Alignment of health financing with health systems goals for universal health coverage, health security, and addressing social determinants of health: technical brief

Alignment of health financing with health systems goals for universal health coverage, health security, and addressing social determinants of health Technical brief

Alignment of health financing with health systems goals for universal health coverage, health security, and addressing social determinants of health Technical brief Alignment of health financing with health systems goals for universal health coverage, health security, and addressing social determinants of health: technical brief ISBN: 978-929023507-1 © WHO African Region, 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/ igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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All photos: ©WHO Designed in Brazzaville, Republic of Congo iii Contents Acknowledgements ......................................................................................................vi Abbreviations .............................................................................................................vii Executive summary ....................................................................................................viii 1. Background ............................................................................................................. 1 2. Methodology ............................................................................................................ 6 2.1 Inclusion and exclusion criteria ................................................................................................7 2.2 Search strategy ..........................................................................................................................7 2.3 Selection process .......................................................................................................................8 2.4 Data extraction...........................................................................................................................8 2.5 Data analysis ............................................................................................................................18 3. Findings ................................................................................................................... 9 3.1 Current focus of different sources of health funds in relation to the 13 health system elements .....................................................................................................10 3.2 Framework for assessing financing sources for health system elements ............................19 3.2.1 Efficiency .......................................................................................................................23 3.2.2 Equity .............................................................................................................................23 3.2.3 Sustainability .................................................................................................................23 3.2.4 Feasibility .......................................................................................................................23 3.2.5 Displacement.................................................................................................................24 3.3 Effectiveness of the current ways the 13 health system elements are financed from the four sources of funding ............................................................................................24 3.3.1 Government funding .....................................................................................................24 3.3.2 Out-of-pocket payments ...............................................................................................25 3.3.3 External funding ............................................................................................................25 3.3.4 Private financing ...........................................................................................................26 3.4 Perceptions on improving the targeting of the four sources of funds towards the 13 elements of the system for effective functioning .......................................................27 3.4.1 Human resources for health .........................................................................................37 3.4.2 Service delivery .............................................................................................................28 3.4.3 Infrastructure .................................................................................................................29 3.4.4 Information management systems ..............................................................................29 iv 3.4.5 Governance....................................................................................................................29 3.4.6 Medical products ...........................................................................................................29 3.5 Suggest more efficient methods for allocating current sources of funds to the 13 health system elements in order to maximize resource adequacy, efficiency and equity ...............................................................................................................30 4. Conclusion .............................................................................................................33 References .................................................................................................................35 Annex 1: List of reviewed literature ..................................................................................................42 Annex 2: Detailed summary of the different elements by country, according to the national health accounts .................................................................................................................49 Annex 3: Detailed health financing frameworks and framework elements identified in literature 55 List of figures Figure 1: Scope and relationships of health system elements .........................................................4 Figure 2: Literature selection flow diagram .....................................................................................10 Figure 3: Trends in contributions of health financing sources to total health expenditure in SSA 11 Figure 4: Absolute health expenditures by source in SSA................................................................11 Figure 5: Proportion of total health expenditure by health system function in SSA ......................12 Figure 6: Absolute total health expenditures by health system function in SSA ............................12 Figure 7: Share of, and absolute expenditure (in United States dollars) on health system functions from public sources of funding in SSA ..............................................................13 Figure 8: Share of, and absolute expenditure (in United States dollars) on health system functions from private sources of funding in SSA ...........................................................14 Figure 9: Share of, and absolute expenditure (in United States dollars) on health system functions from external/donor sources of funding in SSA .............................................14 Figure 10: Allocation of Global Fund Round 8 to health systems strengthening ............................15 Figure 11: Frequency of reporting expenditure for health system elements in NHA for the African Region .......................................................................................................19 List of tables Table 1: Summary of the different elements by country, according to the national health accounts ...................................................................................................................16 Table 2: Health financing frameworks identified in literature.........................................................20 vTable 3: Framework for assessing health financing sources ...........................................................22 Table 4: Performance of health financing sources against assessment criteria .............................24 Table 5: Public-private partnership models used in health in Africa (Whyle & Olivier, 2016) ........26 vi Acknowledgements The technical brief was developed under the stewardship of the Assistant Regional Director (ARD) Cluster in the WHO Regional Office for Africa. The Cluster coordinates and stewards cross- cutting technical functions of the WHO Regional Office for Africa. The brief was developed under the leadership of Dr Lindiwe Makubalo, the Cluster Director. Technical coordination was led by Dr Humphrey Karamagi, Team Lead of the Data, Analytics and Knowledge Management (DAK) Team. The assessment was conducted by independent experts from Member States, and included Edwine Barasa, David Njuguna and Herve Djossou. Internal appraisal was carried out by ULC, Professor Benjamin Musembi Nganda, Ms Diane Karenzi Muhongerwa, Mr Kingsley Addai Frimpong and Dr Juliet Nabyonga, and Aminata Binetou Wahebine Seydi DAK/ARD cluster. Coordination support from the regional office was provided by Solyana Ngusbrhan Kidane, DAK/ARD. vii Abbreviations CGH: common goods for health CASP: Critical Appraisal Skills Programme Gavi: Gavi, the Vaccine Alliance GHSA: Global Health Security Agenda GDP: gross domestic product HRH: human resources for health LMICs: low- and middle-income countries NCDs: noncommunicable diseases NGOs: nongovernmental organizations NHA: national health accounts OOPS: out-of-pocket spending PEPFAR: The U.S. President’s Emergency Plan for AIDS Relief PHC: primary health care PICO: participants, intervention, comparator and outcome PRISMA-ScR: preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews PFM: public financial management PPPs: public-private partnerships SDGs: Sustainable Development Goals SWAps: sector-wide approaches SSA: Sub-Saharan Africa THE: total health expenditure UHC: universal health coverage VAT: value-added tax WHO: World Health Organization viii Executive summary Health financing is critical to the attainment of universal health coverage. It ensures that funding is available and sets the right financial incentives to health providers for all individuals to access effective public health and personal health care. Currently, health financing focuses on complex and dynamic systems which interplay across 13 health system elements. However, there is a lack of detailed conceptualization on how the current health financing mechanisms interplay across those elements. This scoping review summarizes evidence on the potential for different funding sources for the specific elements of the health system. We included 119 articles in this review that employed a combination of conceptual studies (13%) and empirical studies (87%), published from 1975 to 2021. Moreover, 45% of the studies focused on service delivery, 13% on human resources for health, 5% on medical products and 3% on infrastructure and governance. Studies reporting multiple health system elements contributed 8% to the papers included. Health financing assessment frameworks were presented in 23% of these studies. Broadly, there was sufficient evidence to conclude that public sources were the dominant form of financing for the 13 health system elements. On the other hand, there was no preference to fund specific elements of the health system with any of the four funding sources. Additionally, global documentation on health expenditure does not track funding for all the dimensions that informed the conceptual framework of this scoping review. The available evidence tracks the spending for tangible elements of the health system and not the intangible ones. Sustainable policies for gradually exiting from donor funding for health are required, as dependence on humanitarian actors will continue to cripple countries’ ability to be self-sufficient and self-reliant. 