallocating funds away from the poor to more expensive specialist and tertiary care. Another risky response relates to ways of raising additional revenues, especially in countries where health facilities already charge user fees in the absence of prepayment. Relatively poor patients who pay fees when seeking care may have to sell assets and incur debts, which may push them into poverty or deeper into poverty. Protecting households against falling into poverty and ensuring access to essential health services are thus top priorities for governments committed to universal health cover- age (UHC) in the region. Achieving this objective requires solving several pertinent problems. A challenge faced by many low- and middle-income coun- tries is how to finance access to quality care for a large low- income population in a fiscally constrained setting. Fiscal defi- cits are a common feature in developing countries where the tax base is narrow due to a large informal sector. Limited revenue- raising capacity and a policy focus on controlling the deficit put pressure on the amount that governments can spend on health Received 17 August 2018; revised 18 August 2018; accepted 18 August care. Some governments are looking to health insurance as a 2018. method to increase pooled revenues and mobilize additional *Correspondence to: Pia Schneider; Email: pschneider@worldbank.org resources for the sector. However, expanding insurance to low- © 2018 International Bank for Reconstruction and Development / The World Bank income and informal-sector groups has proven to be difficult. This is an Open Access article distributed under the terms of the Creative Another challenge is the flow of health funds in the system. How Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), can financial systems ensure that health budgets reach providers which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. on time to finance the provision of care as planned? 267 268 Health Systems & Reform, Vol. 4 (2018), No. 4 Addressing these challenges in East and Southern Africa countries (Kenya, Malawi, the Seychelles, Tanzania, Zambia, calls for more and better data and analysis on health finan- and Zimbabwe) on how to make health financing more cing reforms to extend coverage. Though a relatively rich effective and equitable. These countries were included literature on these issues exists in Organization for because of newly available information on their health finan- Economic Cooperation and Development countries, there is cing reforms and a very active policy dialogue on health a dearth of peer-reviewed publications that focus on East and financing between the governments and the World Bank. Southern Africa. This special issue is contributing such analysis and lessons from the region to help identify ways to make health financing more effective and equitable. A THIS SPECIAL ISSUE subregional focus makes sense because governments in the region are faced with similar policy questions. The work This issue includes three commentaries from Zambia, presented in this special issue was prepared by World Bank Seychelles, and Tanzania and seven research articles. The staff and their country counterparts working in the East and latter tackle the following main themes: how out-of-pocket Southern Africa region. payments affect household welfare, domestic resource mobi- lization, social health insurance as a method to expand coverage, public financial management in health, and resource allocations within a health system. These themes HEALTH FINANCING AT THE WORLD BANK were selected for detailed analyses because they are the Health financing continues to be an important issue in global focus of reforms in these countries. They also represent health and a focus of many development partners supporting themes related to health financing reform that are increas- the health sector and financing transitions. The topic is ingly debated around the world and where existing literature strategically important for the World Bank. The Bank is is relatively limited. considered to have a comparative advantage in the field The findings in this issue are sobering for policy makers because it is a multisector organization and includes as a who may have hoped to find quick solutions. Health finan- core mandate sustainable financing, overall fiscal health, and cing reforms never end. Moreover, just increasing funding is economic development. Health financing is an important not enough but needs to be accompanied by good govern- public policy concern and strongly represented in the ance in health and political will to implement. Bank’s multisector operations and analytical work. During The special issue begins with a commentary prepared the past decade, the World Bank implemented about 200 by the Zambian Honorable Minister of Health on the way lending operations that included support to health financing toward UHC, “Crunch Time: The Transformational reforms in about 70 countries around the world. In addition, Universal Health Coverage Agenda for Zambia.” The the Bank produced a large body of analytical work on health authors describe the efforts made since the early 1990s financing, whic'h included 98 public expenditure reviews, 10 with institutional and financing reforms. Results achieved public expenditure tracking surveys, 20 poverty assessments, are presented as well as the remaining challenges that still about 70 economic and sector work activities, eight fiscal need to be addressed, including a shortage in financing and space studies, and a growing number of impact evaluations in human resources, inadequate infrastructure, and weak globally.1 About one third of this work took place in the supply chains and public financial management systems. Bank’s Africa region. Bank support to health financing The authors explain how external factors are putting pres- depends on country context. Bank lending to lower-income sure to move quickly. These include a growing economy, countries has a strong focus on strengthening public revenue which has led to a shift in donor attention to other priority collection, whereas support to risk pooling and purchasing is countries, and population growth and a changing disease more common in middle-income countries. Poverty