Innovative domestic financing mechanisms for health in Africa: An evidence review

OBJECTIVES

This article synthesizes the evidence on what have been called innovative domestic financing mechanisms for health (i.e. any domestic revenue-raising mechanism allowing governments to diversify away from traditional approaches such as general taxation, value-added tax, user fees or any type of health insurance) aimed at increasing fiscal space for health in African countries. The article seeks to answer the following questions: What types of domestic innovative financial mechanisms have been used to finance health care across Africa? How much additional revenue have these innovative financing mechanisms raised? Has the revenue raised through these mechanisms been, or was it meant to be, earmarked for health? What is known about the policy process associated with their design and implementation?

METHODS

A systematic review of the published and grey literature was conducted. The review focused on identifying articles providing quantitative information about the additional financial resources generated through innovative domestic financing mechanisms for health care in Africa, and/or qualitative information about the policy process associated with the design or effective implementation of these financing mechanisms.

RESULTS

The search led to an initial list of 4035 articles. Ultimately, 15 studies were selected for narrative analysis. A wide range of study methods were identified, from literature reviews to qualitative and quantitative analysis and case studies. The financing mechanisms implemented or planned for were varied, the most common being taxes on mobile phones, alcohol and money transfers. Few articles documented the revenue that could be raised through these mechanisms. For those that did, the revenue projected to be raised was relatively low, ranging from 0.01% of GDP for alcohol tax alone to 0.49% of GDP if multiple levies were applied. In any case, virtually none of the mechanisms have apparently been implemented. The articles revealed that, prior to implementation, the political acceptability, the readiness of institutions to adapt to the proposed reform and the potential distortionary impact these reforms may have on the targeted industry all require careful consideration. From a design perspective, the fundamental question of earmarking proved complex both politically and administratively, with very few mechanisms actually earmarked, thus questioning whether they could effectively fill part of the health-financing gap. Finally, ensuring that these mechanisms supported the underlying equity objectives of universal health coverage was recognized as important.

CONCLUSIONS

Additional research is needed to understand better the potential of innovative domestic revenue generating mechanisms to fill the financing gap for health in Africa and diversify away from more traditional financing approaches. Whilst their revenue potential in absolute terms seems limited, they could represent an avenue for broader tax reforms in support of health. This will require sustained dialogue between Ministries of Health and Ministries of Finance.

A theory-based evaluation of the Leadership for Universal Health Coverage Programme: insights for multisectoral leadership development in global health

Background

Leadership to manage the complex political and technical challenges of moving towards universal health coverage (UHC) is widely recognized as critical, but there are few studies which evaluate how to expand capacities in this area. This article aims to fill some of this gap by presenting the methods and findings of an evaluation of the Leadership for UHC (L4UHC) programme in 2019–2020.

Methods

Given the complexity of the intervention and environment, we adopted a theory-driven evaluation approach that allowed us to understand the role of the programme, amongst other factors. Data from a range of sources and tools were compared with a programme theory of change, with analysis structured using an evaluation matrix organized according to the Organisation for Economic Co-operation and Development–Development Assistance Committee (OECD-DAC) criteria. Data sources included key informant (KI) interviews (89 in total); surveys of the 80 workshop participants; a range of secondary data sources; case studies in two countries; and observation of activities and modules by the evaluator.

Results

Participants and KIs at the global and country levels reported high relevance of the programme and a lack of alternatives aiming at similar goals. In relation to effectiveness, at the individual level, there was an increase in some competencies, particularly for those with less experience at the baseline. Less change was observed in commitment to UHC as that started at a relatively high level. Understanding of UHC complexity grew, particularly for those coming from a non-health background. Connections across institutional divides for team members in-country increased, although variably across the countries, but the programme has not as yet had a major impact on national coalitions for UHC. Impacts on health policy and practice outcomes were evident in two out of seven countries. We examined factors favouring success and explanatory factors. We identified positive but no negative unintended effects.

Conclusions

While noting methodological constraints, the theory-based evaluation approach is found suitable for assessing and learning lessons from complex global programmes. We conclude that L4UHC is an important addition to the global and national health ecosystem, addressing a relevant need with some strong results, and also highlight challenges which can inform other programmes with similar objectives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00907-1.