11Background 2 3 “Ensure healthy lives and promote well-being for all at all ages” is the third of the 17 Sustainable Development Goals (SDGs) established by the United Nations in 2015 (UN, 2015). This third goal is attained by achieving multiple health and related targets across the SDGs (UN, 2015). These multiple targets are brought together in three interconnected themes: universal health coverage (UHC); health security (HSE); and coverage of health determinants (CHD). Universal health coverage is a global health priority, anchored in Sustainable Development Goal 3, target 3.8. It ensures financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all (UN, 2015). Global public health security includes proactive and reactive activities, which lower the risk and impact of acute public health events that endanger people’s health across geographical regions and international boundaries. Health security works at the individual and population levels. Individually, health security considers the risks and threats, as well as the underlying vulnerabilities to both communicable and noncommunicable diseases (NCDs). At the population level, health security overlaps State security. According to the current international liberal architecture, the relationship between health security and their realization is dependent on the citizen-State relationship. In this rendering, health security does not have a global guarantee; it is not itself a global public good (Frenk et al., 2014; Lisk, 2009). Determinants of health may be biological, behavioural, sociocultural, economic and ecological. Broadly, the determinants of health can be divided into four core categories, which are like the four pillars of a foundation: nutrition, lifestyle, environment and genetics. When any one of the pillars becomes weak, a support system is needed. The support system, which involves medical care, is considered the fifth determinant of health. Two of the determinants that have a significant influence on health are the environmental and social conditions in which people live. There is a large amount of empirical evidence showing that social inequalities, especially poverty, affect inequalities in health and well-being (Patwardhan et al., 2015). There is an increased commitment to improving health and achieving health equity through multisectoral approaches that address social, economic and environmental factors that influence health. In 2013, the review of social determinants and the health divide in the World Health Organization (WHO) European Region recommended developing more “partnerships at all levels of government that enable collaborative models of working, foster shared priorities between sectors and ensure accountability for equity” (Marmot et al., 2012). Health financing is the function of a health system that refers to how financial resources are used to ensure that the health system can adequately cover the collective health needs of every person. It deals with the mobilization, accumulation, efficient and effective allocation of funds to cover the health needs of the people, individually and collectively. It makes funding available and sets the right financial incentives to providers to ensure that all individuals access effective public health and personal health care. Besides, it is an enabling factor in the ability of countries to achieve universal health coverage by improving effective service coverage and financial protection (Kutzin, 2013). It is critical for achieving universal health coverage by raising adequate funds for health in ways that ensure that people can use the needed services and are protected from financial risk (WHO, 2018). By understanding financing of health systems and services, programmes and resources can complement the health financing already in place, advocate for more funding of priority areas and increase population access to available health services (Schieber et al., 2006). 2 3 Health systems differ widely across the globe in terms of their financing schemes. Funds are from four sources: government schemes, donors, out-of-pocket and private health insurance. Government schemes typically receive budget allocations out of the overall government revenue. Out-of-pocket spending (OOPS) is exclusively financed from household revenue. Donors give donations or additional income from investments or rentals. Resident financing schemes can also receive transfers from abroad as part of bilateral cooperation with foreign governments or other development partners. Social health insurance is usually financed out of social contributions payable by employees and employers. However, these schemes may also receive a varying proportion of their revenues from governmental transfers. The main sources of revenue for private health insurance are either compulsory or voluntary prepayments, which typically take the form of regular premium payments, as part of an insurance contract (Campos, 2018). Despite continued global agreement on the need to strengthen national health financing systems to develop sustainable and comprehensive policies, health financing in low- and middle-income countries (LMICs) and individuals’ access to essential health services depend on OOPS. Such access barriers contribute to a high burden of disease and preventable deaths. In addition, more than approximately 800 million people spend at least 10% of their income on health care through OOPS, which pushes millions of individuals further into poverty each year (Salari et al., 2019). This can be attributed to the cost-sharing policy in public hospitals (E. W. Barasa et al., 2017)”type”:”article- journal”,”volume”:”16”},”uris”:[“http://www.mendeley.com/documents/?uuid=329691b0- 3ef1-4431-895f-b91aa30d9cb0”]}],”mendeley”:{“formattedCitation”:”(E. W. Barasa et al., 2017, low health insurance coverage and low expenditure on health by the government (Mcintyre D, 2014). Strengthening of domestic financing is crucial to avoiding OOPS; and countries must increase their allocated spending on primary healthcare by at least 1% of their gross domestic product if the health targets of the 2030 Agenda for Sustainable Development are to be met. Besides, these different sources of funding are usually focused on the different elements of the health system. This scoping review is guided by a conceptual framework developed by the WHO Regional Office for Africa, to call for a shift from the focus on investment in the six building blocks (World Health Organization, 2007), to a focus on having complex, dynamic systems that allow for interplay across the 13 elements namely (Figure 1): • Three tangible hardware - health workforce, health products, health infrastructure. • Four tangible software - service delivery, governance processes, information system, and financial management system. • Six intangible software - values and norms, beliefs, practices, organizational culture, interests and networks, and relationships and power (Region, 2022). 4 5 The framework posits that a good system is one where the interplay among these elements allows the operationalization of the shifts needed to attain its expected results. The framework further proposes four capacities that a system needs to have, irrespective of the way it mixes and matches its constituent elements, for it to deliver on its results. These include the capacity to: • overcome barriers the population may face when accessing essential services; • ensure that the process of care provision is person-centred and effective; • engage with the beneficiaries, to ensure that what the system has provided is aligned to their own needs; and • anticipate, absorb, adapt and transform itself when facing a shock event, minimizing its impact. The framework asserts that the funding for any health system needs to focus on attaining these capacities. It is therefore crucial to repivot health system development in the WHO African Region to focus on the attainment of these capacities, to achieve the expected results in terms of universal health coverage, health security and coverage of health determinants. It is therefore important to explore whether these common allocations of health funds present the most appropriate way for using the resources, and where they could be put to better use. African countries are grappling with difficult economic conditions and large informal sectors that are difficult to draw into taxation systems or contributory health insurance. However, it is still possible for all countries to achieve UHC. This scoping review presents a typology of financing strategies for the 13 health system elements, their health financing options and lessons for African countries. The study findings will help them to put their financing options in the context of their institutional resources and Figure 1: Scope and relationships of health system elements 4 5 capacities, the efficiency and ease of their collection, their potential to avoid cost escalation and their political and social acceptability. The aim of this scoping review was to generate evidence on the most appropriate ways for utilizing resources to maximize resource adequacy, efficiency and equity in the WHO African Region. 6 7 2 Methodology 6 7 Design A scoping review was performed using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) checklist (Tricco et al., 2018). See appendix 4. This systematic review was not formally registered. 2.1 Inclusion and exclusion criteria This scoping review did not employ any time or geographical restrictions and included studies up to the time of the literature search (31 December 2021). The review included peer-reviewed articles: (a) that were published in the English language (b) reporting empirical research or conceptual papers on the financing of health system functions (c) that were open access. In addition, a thematic review of grey literature on health financing, including the WHO global health expenditure database was also conducted. The team ensured that all the evidence synthesized had undergone methodological and expert scrutiny. 2.2 Search strategy The databases searched included Medline, Cochrane Library, PubMed, WHO database, World Bank database and Google Scholar search engines. In addition to the database search as outlined above, we also undertook the following to identify key evidence for the review: 1. Liaison with topic experts. 2. Citation searching on papers included and other key papers identified by topic experts. 3. Scrutiny of reference lists included in primary studies and relevant systematic reviews. 4. Scrutiny of recent reviews of services and guideline documents for relevant peer-reviewed evidence. The search strategy was structured as follows: • Population – studies reporting health systems financing globally • Intervention – health systems financing • Comparator - there was no comparator for this scoping review • Outcomes – there were main outcomes included. (a) Current focus of different sources of health funds in relation to the 13 health system elements (b) Framework for assessing financing sources for health system elements 8 9 (c) Effectiveness of the current ways in which the 13 health system elements are financed from the four sources of funding (d) Perceptions on how to improve targeting of the four sources of funds towards the 13 elements of the system for them to function effectively (e) Proposing more effective ways for channelling the current sources of funds to the 13 health system elements in order to maximize resource adequacy, efficiency and equity. The following search terms were employed: (“health financing” OR “financing” OR “funding”) AND (“health workforce” OR “human resources for health” OR Staff OR drugs OR medicine OR “medical products” OR “health infrastructure” OR “Service delivery” OR “governance” OR “information systems” OR “health investment” OR “Health system strengthening” OR “universal health coverage” OR “health security” OR “common goods for health”). Additionally, we specifically retrieved and reviewed the latest available national health accounts (NHA) reports for African countries. 2.3 Selection process We operationalized our inclusion criteria based on our PICO elements. Five reviewers (EB, HB, ND, HCK and SNK) participated in the design of the knowledge synthesis. Three reviewers (EB, HB and ND) participated in the development of the search strategy and the selection of eligible studies. HB searched for grey literature, ND searched for published literature while EB consolidated the findings for relevance. The study selection was done independently and checked by another (EB). 