assess- profile, which have resulted in increasing demand for care. ments most frequently examine the proportion of low- The government is committed to increasing funding for the income populations in risk pooling schemes and the benefit health sector, but according to the Ministry of Health, incidence of public health expenditures. The majority of the results can only be achieved if this is in conjunction with Bank’s impact evaluations in health financing have analyzed efficiency gains in implementation and by including equity the effect of results-based financing, followed by a few in priority setting. Two articles in this issue (presented studies on the effectiveness of health insurance.1 below) further elaborate on these points and present more The articles included in this issue draw upon the Bank’s detailed results from Zambia on how public financial recent analyses from the region and present studies from six management systems can affect health service delivery Schneider et al.: Introduction to Special Issue on Health Financing in East and Southern Africa 269 and the poverty impact of out-of-pocket spending based on The following two research articles from Zimbabwe and household survey data. Zambia use data from national household surveys to show The commentary on Seychelles, “The Health Sector in how out-of-pocket spending affects households. In Seychelles: Prioritization and Accountability,” is written by “Utilization of Health Care and Burden of Out-of-Pocket the Honorable Minister of Health for Seychelles, Dr. Jean- Health Expenditure in Zimbabwe: Results from a National Paul Adam. The commentary highlights the factors that have Household Survey,” Zeng, Lannes, and Mutasa exploit a contributed to the sustained success of the health sector in recent household survey data set with data collected on the country. Success factors include the long-term and sus- health utilization and health expenditure at the individual tained investments by the government in the health sector level. The authors use standard methods to analyze the and two types of accountability that include accountability to level and inequalities in service utilization and in financial the population as well as clarity in roles and the account- protection. The findings offer interesting insight on the pat- abilities of the different structures of the Ministry of Health. terns of health expenditures in Zimbabwe and on the ways in The commentary acknowledges as important factors the which health expenditures contribute to poverty. collaboration with external partners and the use of analytical Catastrophic health expenditure was considerably more com- work to learn and adapt over time. Finally, the commentary mon among the poorest (13.4%) than among the richest offers lessons from the country for other nations seeking to groups (2.8%), and some households fell into poverty due move along the road to UHC. to their illness. The study recommends giving priority to The next commentary on Tanzania, “Progressive Pathway interventions targeting vulnerable groups to improve finan- to Universal Health Coverage in Tanzania: A Call for cial risk protection in Zimbabwe. Preferential Resource Allocation Targeting the Poor,” is writ- In the article on Zambia, “Myriad of Health Care ten by the Permanent Secretary at the Ministry of Health, Financing Reforms in Zambia: Have the Poor Benefited?” Community Development, Gender, Elderly and Children and Chitah, Chansa, Kaonga, and Workie examine whether the World Bank colleagues. The authors focus on the need for poor have benefited from decades of health reforms, includ- explicit prioritization of the poor in the health system. The ing a needs-based resource allocation formula and free pub- commentary looks at several vehicles for more explicit tar- lic health care. Using data from three household surveys, the geting of the poor, including (1) grant transfer to local authors conduct a benefit incidence analysis to examine the government authority, (2) considerations in in-kind transfers distributional impact of reforms. They find that public health from the government, and (3) government contributions to facilities have consistently benefited the population in urban insurance funds. The commentary concludes with specific provinces and that their resources are not aligned with the pro-poor policy recommendations for the ongoing develop- disease burden that facilities are to manage. Outpatient and ment of a single national health insurance platform. inpatient benefits in public and private health facilities favor Following these commentaries, the first research article the rich. Interestingly, mission health facilities also became asks: “What Are Governments Spending on Health in East pro-rich over time, although they are predominantly located and Southern Africa?” written by Piatti-Fünfkirchen, in rural poor areas. Despite decades of reforms, Zambia has Lindelow, and Yoo, this article shows that government health not attained equitable access to quality health care. The spending in countries in East and Southern Africa has authors recommend a strategic approach to implementing a increased but not as fast as economic growth. They argue comprehensive needs-based resource allocation formula. that progress toward UHC will require sustained increases in The next article, “Fresh Money for Health? The (False?) public spending to allow out-of-pocket financing to decrease. Promise of ‘Innovative Financing’ in Malawi” by Chansa, The article considers a list of methodological issues that can Mwase, Matsebula, Kandoole, Revill, Makumba, and help explain differences in health expenditures when compar- Lindelow, is focused on proposals for “innovative financing ing estimates from the World Health Organization’s Global methods” to increase fiscal space for health in Malawi. Health Expenditure Database to country-specific public Using Delphi forecasting and the gross domestic product- expenditure reviews. The authors argue for transparency and based effective tax rate forecasting method, the article esti- increased efforts to strengthen national data capacity and mates how much additional tax revenues could be generated promote quality and consistency of data. The World Health from existing and new