Revenue-raising potential for universal health coverage in Benin, Mali, Mozambique and Togo

Increasing overall fiscal space is important for the health sector due to the centrality of public financing to make progress towards universal health coverage. One strategy is to mobilize additional government revenues through new taxes or increased tax rates on goods and services. We illustrate how countries can assess the feasibility and quantitative potential of different revenue-raising mechanisms. We review and synthesize the processes and results from country assessments in Benin, Mali, Mozambique and Togo. The studies analysed new taxes or increased taxes on airplane tickets, phone calls, alcoholic drinks, tourism services, financial transactions, lottery tickets, vehicles and the extractive industries. Study teams in each country assessed the feasibility of new revenue-raising mechanisms using six qualitative criteria. The quantitative potential of these mechanisms was estimated by defining different scenarios and setting assumptions. Consultations with stakeholders at the start of the process served to select the revenue-raising mechanisms to study and later to discuss findings and options. Exploring feasibility was essential, as this helped rule out options that appeared promising from the quantitative assessment. Stakeholders rated stability and sustainability positive for most mechanisms, but political feasibility was a key issue throughout. The estimated additional revenues through new revenue-raising mechanisms ranged from 0.47-1.62% as a share of general government expenditure in the four countries. Overall, the revenue raised through these mechanisms was small. Countries are advised to consider multiple strategies to expand fiscal space for health.

What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies

BACKGROUND

All health systems struggle to meet health needs within constrained resources. This is especially true for low-income countries. It is critical that they can learn from wider contexts in order to improve their performance. This article examines policy transfer and evidence use linked to it in low- and middle-income settings. The objective was to inform international investments in improved learning across health systems.

METHODS

The article uses a comparative case study design, drawing on case studies conducted in Bangladesh, Burkina Faso, Cambodia, Ethiopia, Georgia, Nepal, Rwanda and Solomon Islands. One or two recent health system reforms were selected in each case and 148 key informants were interviewed in total, using a semi-structured tool focused on different stages of the policy cycle. Interviewees were selected for their engagement in the policy process and represented political, technical, development partner, non-governmental, academic and civil society constituencies. Data analysis used a framework approach, allowing for new themes to be developed inductively, focusing initially on each case and then on patterns across cases.

RESULTS

The selected policies demonstrated a range of influences of externally imposed, co-produced and home-grown solutions on the development of initial policy ideas. Eventual uptake of policy was strongly driven in most settings by local political economic considerations. Policy development post-adoption demonstrated some strong internal review, monitoring and sharing processes but there is a more contested view of the role of evaluation. In many cases, learning was facilitated by direct personal relationships with local development partner staff. While barriers and facilitators to evidence use included supply and demand factors, the most influential facilitators were incentives and capacity to use evidence.

CONCLUSIONS

These findings emphasise the agency of local actors and the importance of developing national and sub-national institutions for gathering, filtering and sharing evidence. Developing demand for and capacity to use evidence appears more important than augmenting supply of evidence, although specific gaps in supply were identified. The findings also highlight the importance of the local political economy in setting parameters within which evidence is considered and the need for a conceptual framework for health system learning.

The free healthcare initiative in Sierra Leone: Evaluating a health system reform, 2010-2015

This article presents the findings of a theory-based evaluation of the Sierra Leone Free Health Care Initiative (FHCI), using mixed methods. Analytical approaches included time-series analysis of national survey data to examine mortality and morbidity trends, as well as modelling of impact using the Lives Saved Tool and expenditure trend analysis. We find that the FHCI responded to a clear need in Sierra Leone, was well designed to bring about needed changes in the health system to deliver services to the target beneficiaries, and did indeed bring funds and momentum to produce important systemic reforms. However, its ambition was also a risk, and weaknesses in implementation have been evident in a number of core areas, such as drugs supply. We conclude that the FHCI was one important factor contributing to improvements in coverage and equity of coverage of essential services for mothers and children. Modelled cost-effectiveness is high-in the region of US$ 420 to US$ 444 per life year saved. The findings suggest that even-or perhaps especially-in a weak health system, a reform-like fee removal, if tackled in a systematic way, can bring about important health system gains that benefit vulnerable groups in particular.

Removing user fees: learning from international experience to support the process

Removing user fees could improve service coverage and access, in particular among the poorest socio-economic groups, but quick action without prior preparation could lead to unintended effects, including quality deterioration and excessive demands on health workers. This paper illustrates the process needed to make a realistic forecast of the possible resource implications of a well-implemented user fee removal programme and proposes six steps for a successful policy change: (1) analysis of a country's initial position (including user fee level, effectiveness of exemption systems and impact of fee revenues at facility level); (2) estimation of the impact of user fee removal on service utilization; (3) estimation of the additional requirements for human resources, drugs and other inputs, and corresponding financial requirements; (4) mobilization of additional resources (both domestic and external) and development of locally-tailored strategies to compensate for the revenue gap and costs associated with increased utilization; (5) building political commitment for the policy reform; (6) communicating the policy change to all stakeholders. The authors conclude that countries that intend to remove user fees can maximize benefits and avoid potential pitfalls through the utilization of the approach and tools described.