2.4 Data extraction Three reviewers (EB, HB and ND) participated in the data extraction. HB extracted data from the grey literature, ND extracted data from published literature while EB consolidated the findings. Full-text articles that fit the inclusion criteria were extracted for country, NHA year, health system elements financed, elements, title, assessment criteria, criteria definitions and criteria indicators, author, publication year focus, and the conceptual or theoretical nature of the study. The extracted data was entered into an excel matrix. All disagreements were re-examined jointly and appropriate corrections made for all studies included in the review. 2.5 Data analysis Four reviewers (EB, HB, ND, SNK and HCK) contributed to the analysis or interpretation of the data. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. In addition, a thematic review of grey literature on health financing, including the WHO Global Health Expenditure Database was also conducted. We also conducted a literature research and developed a five-criterion framework for assessing the alignment of health financing sources aimed at funding health system functions. We synthesized extracted data on health financing assessment frameworks, and integrated recurrent and relevant elements of multiple frameworks to develop a framework for assessing health financing sources. See table 2 below. The team ensured that all the evidence synthesized had undergone methodological and expert scrutiny. 8 9 3Findings 10 11 Selection of studies We identified a total of 1141 papers. Of these, 642 articles were excluded after the titles and abstracts had been screened. An assessment of the full-text formats of the remaining 499 papers resulted in a further 334 exclusions. A total of 165 studies were finally included in the review (Figure 2). Figure 2. Literature selection flow diagram Characteristics of included studies All included studies were published from 1975 to 2021. They were conceptual (13%) or empirical (87%) studies. With regard to the focus of the papers, 45% of the selected papers focused on service delivery, 13% on human resources for health, 5% on medical products and 3% on infrastructure and governance. Papers that focused on multiple health system elements contributed 8% to the total selected papers. Health financing assessment frameworks were presented in 23% of the selected papers. 3.1 Current focus of different sources of health funds in relation to the 13 health system elements Figures 3 and 4 present an analysis of the contribution of different financing sources to total health expenditure (THE) in sub-Saharan Africa (SSA) over a 20-year period, using data from the WHO database on global health spending. Several issues emerge from these analyses. First, private financing sources Id en ti fi ca ti on In cl ud ed Sc re en in g n= 13 1 Records identified (n=1141): Google Scholar (n=333), MEDLINE (n=683), PubMed (n=101), Cochrane library (n=14), WHO database=6, World bank database=4 Title and Abstract screening n=1,141 Records excluded n=642 Records excluded n=334 Full text screening n=499 Studies included in the review n=165 10 11 represent the largest proportion of total health spending, falling from 60% in 2000 to 51% in 2019. They remain a substantial contribution to total health spending in Africa despite countries’ commitment to progress. towards UHC by intensifying, among other things, prepayment health financing mechanisms. In second place we have public sources which experienced slight growth overall from 2000 to 2019, going from 35% to 40%. Third, donor funding increased between 2000 and 2013, but has stagnated since then. This situation is similar to health system financing and is considered globally (WHO, 2017). Fourth, the contribution of private sector financing appears to have declined, from 28% in 2000 to 21% in 2019. Figure 3. Trends in contributions of health financing sources to total health expenditure in SSA Figure 4. Absolute health expenditures by source in SSA An analysis of total health expenditure by health system functions reveals that the global health expenditure database tracks funding for only three of the 13 health system elements: governance; medical goods; and service delivery, which is disaggregated to preventive, curative, long-term, rehabilitative, ancillary and other healthcare services. Figures 5 and 6 outline the level of funding for each of these functions in SSA between 2016 and 2019. Findings show that service delivery received the greatest share of health sector funding in SSA during this period, followed by governance and administration, and lastly health commodities. 12 13 Figure 5. Proportion of total health expenditure by health system function in SSA Figure 6. Absolute total health expenditures by health system function in SSA 12 13 An assessment of expenditures on health system functions by funding sources in SSA reveals a similar pattern, with most of the funding allocated to service delivery, followed by governance and administration, and lastly health commodities (Figures 7, 8 and 9). The exception is private and out-of-pocket expenditure, where health commodities appear to come second to service delivery. It was not possible to separate private prepaid expenditures from out-of-pocket expenditures for this specific analysis (expenditure by health system functions) since the WHO health expenditure database does not provide that data to this level of disaggregation. Figure 7. Share of, and absolute expenditure (in US$) on health system functions from public sources of funding in SSA 14 15 Figure 8. Share of, and absolute expenditure (in US$) on health system functions from private sources of funding in SSA Figure 9. Share of, and absolute expenditure (in US$) on health system functions from external/donor sources of funding in SSA 14 15 Figure 10. Allocation of Global Fund Round 8 to health systems strengthening Two key messages emerge from this analysis of health expenditures in SSA. First, at the system level, there seems to be no preference to fund specific health system functions with specific funding sources. It appears that funding from all the four sources is allocated across all health system functions. This is in line with the expectations of a system that pools and allocates funds across health sector priorities. Even though the level of pooling of healthcare resources in SSA varies (McIntyre et al, 2018), and pooling mechanisms in SSA are characterized by substantial fragmentation (Diane McIntyre, 2008), these data show that health funding allocation in SSA benefits, to some degree, from pooling and allocation of resources across priorities. Second, a closer analysis of external funding reveals that the highly aggregated data masks important patterns. While external funding was initially focused on vertical service delivery, with little focus on horizontal health system strengthening, there has been a trend towards increased focus on health system strengthening (Nattrass et al., 2016). For instance, an analysis in 2013 showed that 37% of the Global Fund Round 8 funding was allocated to health systems strengthening (Warren et al., 2013). However, a deeper assessment of health system investments by the major external funders shows that the bulk of their health system spending was channelled to vertical disease programmes, with very little going to system-wide investments (Warren et al., 2013). For instance, 37% of the Global Fund funding was spent on health system strengthening, while approximately 62% was invested in disease-specific system support (Figure 6) (Warren et al., 2013). An assessment of external funding investments in broader health systems shows that there is a bias in allocation across health system elements. For instance, an analysis of the Global Fund Round 8 revealed that around 82% of health systems strengthening funding was allocated to service delivery, human resources, and medicines and technology, while governance, financing, and information building blocks received relatively low funding (Figure 10) (Moucheraud et al., 2016; Warren et al., 2013). Service delivery 31% Governance Financing Information Human Resources Medecines and Technology 5% 1% 23% 12% 28% 16 17 With regard to human resources for health, analyses of major external funders show that substantial investments are channelled to human resources for health. However, when overall external funding for health is assessed, funding for human resources was minimal, not going over 7% between 1990 and 2016 (Micah et al., 2018). This notwithstanding, external funding allocations for health have been increasing. For instance, between 1990 and 2016, development assistance for human resources for health increased by 15.7% each year (Micah et al., 2018). The most common external investment in human resources is short-term in-service training. There is relatively little investment in expanding pre-service training capacity, despite severe health worker shortages in developing countries (Vujicic et al., 2011). Third, global documentation of health expenditure does not track funding on all the 13 dimensions that informed the conceptual framework of this assignment. It tracks expenditure on health system tangible hardware (health commodities), and tangible software (governance and financial administration, and service delivery). Global tracking of funding emphasizes service delivery, and disaggregates service delivery expenditures further into curative, preventive, rehabilitative/ palliative care, and also tracks expenditures on the level of care, with a focus on primary health care (PHC). It does not, however, track expenditure on health security, making it difficult to assess the prioritization of health security by health systems. Global tracking of health expenditures is guided by the system of health accounts, that provides a systematic description of the financial flows related to the consumption of health care goods and services (OECD et al., 2017). It is apparent that the system of health accounts recognizes and includes both health system tangible hardware and tangible software elements. Expenditures on intangible elements of the health system are not tracked, which is not surprising, given the difficulty in tracking and quantifying such expenditures. This later finding is emphasized by an analysis of the format and reporting on country health expenditures in national health accounts (NHA). We analysed the latest NHA reports from 20 African countries. See Table 1 below. Table 1: Summary of the different elements by country, according to the national health accounts Reference in chronological order Assessment criteria Efficiency Equity Sustainability Feasibility Fungibility Others World Bank (1975) √ WHO (1978) √ √ Zschock (1979) √ √ √ • Impact on healthcare Griffiths and Mills 1983 √ √ √ √ • Impact on health service utilization and provision • Effects on the economy Hoare and Mills 1986 √ √ √ • Effects on supply and provision of services World Bank (1987) √ √ 16 17 Van Balen and Mercenier (1991) √ • Social solidarity • Contribution to continuity of care Parker and Knippenberg (1991) √ • Responsible and empowered local communities Hsiao (1992) √ √ √ Carrin & Vereecke 1992 √ √ Green 1992 √ √ • Effect on service provision • Participation in decision-making • Effect on multisectoral action Barnum & Kutzin (1993) √ √ √ World Bank 1993 √ √ √ √ • Impact on healthcare utilization WHO (1993) √ √ √ √ • Impact on health status Berman & Chawla (1995) √ √ • Accountability • Quality of care Shaw & Griffin (1995) √ √ √ • Public- private sector collaboration Nolan & Turbat (1995) √ √ √ Creese & Kutzin (1995) √ √ √ Stryckman (1996) √ • Responsible and empowered local communities Criel 1998 √ √ √ √ √ • Impact on demand • Impact on utilization • Impact on supply • Impact on quality of care • Impact on community participation • Accountability 18 19 Murray & Frenk (1999) √ √ √ • Effect on citizen participation • Effect on multisectoral action McIntyre 2007 √ √ √ √ Kutzin et al. 2010 √ √ √ • Financial risk protection • Quality • Transparency and accountability Garand et al 2016 √ √ √ • Financial risk protection McIntyre & Kutz- in (2016) √ √ √ • Financial risk protection • Extent of fragmentation Doherty et al. 2019 √ √ √ √ • Financial risk protection • Risk cross- subsidization Jowett et al. (2020) √ √ • Incentives for healthier behaviour by individuals and firms • Health expenditure is based predominantly on public/ compulsory funding sources The review of NHA reports reaffirms the observation that health expenditure tracking focuses on tangible hardware elements and some tangible software elements. Funding of intangible elements is not tracked. Compared to the global health expenditure databases, the NHA provides more disaggregation, especially of tangible hardware elements, as well as service delivery areas. NHA data also does not track health expenditures on health security. Figure 5 outlines the frequency of reporting different health system elements from the NHA reports that were assessed. 