sources. Most promising are taxes on Organization’s Global Health Expenditure Database is best fuel and motor vehicle insurance, but the government has not used in combination with deep-dive country expenditure implemented the proposed taxes despite their revenue poten- assessments. tial. To expand fiscal space for health, efficiency-enhancing 270 Health Systems & Reform, Vol. 4 (2018), No. 4 measures are recommended, including strengthening public Sub-Saharan Africa and Island Nations,” by Workie, Shroff, financial management, which is also the focus of the next Yazbeck, Nguyen, and Karamagi, the last article asks a article. The authors argue that good governance of public provocative question on the need for major reforms. Based finance is needed to improve service delivery, but how this on the experience of the Seychelles, the authors argue that mechanism exactly works remains underexplored. the road to UHC need not be driven by big reforms such as Using a case study approach, the article “From Stumbling health insurance, provider–funder separation, or results- Block to Enabler: The Role of Public Financial Management based financing. Based on a review of public expenditure in Health Service Delivery in Tanzania and Zambia,” by reviews and supporting surveys, the authors conclude that a Piatti-Fünfkirchen and Schneider, examines how the differ- basic supply side–funded, publicly owned and operated, and ent phases in public financial management affect health integrated health system produced remarkable health out- service delivery. By mapping the three stages of the budget comes in a cost-effective way in the Seychelles. Success cycle to performance criteria used in health service delivery, factors included strong political commitment and voice, a the authors identify several stumbling blocks based on data downward accountability culture, reliable public health func- from Tanzania and Zambia. These stumbling blocks include tions, and continued investment in primary health care. the lack of flexibility to provide additional resources for These factors provided support for adapting the health sys- unexpected demand for care, misalignment between budget- tem in the Seychelles to the epidemiological and demo- ing and planning, fragmented funding sources, rigid internal graphic transitions and rising demand for high quality of controls, insufficient budget provision, and a budget evalua- care. The authors suggest that other small-island countries tion system that is compliance driven and gives inadequate may learn from the policy experiences of the Seychelles. attention to issues of equity, quality, and efficiency in service delivery. The sobering part of this article is the lack of examples to show how governments have addressed these CONCLUDING REMARKS stumbling blocks to turn public financial management sys- tems into enabling factors for efficiency gains. This special issue represents an effort to bring together policy- The next article on Kenya is the only essay in this issue that relevant data and analysis on health financing in East and examines lessons from health insurance reform for UHC. Southern Africa. Despite covering only a few countries from “Kenya National Hospital Insurance Fund Reforms: the subregion, it offers new perspectives and valuable insights. Implications and Lessons for Universal Health Coverage,” by The articles identify a series of health financing challenges Barasa, Rogo, Mwaura, and Chuma, is based on a review of the that governments across the subregion are grappling with and literature. The authors describe how UHC has been affected by important lessons. Public spending needs to be accompanied the National Hospital Insurance Fund (NHIF) reforms, includ- by strong political commitment to reforms and good govern- ing the introduction of the civil servants’ scheme and the step- ance to make progress toward UHC. “New” ways to expand wise quality improvement system, the health insurance subsidy fiscal space, innovative financing, and social health insur- for the poor, revised contribution rates and an expanded benefit ances are limited by the formality of a country’s economy. package, and revision of provider reimbursement rates. And there remain tensions between ensuring effective and Although these reforms have contributed to improvements in equitable use of public resources, as well as between incre- several areas, with 14% of the population now enrolled in the mental change and new models and reforms where govern- NHIF, Kenya is far from reaching UHC. Contributing a negli- ments are pressured to deliver quick results. gible share of total health funding, the NHIF is not a significant Pressures on governments to take action on health financing revenue-raising mechanism. Scope for expansion is limited in are strong in East and Southern Africa, due to the ambitious Kenya, due to the predominantly informal-sector population. UHC agenda in the region, bold Sustainable Development Goal The authors recommend tax-financed enrollment to expand commitments, and growing population frustration with under- coverage for informal-sector groups, consolidating fragmented performing health systems. In this context, it is critical that the pooling, and adjusting provider payment to manage financial formulation of health financing strategies is informed by robust incentives set to providers. This study provides an important and relevant data and analysis. Similarly, the implementation of case study on the challenges of using health insurance to such strategies requires continuous feedback to understand stum- achieve UHC. bling blocks and impacts. We hope that this special issue makes a Finally, in “Who Needs Big Health Sector Reforms contribution in this direction and that it helps stimulate further Anyway? Seychelles’ Road to UHC Provides Lessons for research and data collection efforts on health financing chal- lenges and solutions. Schneider et al.: Introduction to Special Issue on Health Financing in East and Southern Africa 271 DISCLOSURE OF POTENTIAL CONFLICTS OF REFERENCES INTEREST 1. Independent Evaluation Group (IEG). World Bank Group Support to Health Financing. Washington (DC): The World Bank; 2014 No potential conflicts of interest were disclosed. accessed 2018 August 18.