18 19 3.2 Framework for assessing financing sources for health system elements In this section, we present a framework for assessing the alignment of health financing sources with the objectives of funding health system functions. We synthesized extracted data on health financing assessment frameworks, and integrated recurrent and relevant elements of multiple frameworks to develop a framework for assessing health financing sources. Table 2 outlines the frameworks and individual elements of those frameworks. Figure 11. Frequency of reporting expenditure for health system elements in NHA for the African Region 20 21 Table 2. Health financing frameworks identified in literature Author of the framework Individual criteria of the framework Efficiency Equity Sustainability Feasibility Fungibility Other elements Kutzin et al 2010 √ √ √ • Financial risk protection • Quality • Transparency and accountability Doherty et al 2019 √ √ √ √ • Financial risk protection • Risk cross- subsidization Garand et al 2016 √ √ √ • Financial risk protection McIntyre 2007 √ √ √ √ McIntyre & Kutz- in (2016) √ √ √ • Financial risk protection • Extent of fragmentation Murray & Frenk (1999) √ √ √ • Effect on citizen participation • Effect on multisectoral action Green 1992 √ √ • Effect on service provision • Participation in decision-making • Effect on multisectoral action Carrin & Vereecke 1992 √ √ Hsiao (1992) √ √ √ Barnum & Kutzin (1993) √ √ √ Berman & Chawla (1995) √ √ • Accountability • Quality of care Shaw & Griffin (1995) √ √ √ • Public- private sector collaboration Nolan & Turbat (1995) √ √ √ Creese & Kutzin (1995) √ √ √ 20 21 Criel 1998 √ √ √ √ √ • Impact on demand • Impact on utilization • Impact on supply • Impact on quality of care • Impact on community participation • Accountability World Bank (1975) √ World Bank (1987) √ √ World Bank 1993 √ √ √ √ • Impact on healthcare utilization WHO (1978) √ √ WHO (1993) √ √ √ √ • Impact on health status Zschock (1979) √ √ √ • Impact on healthcare Van Balen and Mercenier (1991) √ • Social solidarity • Contribution to continuity of care Griffiths and Mills 1983 √ √ √ √ • Impact on health service utilization and provision • Effects on the economy Hoare and Mills 1986 √ √ √ • Effects on supply and provision of services Parker and Knippenberg (1991) √ • Responsible and empowered local communities Stryckman (1996) √ • Responsible and empowered local communities Jowett et al (2020) √ √ • Incentives for healthier behaviour by individuals and firms • Health expenditure is based predominantly on public/compulsory funding sources 22 23 The review revealed that there is substantial literature that discusses and/or applies criteria for the assessment of health financing mechanisms. While some authors were explicit about proposing assessment frameworks, others were implicit in the sense that they applied a set of criteria without formally proposing them as part of a framework for health financing assessments. Further, frameworks and criteria typically focused on the entire health financing function rather than the revenue mobilization function, which is the focus of this work. Drawing on this review, specifically focusing on recurrent themes and suitability of criteria to assess funding sources, we propose a framework for assessing funding sources. The framework comprises five criteria and 10 indicators (Table 3). These five criteria have been selected based on their recurrence in the health financing frameworks reviewed. See Table 2 above. Table 3. Framework for assessing health financing sources Criteria Definition Criteria indicators Efficiency An efficient health financing source maximizes revenue collection and enhances technical and allocative efficiency of the health system Indicator 1: Proportion of administrative costs for revenue collection Indicator 2: Revenue generation potential of the funding source Indicator 3: Extent to which the funding sources can be flexibly allocated across priorities Feasibility A feasible health financing source has political support and is aligned with the system’s capacity to implement the health financing mechanism Indicator 4: Level of political acceptability and support Indicator 5: Level of administrative ease of revenue collection Sustainability A sustainable health financing source maintains predictable levels of funding over the medium to long term Indicator 6: Whether revenues from the source are projected to remain at the same level or grow over the long term (Revenue growth rate by funding sources) Equity An equitable health financing source enhances equity in financial contributions and use of health services Indicator 7: Level of progressivity of financial contributions Indicator 8: Extent of risk cross-subsidization Indicator 9: Effect on financial risk protection Displacement A health financing source has a displacement effect when it causes a reduction or reallocation of other sources of funding to other priorities Indicator 10: Whether the funding sources have a displacing effect on other sources of revenues 22 23 3.2.1 Efficiency There are two aspects of efficiency. Allocative efficiency is the capacity to finance healthcare based on the effectiveness of public programmes in meeting its strategic objectives. It requires proper arrangements within line ministries for sector policy formulation and sufficient technical capacity within spending agencies to select the most cost-effective programmes, projects, and activities. Technical efficiency refers to the ratio of resources financed to the output produced. It is achieved when maximum outcomes are achieved for a given level of inputs and no other combination of inputs can achieve a higher outcome (Diamond & Potter, 1999). An efficient health financing source maximizes the levels of funding while minimizing the costs associated with revenue mobilization (Hoare & Mills, 1986; Diane McIntyre, 2007). Such a funding source has a high revenue generation potential (Diane McIntyre, 2007). When fund collection costs are kept at a minimum, high net revenues are available to allocate to health system functions. 3.2.2 Equity The International Association for Equity in Healthcare Services defines equity as “the lack of systematic and potentially removable differences in one or more aspects of health in a population and its economic, social and geographical subgroups” (Black & Mooney, 2002). Equity in health financing can be defined in terms of vertical equity (unequal treatment of un-equals in a fair sense) and horizontal equity (equal treatment for equal need) (Wagstaff & Van Doorslaer, 1993). An equitable health financing source is therefore progressive in the sense that financial contributions as a share of income increases as the socioeconomic status rises. An equitable health financing source will hence be characterized by risk-cross subsidization and will also provide financial risk protection to avoid exposing households to catastrophic expenditure or impoverishment. 3.2.3 Sustainability Sustainability is the capacity of a government to finance its desired expenditure programmes, to service any debt obligations and to ensure its solvency (Heller, 2005). Expenditure and revenue should be aligned in a way that maximizes the attainment of health system objectives, subject to the requirement of fiscal balance, which in turn depends upon what is going on in other areas of government spending, and on the value to be had from spending on health, relative to the value to be had from spending elsewhere (Thomson et al., 2009). 3.2.4 Feasibility The feasibility of health financing sources refers to the political and operational ease of fund mobilization. A feasible health financing source has political support from relevant actors in the health system. In addi- tion, the health system needs to have the capacity to operationalize revenue generation for the funding source. Administrative capacity includes technical skills, information systems and mechanisms for enforc- ing collection. 24 25 3.2.5 Displacement The displacement criterion refers to the extent to which the health financing source has an additive effect on overall health resource mobilization efforts. That is, every dollar mobilized through this source results in an additional dollar in net resource mobilization, rather than displacing some funds from other sources. 3.3 Effectiveness of the current ways the 13 health system elements are financed from the four sources of funding In this section, we use the five-criterion framework developed in section 3.2 to assess the suitability of funding sources and arrangements for health system elements. A summary of this assessment is provided in Table 4. Table 4. Performance of health financing sources against assessment criteria Source of funding/assessment criteria Efficiency Equity Sustainability Feasibility Displacement effect Public sources + + + + - Private sources - - - - ND Out-of-pocket funding - - - - ND External funding ND - - + + + enhances – reduces ND - no data on criteria 3.3.1 Government funding There is consensus that public expenditure on health is a key determinant of the achievement of UHC. It has been proposed that for countries to achieve UHC, their public spending on health, as a share of their gross domestic product (GDP) will need to be at least 5% (Diane McIntyre et al., 2017). Countries must raise sufficient funds and reduce their reliance on direct payments to finance services, in order to improve efficiency and equity. The extent to which public spending on health aligns with health system goals is dependent on the financing arrangements. Public funding can be mobilized through taxation or social health insurance contributions. Improving the efficiency of revenue collection will increase the funds that can be used to provide services or buy them on behalf of the population. The mobilization of revenues for the health sector through taxation is more efficient, and sustainable compared to social health insurance contributions (Diane McIntyre, 2007; Diane McIntyre et al., 2018). While generation taxation is typically progressive and hence equitable, indirect taxes such as value-added tax (VAT) have mixed effects. For instance, while VAT was found to be progressive in Ghana (Diane McIntyre et al., 2018), it was regressive in Kenya (Munge & Briggs, 2013). Social health insurance contributions have been found to be inefficient and unsustainable in mobilizing health sector resources in SSA, as well as inequitable (E. Barasa et al., 2021). The feasibility and sustainability of social health insurance in SSA is compromised by high informality and poverty (E. Barasa et al., 2021). 24 25 3.3.2 Out-of-pocket payments Out-of-pocket payments are fragmented and hence inefficient (Kutzin & Sparkes, 2016). OOPS are regressive and do not cross-subsidize risk (Diane McIntyre, 2007). They are also responsible for catastrophic health expenditures and impoverishment. OOPS are therefore inequitable as a source of funding. OOPS have had negative implications on equity. 3.3.3 External funding Considerable external funding has been channelled to low- and middle- income countries (LMICs) over the past 30 years (Fitzmaurice et al., 2017). There is overwhelming evidence that this funding has had a significant impact on expanding access to critical health services in LMICs (Ejughemre, 2013). For instance, assessments have shown the huge impacts that Gavi, the Vaccine Alliance has had on expanding access to immunization (Ikilezi et al., 2020), PEPFAR on HIV/AIDs , and the Global Fund on HIV/AIDS, tuberculosis (TB), and malaria (Yu et al., 2008). Beyond the positive impact on expanding access to care, external funding has been characterized by several attributes of concern. First, external funding has predominantly been channelled to vertical programmes (Desai et al., 2010; Ejughemre, 2013; Mounier-jack et al., 2010; Rudge et al., 2010). While there is evidence that verticalization has contributed to the success of specific disease programmes (malaria, HIV/AIDS, TB, immunization), it has had unintended effects, with implications for the efficiency of health systems (Mwisongo & Nabyonga-orem, 2016). Vertical programmes have compromised the coordination of overall health systems because they have typically not been well integrated with the rest of the system (Desai et al., 2010; Mounier-jack et al., 2010; Mwisongo & Nabyonga-orem, 2016; Rudge et al., 2010), resulting in duplication of functions such as procurement, monitoring and evaluation, information systems and drained health workers from other services, because of added financial incentives for health workers in these donor-funded programmes (Yu et al., 2008). The fragmented and vertical funding arrangements are exacerbated challenges by governments to track their resources (Mwisongo & Nabyonga-orem, 2016). The terms of external funding also often means that donors influence public health priorities, sometimes at odds with local priorities (Mwisongo & Nabyonga-orem, 2016). For instance, an assessment of the Global Fund rounds 1 to 7 funding found that investments in human resources or health were not coordinated with the rest of the system (Bowser et al., 2014). Further, external funding has been fragmented, with little coordination across different donors. While there have been efforts to coordinate donor funding at the country level through the sector-wide approaches (SWAps) (Sweeney & Mortimer, 2016), and at the global level through initiatives such as the Health Systems Funding Platform, the extent to which these initiatives have been successful is debatable (Brown et al., 2013; Hill et al., 2011; Moucheraud et al., 2016; Stierman et al., 2013). The narrow focus, combined with the poor integration and coordination of external funding has therefore compromised the efficiency of health systems (Bowser et al., 2014; Moucheraud et al., 2016). Further, there is evidence that when external funds are concentrated in urban areas, they have contributed to maldistribution of health workers. Financing salaries and incentives of health workers has, in some cases, made an important contribution to country efforts to increase staffing and improve retention. However, health workers, attracted by financial (allowances) and nonfinancial (training) incentives, move to health facilities in urban areas that are donor funded, resulting in inequities in the distribution of health workers (Brugha et al., 2010). For example, 26 27 countries employed a variety of mechanisms, including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers, using Global Fund financing (Bowser et al., 2014). There are also concerns about the sustainability of external funding. While historically, external funding has played a significant role in financing LMIC health systems, there are plans by major donors such as Gavi and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to progressively exit as countries graduate to middle-income status (Gilbert et al., 2019). This means that donor funding cannot be considered sustainable in the long term. Finally, donor funding has been shown to have a displacement effect on public expenditure on health. An analysis of financial flows data spanning 119 countries and 16 years showed that US$ 1 year-on-year increase in development assistance for health channelled to governments leads to a US$ 0.62 decrease in domestic government spending on healthcare (J. L. Dieleman & Hanlon, 2014). 3.3.4 Private financing Private funding is mobilized through multiple mechanisms, including private health insurance, delivery of funding through the private sector, corporate philanthropy or social responsibility initiatives, and public private partnerships. Private insurance has been shown to mobilize limited resources for healthcare, achieve limited population coverage because of the challenge of scaling up voluntary contributions in LMICs that are characterized by high poverty and informality and hence too inefficient and unsustainable to be equitable (E. Barasa et al., 2021). Public-private partnerships (PPPs) have been used as a mechanism to leverage private sector resources to further public health goals (Whyle & Olivier, 2016). Table 5 outlines the common models of public-private partnerships used in health in Africa (Whyle & Olivier, 2016). Table 5. Public-private partnership models used in health in Africa (Whyle & Olivier, 2016) Model Definition Public-private partnership Long-term contractual arrangements for the development, financing and/or provision of public infrastructure (and sometimes services), in which risk and management responsibility are shared. Six sub-types of PPPs are: private finance initiative; public-private integrated partnership; Alzira model; franchise; co-location PPP; and global PPP Social marketing The social marketing approach uses commercial sector marketing and communication approaches to “sell” products of a high social or public health value, or to bring about behaviour change among a target population. Commonly, social marking programmes use community-based organizations, nongovernmental organizations (NGOs), or public sector facilities to distribute products. They often involve product subsidy to ensure affordability and rely on external funding. Sector-wide approach A ministry of health-led formal, sustained cooperative agreement with civil society and donors in which all parties are obligated to pool available resources and work together in accordance with jointly approved and negotiated sectoral national strategies and expenditure frameworks to improve population health outcomes and facilitate national development. Public-private mix (PPM) approach A PPM approach consists of initiatives to increase collaboration and improve relationships among all forms of health care providers for a particular disease Voucher programmes A public authority delegates responsibility for the provision or management of a service on behalf of the State in exchange for a fee, using a contract that specifies the type, quantity and time period of the services to be provided. 26 27 Dual practice regulation The development and enforcement of regulations, policy and other mechanisms to prevent or control public sector health providers working in the private sector. Financing Public financing of privately delivered health services through grants to providers or public insurance, covering private sector services. Private finance initiative or (DBFO) This is a long-term contract in which the design, building financing and nonclinical operation of a facility, in accordance with public authority requirements, is contracted to a private consortium. Public-private integrated partnership A long-term partnership between the State and a private consortium in which contracted services include infrastructure, nonclinical operations and clinical operations delivered to a specified segment of the population. Alzira model The Alzira model is characterized by a contractual arrangement that combines the building of facilities with the operating of nonclinical services and clinical services, including primary care provision for a defined population in return for capitated payment. Franchise The public authority uses contracting arrangements to harmonize the activities of a network of providers, supporting the providers through branding and bulk drug purchasing, while strictly controlling the quality, quantity and package of services provided, and disallowing cream-skimming Co-location public- private partnership A long-term partnership through which a portion of a public hospital’s premises is granted for use by a private provider, sharing infrastructure and support services but operating as distinct facilities, in return for payment and specified benefits to the public party Global public- private partnership (GPPP) A collaborative relationship, transcending national boundaries, in which both government and nongovernment entities provide financing and participate in decision-making through a mutually agreed upon and well-defined division of labour, so as to achieve a shared goal. All partners contribute and benefit equally. GPPPs are commonly three-way partnerships comprising international donors, recipient governments and NGOs or corporations. PPPs in the health sector have focused mostly on health system functions. For instance, PPPs have been used to develop human resource capacity through training programmes (Sirili et al., 2019; Vian et al., 2007), to finance hospital care (Sadeghi et al., 2016) and healthcare commodities (Shrivastava et al., 2019). There are mixed findings on the impact of PPPs within the health sector. While they have been shown to be successful in scaling up the provision of services such as laboratory services (Shrivastava et al., 2016) and in delivering essential commodities (Shrivastava et al., 2019), some PPPs have been shown to be unsustainable, inefficient (Metsing, 2008; Vian et al., 2015), and inequitable (Marten & Sullivan, 2020). A key challenge with PPPs in Africa is the weak regulatory and policy environment, such that quite often, PPP arrangements are informal. Another challenge is the capacity of government to negotiate and structure PPPs whose terms are aligned with health system goals or public goods. This contributes to the inappropriate distribution of risk and reward, leading to moral hazards (Kamugumya & Olivier, 2016; Nuhu et al., 2020). 3.4 Perceptions on improving the targeting of the four sources of funds towards the 13 elements of the system for effective functioning 3.4.1 Human resources for health First, donors should work with governments to understand how national and donor policies could impact programme sustainability, integration and coordination, so as to maximize human resources for health (HRH) investments and improve health outcomes. Innovative financing mechanisms should work for both the health system and the overall health workforce. Better 28 29 coordinated financing of HRH training and activities will lead to less duplication, lower costs for training programmes and strengthen national training programmes that focus on long-term, pre-service training rather than short-term, in-service training. Quantifying the impact of donor activities on health systems and health outcomes will require a coordinated effort with current tracking, monitoring and health management information systems (Bowser et al., 2014) (Micah et al., 2018). To this end, some of the existing initiatives, such as the International Health Partnership and the Health Systems Funding Platform, may present viable and timely approaches for the three agencies to pursue more effective HRH-related financing efforts in low and middle-income countries (Vujicic et al., 2011). Second, there is a need to establish a policy to support resource mobilization for increasing health worker training at the county level, as well as the number of health workers, based on proper assessment and forecasting. This is to determine: the cadres to be supported, based on county, regional and national needs; and the number of beneficiaries eligible for funding each year. A framework would then be put in place for revolving the funding, to ensure sustainability and grow funds, such that all health disciplines are supported at all levels of training (Hughes & Mann, 2020; Lu et al., 2020; Milo et al., 2021; Okech, 2016). Third, greater investment by donors and governments in the basic pre-service training of nurses, clinical officers, medical assistants and doctors is required (Brugha et al., 2010). (Sablah, 2019) recommend that the Government of Ghana and the Global Fund should increase dialogue, intensify health education and cooperate to enhance health personnel capacity. The Government should further regulate health staff transfers and increase health budget allocation to promote health development in the country. 3.4.2 Service delivery Donors should be more attentive to domestic resource constraints and integrate fully with existing health systems and address these constraints up front to limit possible negative effects on the delivery of other health services (Grépin, 2012). Moreover, it would be extremely desirable to carry out a mapping of the areas and sectors where government needs support from the NGOs. There on, it would be better to define clear roles and responsibilities of the parties, the nature and timeline of deliverables, and a clear plan for scaling up and sustainability (Ejaz et al., 2011). There is also a need for allocative efficiency of public spending on primary health care (PHC). Benefits can be differentiated among recipient countries, depending on: (a) the political will to improve both financing and delivery of PHC services in the recipient country; (b) harmonization or at least strong synergies of external and domestic spending on PHC; and (c) allocation of spending to PHC services most relevant to reducing the country’s burden of disease (Shaw et al., 2015). Global-health initiatives should have a proactive and balanced investment approach, so as to concurrently strengthen PHC systems, achieve programme targets, and sustain the gains in resource-poor settings (Assefa et al., 2018). Second, there is a need to invest in increased coverage of prepaid health financing mechanisms as it would reduce overreliance on potentially catastrophic and impoverishing out-of-pocket payments (Sambo et al., 2013). Safety nets for the poor are also needed to reduce the burden of spending by households (Sidze et al., 2013). Policy interventions aimed at financial risk pooling mechanisms are crucial to reducing the intensity and impact of OOP payments among vulnerable households (especially those living with severe mental disorders), and supporting the goal of universal health coverage (Hailemichael et al., 2019). 28 29 Third, governments need to track how resources are allocated sub-nationally to maximize equity and ensure that allocations are commensurate with health needs (J. Borghi et al., 2018; Klugman, 2004). Also, countries and international partners should pay more attention to the efficiency in the use of the available resources, as savings can go a long way in decreasing the funding gaps and increasing the impact (Ithibu & Amendah, 2019). Resource tracking at country and donor levels will help hold countries and donors to account for their commitments (J. O. Borghi et al., 2006; Mookherji et al., 2015). 3.4.3 Infrastructure First, there is an urgent need for countries to develop health policies that address inequities and health financing models that optimize the use of health resources and strengthen health infrastructure (Sambo et al., 2013). Second, further research needs to be carried out to determine the sustainability of the gains made in the health system infrastructure as a result of donor funds and to also to evaluate the effectiveness of donor-funded health system infrastructure in comparison to nonfunded health system infrastructure (OMONDI, 2015). 3.4.4 Information management systems The donor-supported programme needs to integrate parallel reporting systems with the district health information system to make it more flexible, reliable, and robust (Atun et al., 2011). In addition, coordinated efforts are needed towards strengthening monitoring and evaluation systems, thereby allowing countries to collect and use data to design, plan, implement, analyse, evaluate and manage their health programme (Jain & Zorzi, 2017). 3.4.5 Governance Future work will need to explore how donor financing of civil society influences policy agenda- setting and institutional innovations for increased civic participation in health governance and accountability to citizens (Gómez & Atun, 2012). 3.4.6 Medical products Tracking changes in health financing patterns across time and benchmarking against global trends is vital to addressing missed opportunities, ensuring access to medicines and high quality services, and pursuing universal health coverage (J. Dieleman et al., 2017). In Tajikistan, out-of- pocket expenditure, especially for drugs, has increased over time, and varies substantially across geographical areas and economic status. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies for improving access of patients to services (Schwarz et al., 2013). Finally, government engagement with private health facilities, particularly pharmacies, is quite limited. Improving engagement will help governments with limited resources to better take advantage of the private sector capacity to meet access and equity objectives (Sood et al., 2011). 30 31 3.5 Methods for allocating current sources of funds to the 13 health system elements in order to maximize resource adequacy, efficiency and equity Drawing on this review, below are several proposals for aligning health financing sources with the goals of financing health system elements: • Mind-set shift: Mindsets orient an individual to a particular set of associations and expectations. They influence decision-making under uncertainty and allow individuals to solve problems efficiently. Shifting mindsets is crucial to communication and advocacy efforts for UHC. Besides, a mindset shift that is centred on strengthening ecological thinking about health might create space for changes to policies that affect the social determinants of health. Also, a mindset shift is critical to enabling national governments to share responsibility and to demonstrate the importance of having the security of a robust health system, beyond the health ministries, to include multiple stakeholders, such as the private sector and indeed, the population at large. • Updating frameworks for health expenditure tracking: Health expenditure tracking aims to empower actors and increase accountability, transparency and responsiveness in health systems, to advance towards universal health coverage. Most health expenditure tracking exercises are guided by the system of health accounts (SHA). While the conceptualization of health systems has evolved over time, health expenditure tracking frameworks have not kept pace. As a result, it is difficult to track budgets and expenditures for most system software and for important functions such as health security and other public and common goods for health. We recommend that health expenditure tracking frameworks are updated to reflect relevant health system software, and public and common goods for health, including health security. Moreover, it is crucial to develop, test and improve financial systems to track resources and ensure adequate and timely reimbursement for public health emergency preparedness. • Improved coordination of sources of funding (globally and locally): While there are continuing efforts to coordinate external funding to LMICs at the global and national level, evidence shows that those global efforts have mostly failed, while gaps exist with national efforts. There is a need for coordination of donor funding at both these levels, and alignment of these funding approaches with local priorities. Roadmaps to UHC should consider the complex and changing needs of different contexts. Tailored, country-specific plans and coordination mechanisms that aim to build and finance health systems that are adaptable for unforeseen changes like global pandemics, will help accelerate progress along the path toward UHC. Moreover, health security and emergency preparedness can be achieved by providing joint support to accelerate progress on UHC in countries facing conflicts and protracted crises by improving disease outbreak coordination at the local level, ensuring continuity of service provision to affected populations and areas and strengthening primary health care. • Integration: The case for integration is even stronger now, given plans by donors to transition. Donors and LMICs will need to make concrete plans for integrating vertical programmes into the broader health system, to improve efficiency and ensure the sustainability of these service delivery areas. Moreover, the social determinants of health are vital to the equitable pursuit of healthy lives and health services delivery for all. There is a need to expressly incorporate 30 31 social determinants of health into the framework for monitoring UHC, through integration. Integration disaggregates UHC indicators to reflect the social gradient and the complexity of social stratification. Also, through integration, we can connect health indicators, both outcomes and coverage, with the social determinants of health and policies within and outside of the health sector. Failure to integrate health services increases the risk of going down a narrow route that limits the right to health coverage of services and financial risk protection. • Donor transition plans: In terms of integration, LMICs will need to develop pragmatic and feasible donor transition plans. These donor transition plans must be anchored on three broad principles that guide health financing reforms to accelerate progress towards universal health coverage. The first is to move towards a predominant reliance on public funding sources. The second is to reduce fragmentation in pooling, to enhance the redistribution capacity of these prepaid funds. The third is the move towards strategic purchasing, which seeks to align funding and incentives with promised health services. Such plans will need to be country driven, pragmatically aligned to country fiscal capacity and accompanied by efficiency measures such as integration and feasible co-financing commitments. Countries will need to honour these commitments to avoid disruption to the gains made. Also, emergency programming has short funding cycles that do not facilitate medium- to long- term strategic planning. This complicates efforts to build programme ownership and capacity among the affected populations, and prolongs the use of expensive emergency-oriented programme strategies. Consequently, there is a need to focus on resilience programming that links emergency and development responses under the framework of supporting a programme that will enable communities to withstand future shocks. • Scale-up prepayment financing mechanisms: LMIC countries will need to continue the shift from out-of-pocket payment mechanisms to prepayment mechanisms. The case for this shift cannot be belaboured. Increased prepayment and pooling result in efficiency gains; for example, from enhanced bargaining power of purchasers. Moreover, people do not forego health care and no longer need to sell assets or borrow to meet health payments. This means that they can cover health costs while continuing to spend and invest in other areas. This contributes to reducing poverty and inequities, while spurring economic growth. These UHC gains allow health indicators to improve steadily while regional disparities decline, thereby helping to consolidate a country’s social stability. • Tax funding: There is overwhelming evidence that tax-funded mechanisms are more feasible, equitable, efficient and sustainable than contributory health insurance, for instance. LMIC countries with high poverty and informality should prioritize tax funding as a foundation for UHC financing reforms. Increased general taxation financing has been associated with increased health service coverage and improved financial protection. The tax reforms will have to be ambitious and concern all types of taxes. Those directly related to health, such as excise duties on products harmful to health and UHC contributions should lead in financing the health sector. Other taxes, with their impact on increasing tax revenues for the general State budget, will also help improve funding for the sector. 32 33 • Policy and regulatory framework for public private partnerships: Public-private partnerships have become a popular way for governments to engage private actors in the delivery of health services, to increase quality and provide better value for money. Most governments have been exploring PPPs with the intention of achieving universal health coverage, either by expanding the coverage of services, which have conventionally not been available or are in short supply in the public sector, or by providing better access to certain services in specific under-served regions. The COVID-19 crisis also revealed that the government departments and public sector bodies are not sufficiently equipped to effectively respond to public health emergencies. The private sector has made major contributions and rapid and innovative solutions by working in partnership with the public sector to strengthen some existing services and develop new ones. In the long term, it is crucial to assess whether the introduction of such partnerships creates or exacerbates social and health inequalities. While PPPs may offer an alternative for mobilizing additional resources for the health sector, governments will need to lead the way, and develop effective policy and regulatory frameworks to guide their formation and implementation in the health sector. Fund software: Evidence shows that health system software elements play as important a role in health system performance as health system hardware. There is a need to invest in improved service delivery by ensuring UHC of essential health care services, paying particular attention to vulnerable populations. Also, governments should work on reducing risk factors to health, and address social determinants of health and health inequalities. Finally, they should strengthen capacity in health information and financial system management for evidence- based policy-making, and as part of health system reforms. • Incentivize and nurture health system intangibles: The public recognition given to health system intangibles is valuable in creating a culture of quality improvement, which is critical to achieving UHC and meeting the health-related SDGs. The success and value of UHC depend on its ability to provide quality services to all people, everywhere. Alongside the need to fund health system software elements, is the importance to incentivize and nurture health system intangibles, given the difficulty in directly funding them. Ways of doing that include explicitly recognizing them as important, including them as part of performance management for staff and health system organizations, and funding efforts to develop their capacities in soft skills and emotional intelligence training, and coaching and mentoring health system leaders and managers. 32 33 4Conclusion 34 35 The current focus of different funding sources for the 13 health system elements is skewed, with public sources being the significant contributor and the private sector lagging behind. This points to opportunities for more balanced investments. Moreover, no distinction is made between which funding sources should be used for specific health system functions. It appears that funding from all four sources is allocated across all the health system functions. Besides, global documentation of health expenditure does not track funding on all the 13 health system elements that informed the conceptual framework of this work. 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Globalization and Health, 4(1), 1–10. 42 43 Annex 1: List of reviewed literature Author and publication year Title Focus Type of study World Bank (1975) Health sector policy paper Health financing framework Conceptual WHO (1978) Financing of health services: report of a WHO study group Health financing framework Conceptual Zschock (1979) Health care financing in developing countries Health financing framework Empirical Griffiths and Mills 1983 Health sector financing and expenditure surveys Health financing framework Empirical Hoare and Mills 1986 Paying for the health sector Health financing framework Empirical World Bank (1987) A World Bank policy study. Financing health services in developing countries. An agenda for reform Health financing framework Conceptual Van Balen and Mercenier (1991) Financing of the health service contribution to primary health care Health financing framework Empirical Parker and Knippenberg (1991) Community cost-sharing and participation: a review of the issues Health financing framework Empirical Green 1992 Financing health care. An introduction to health planning in developing countries Health financing framework Conceptual Hsiao (1992) International Conference on Macroeconomics and Health in Countries in Greatest Need. Session II: Health Care finance Health financing framework Conceptual Carrin & Vereecke 1992 Economic analysis of community financing schemes. Health financing framework Empirical World Bank 1993 Better health in Africa Health financing framework Conceptual Barnum & Kutzin (1993) Public hospitals in developing countries. resource use, cost, financing Health financing framework Empirical WHO (1993) Evaluation of recent changes in the financing of health services. Report of a WHO study group Health financing framework Empirical Berman & Chawla (1995) Resource mobilization. Methodological guidelines. Health financing framework Conceptual Creese & Kutzin (1995) Lessons from cost-recovery in health Health financing framework Conceptual Shaw & Griffin (1995) Financing health care in sub-Saharan Africa through user fees and insurance Health financing framework Empirical Nolan & Turbat (1995) Cost recovery in public health services in sub- Saharan Africa Health financing framework Empirical Stryckman (1996) Comparative analysis of cost, resource use and financing of district health services in sub-Saharan Africa and Asia Health financing framework Empirical Criel 1998 District-based health insurance in sub- Saharan Africa Health financing framework Empirical 42 43 Murray & Frenk (1999) A WHO framework for health system performance assessment Health financing framework Conceptual Mayhew et al 2002 Donor dealings: the impact of international donor aid on sexual and reproductive health services Service delivery Empirical Mwapasa & Kadzandira 2004 Global health initiatives and health care delivery: the case of the Global Fund to Fight AIDS, Tuberculosis and Malaria Service delivery Empirical Blecher et al 2006 Health care financing: core health issues All Conceptual Hernandez et al., 2006 Measuring expenditure for the health workforce: evidence and challenges Human resources for health Empirical Borghi et al 2006 Mobilising financial resources for maternal health Service delivery Empirical Powell-Jackson et al 2006 Countdown to 2015: tracking donor assistance to maternal, newborn, and child health Service delivery Empirical McIntyre 2007 Learning from experience: Healthcare financing in low- and middle-income countries Health financing framework Empirical Puri et al 2008 Examining out-of-pocket expenditures on reproductive and sexual health among the urban population of Nepal Service delivery Empirical Yu et al 2008 Investment in HIV/AIDS programmes: does it help strengthen health systems in developing countries? Service delivery Empirical Embrey et al 2009 How AIDS funding strengthens health systems: progress in pharmaceutical management. Medical products Empirical Baker 2009 The Long and Tortured Road to Adequate, Sustained, and Spendable Domestic and Donor Financing for Health Service delivery Empirical Gordon et al 2009 Fuel, beds, meals and meds: out-of-pocket expenses for patients with cancer in rural Queensland Service delivery Empirical McCoy et 2009 Global health funding: how much, where it comes from and where it goes Service delivery Empirical Perkins et al 2009 Out-of-pocket costs for facility-based maternity care in three African countries Service delivery Empirical Brugha et al., 2010 Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia. Human resources for health Empirical Rudge et al 2010 Critical interactions between Global Fund- supported programmes and health systems: a case study in Papua New Guinea. All Empirical Edström et al 2010 The pipers call the tunes in global aid for AIDS: The global financial architecture for HIV funding as seen by local stakeholders in Kenya, Malawi and Zambia Governance Empirical Kutzin et al 2010 Conceptual framework for analysing health financing systems and the effects of reforms Health financing framework Conceptual Brugha et al., 2010 Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia Human resources for health Empirical Evans et al 2010 Health systems financing and the path to universal coverage Medical products Conceptual 44 45 Schäferhoff et al 2010 Financing maternal and child health — what are the limitations in estimating donor flows and resource needs? Service delivery Empirical Zere et al 2010 Health financing in Malawi: Evidence from National Health Accounts. Service delivery Empirical Atun et al 2011 Critical interactions between the Global Fund-supported HIV programmes and the health system in Ghana All Empirical Vujicic et al., 2011 GAVI: The Global Fund and World Bank support for human resources for health in developing countries Human resources for health Empirical Esser et al 2011 Does global health funding respond to recipients’ needs? Comparing public and private donors’ allocations in 2005–2007 Service delivery Empirical Gomez et al 2012 The effects of Global Fund financing on health governance in Brazil Governance Empirical Grepin et al 2012 HIV donor funding has both boosted and curbed the delivery of different non-HIV health services in sub-Saharan Africa Service delivery Empirical Tibebe et al 2012 Examining out of pocket payments for maternal health in rural Ethiopia: paradox of free health care un-affordability Service delivery Empirical Ejughemre 2013 Donor support and the impacts on health system strengthening in sub-Saharan Africa: assessing the evidence through a review of the literature All Empirical Warren et al 2013 Global health initiative investments and health systems strengthening: a content analysis of global fund investments. All Empirical Mussa et al 2013 Vertical funding, non-governmental organizations, and health system strengthening: perspectives of public sector health workers in Mozambique. Human resources for health Empirical Feng Zhao et al, 2013 Investing in human resources for health: the need for a paradigm shift Human resources for health Conceptual Mohanty et al 2013 Out-of-pocket expenditure on institutional delivery in India Service delivery Empirical Rahman et al 2013 Out-of-pocket expenses for maternity care in rural Bangladesh: a public-private comparison Service delivery Empirical Schwarz et al 2013 Out-of-pocket expenditures for primary health care in Tajikistan: a time-trend analysis. Service delivery Empirical Sidze et al 2013 Reproductive health financing in Kenya: an analysis of national commitments, donor assistance and the resources tracking process Service delivery Empirical Vassal et al 2013 Financing essential HIV services: a new economic agenda Service delivery Empirical Sambo et al 2013 Health financing in the African Region: 2000–2009 data analysis Services Empirical Grepin et al 2014 China’s role as a global health donor in Africa: what can we learn from studying under- reported resource flows? All Empirical 44 45 Bowser et al., 2014 Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening Human resources for health Empirical Shi et al 2014 Time trends and determinants of pharmaceutical expenditure in China (1990–2009). Medical products Empirical Omondi et al 2015 Effect of HIV/Aids donor funding on health system infrastructure in Siaya county health facilities, Western Kenya All Empirical Shaw et al 2015 Donor and Domestic Financing of Primary Health Care in Low Income Countries. All Empirical Mookherji et al 2015 Tracking Global Fund HIV/AIDS resources used for sexual and reproductive health service integration: case study from Ethiopia. Service delivery Empirical Shukla et al 2015 Out-of-pocket expenditure on institutional delivery in rural Lucknow Service delivery Empirical Moucheraud et al 2016 PEPFAR Investments In Governance And Health Systems Were One-Fifth Of Countries’ Budgeted Funds, 2004-14. Governance Empirical Garand et al 2016 Performance evaluation framework for government-sponsored health insurance programmes Health financing framework Conceptual McIntyre & Kutzin (2016) Health financing country diagnostic: a foundation for national strategy development Health financing framework Conceptual Atun et al 2016 Innovative financing for HIV response in sub- Saharan Africa Service delivery Empirical Govil et al 2016 Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India Service delivery Empirical Issac et al 2016 Out of pocket expenditure to deliver at public health facilities in India: a cross sectional analysis Service delivery Empirical Luboga et al 2016 Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level Service delivery Empirical Nattrass et al 2016 Changing donor funding and the challenges of integrated HIV treatment Service delivery Empirical Odekunle et al 2016 The impact of the US President’s emergency plan for AIDS relief (PEPFAR) HIV and AIDS programme on the Nigerian health system. service delivery Empirical Rout et al 2016 Out of pocket expenditure on surgical and nonsurgical conditions in Odisha Service delivery Empirical Servan-Mori et al 2016 A Performance Analysis of Public Expenditure on Maternal Health in Mexico. Service delivery Empirical Doherty et al 2019 If donors woke up tomorrow and said we can’t fund you, what would we do?” A health system dynamics analysis of implementation of PMTCT option B+ in Uganda All Empirical Ministère de la santé 2017 General accounts and health expenditures for malaria, HIV/AIDS and tuberculosis Governance Empirical 46 47 Stenberg et al 2017 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. Human resources for health Empirical Shen et al., 2017 Incentives to change: effects of performance-based financing on health workers in Zambia human resources for health Empirical Marty et al 2017 Taking the health aid debate to the subnational level: the impact and allocation of foreign health aid in Malawi Infrastructure Empirical Dieleman et al 2017 Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries Service delivery Empirical Lohman et al 2017 District Health Officer Perceptions of PEPFAR’s Influence on the Health System in Uganda, 2005-2011. Service delivery Empirical Lu et al 2017 Does foreign aid crowd out government investments? Evidence from rural health centres in Rwanda. Service delivery Empirical Zakumumpa et al 2017 Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria Service delivery Empirical Zakumumpa et al 2017 Alternative financing mechanisms for ART programmes in health facilities in Uganda: a mixed-methods approach Service delivery Empirical Mor et al 2018 Funding the Training of Future Health Services Researchers Human resources for health Empirical Micah et al., 2018 Donor financing of human resources for health, 1990–2016: an examination of trends, sources of funds, and recipients Human resources for health Empirical Oluwashina Afees Noah 2018 Effectiveness of External Financing for Health Infrastructure in Sub-Saharan African Countries Infrastructure Empirical Lukas Roth et al 2018 Expanding global access to essential medicines: investment priorities to sustainably strengthen medical product regulatory systems Medical products Empirical Borghi et al 2018 Health financing at district level in Malawi: an analysis of the distribution of funds at two points in time Service delivery Empirical Goli et al 2018 Out-of-pocket expenditure on maternity care for hospital births in Uttar Pradesh, India Service delivery Empirical Samia et al 2018 Assessing out-of-pocket expenditures for primary health care: how responsive is the Democratic Republic of Congo health system to providing financial risk protection? Service delivery Empirical Doherty et al 2019 Critical assessment of domestic health financing options in East and Southern Africa Health financing framework Empirical Mamdoo, 2019 Financing of medical products in South Africa Medical products Empirical Abdulmalik et al 2019 Sustainable financing mechanisms for strengthening mental health systems in Nigeria Service delivery Empirical Ithibu et al 2019 Domestic financing for HIV, TB and malaria in Global Fund High Impact Asia countries Service delivery Empirical 46 47 Kaiser et al 2019 Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study Service delivery Empirical Kanmiki et al 2019 Out-of-pocket payment for primary healthcare in the era of national health insurance: Evidence from northern Ghana Service delivery Empirical Mishra et al 2019 Out-of-pocket expenditure and distress financing on institutional delivery in India Service delivery Empirical Okungu et al 2019 Sustainability, equity and effectiveness in public financing for health in Uganda: an assessment of maternal and child health services Service delivery Empirical Yohannes et al 2019 Catastrophic out-of-pocket payments for households of people with severe mental disorder: a comparative study in rural Ethiopia Service delivery Empirical Jowett et al (2020) Assessing country health financing systems: the health financing progress matrix Health financing framework Empirical Lu et al., 2020 Development assistance for community health workers in 114 low-and middle- income countries, 2007–2017 Human resources for health Empirical Okunogbe et al., 2020 Global Fund financing and human resources for health investments in the Eastern Mediterranean Region Human resources for health Empirical Hughes et al 2020 Financing The Infrastructure Of Accountable Communities For Health Is Key To Long- Term Sustainability: A legal and policy review to identify potential funding streams specifically for accountable communities for health infrastructure activities Infrastructure Empirical Atim et al 2020 An assessment of domestic financing for reproductive, maternal, neonatal and child health in sub-Saharan Africa: potential gains and fiscal space Service delivery Empirical Gartaula et al 2020 Out of Pocket Expenditure on Health Service Delivery at a Tertiary Care Women’s Hospital: A Descriptive Cross-sectional Study Service delivery Empirical Ikilezi et al 2020 Effect of donor funding for immunization from Gavi and other development assistance channels on vaccine coverage: evidence from 120 low- and middle- income recipient countries Service delivery Empirical Nomura et al 2020 Tracking Japan’s development assistance for health, 2012-2016 Service delivery Empirical Vannakit et al 2020 Fast-tracking the end of HIV in the Asia Pacific Region: domestic funding of key population- led and civil society organisations Service delivery Empirical Zhao et al 2020 Development assistance for health and the Middle East and North Africa Service delivery Empirical Milo et al., 2021 Building a sustainable financial resource base to support health workforce training Human resources for health Empirical Boyce et al 2021 Global Fund contributions to health security in ten countries, 2014-2020: mapping synergies between vertical disease programmes and capacities for preventing, detecting, and responding to public health emergencies. Infrastructure Empirical 48 49 Ikilezi et al., 2021 Estimating total spending by source of funding on routine and supplementary immunisation activities in low-income and middle-income countries, 2000–17: a financial modelling study Medical products Empirical Kairu et al 2021 Examining health facility financing in Kenya in the context of devolution Service delivery Empirical Nomura et al 2021 Tracking Development Assistance for Health: A Comparative Study of the 29 Development Assistance Committee Countries, 2011–2019 Service delivery Empirical 48 49 Annex 2: Detailed Summary of the different elements by country, according to the national health accounts Country NHA year Health system elements financed Element Kenya 2015 Curative inpatient care Service delivery Curative outpatient care Service delivery Medical goods (non-specified by function) Medical product Preventive care Service delivery Health system financing administration Governance processes Governance Governance process Fixed capital formation Infrastructure Others Other Rehabilitative care Service delivery Other healthcare services Service delivery Ghana 2010 Curative care services (drugs, consumables) Service delivery Health administration and health insurance Governance process Capital formation for health care provider institutions Infrastructure Research and development in health Information systems Environmental health Service delivery Medical goods dispensed to outpatient Medical product Liberia 2015 Inpatient curative care Service delivery Outpatient curative care Service delivery Medical goods dispensed to outpa- tients Medical product Public health programmes Service delivery General government administration of health Governance process Technical Assistance Service delivery Capital formation for health care provider institutions Infrastructure Education and training Staff Research and development in health Information systems Environmental health Service delivery 50 51 Mauritius 2018 Gross capital formation (Infrastructure, machinery and equipment) Infrastructure Curative care, rehabilitative care, long-term care Service delivery Rehabilitative care Service delivery Medical goods (non-specified by function) Medical product Governance, and health system and financing administration Governance process Public health programmes Service delivery Mozambique 2006 Hospitals Infrastructure Ambulatory health service provider Service delivery Curative care service Service delivery Gross capital Infrastructure Personnel education and training on health Staff Retail sales and other medical material providers Medical product Public health programmes management and administration Governance process General health and insurance administration Governance process Institution providing health service Service delivery Namibia 2013 Public health programmes management and administration Governance process Governance, and health system and financing administration Governance process Inpatient curative care Service delivery Outpatient curative care Service delivery Medical goods Medical product Capital formation Infrastructure Rwanda 2006 Inpatient curative care Service delivery Outpatient curative care Service delivery Prevention and public health programmes Service delivery Pharmaceuticals and nondurables Medical product Health administration Governance process Capital formation Infrastructure 50 51 Seychelles 2013 Inpatient Service delivery Outpatient Service delivery Dental care Service delivery Pharmaceutical Medical product Health administration Governance process Capital formation Infrastructure Prevention and public health Service delivery Sierra Leone 2013 Machinery and equipment Infrastructure Infrastructure Infrastructure Information, education and counselling programme Staff Inpatient Service delivery Outpatient Service delivery Governance and administration Governance process Ancillary service Service delivery Tanzania 2010 Facilities development Infrastructure Curative inpatient care Service delivery Curative outpatient care Service delivery Medical goods (equipment and pharmaceutical products) Medical product Prevention and public health programmes Service delivery Governance, health system and financing administration Governance process Capital formation Infrastructure Others Other Sudan 2018 Government administration of health and social health insurance administration Governance process Health providers of preventive care Service delivery Infrastructure Infrastructure Unspecified health care providers Service delivery Eastern and Southern Africa 1998 Providers of pharmaceuticals and medical supplies Medical product Public health programmes Service delivery Outpatient care centres Service delivery Management of the health system Governance process Infrastructure Infrastructure 52 53 Zambia 2018 Health care system administration and financing Governance process Hospitals Infrastructure Ambulatory healthcare Service delivery Retailers and other providers of medical goods Medical product Preventive care Service delivery Medical goods (non-specified by function) Medical product Uganda 2012-2014 Infrastructure Infrastructure Ambulatory health care Service delivery Retailers and other providers of medical goods Medical product Preventive care Service delivery Health care system administration and financing Governance process Inpatient curative care Service delivery Outpatient curative care Service delivery Machinery and equipment Infrastructure Benin 2014-2015 Infrastructure Infrastructure Staff Staff Ambulatory health care Service delivery Retailers and other providers of medical goods Medical product Preventive care Service delivery Health care system administration and financing Governance process Inpatient curative care Service delivery Outpatient curative care Service delivery Machinery and equipment Infrastructure Ethiopia 2010 – 2011 Outpatient services Service delivery Inpatient Service delivery Public health programmes Service delivery Communicable disease prevention Service delivery Maternal and child health Service delivery General health administration Governance process Capital formation in the health sector Infrastructure Investment in construction Infrastructure Equipment and vehicle purchase Infrastructure Education, training and research Staff 52 53 Egypt 2007–2008 Pharmaceuticals and private clinics Infrastructure MOH facilities Infrastructure Public facilities Infrastructure Outpatient curative care Service delivery University hospitals Service delivery Primary health care Service delivery Tertiary care Service delivery Botswana 2013 – 2014 Hospitals Infrastructure Health centres Service delivery Curative care Service delivery Prevention and planning services Service delivery Management and administration Governance process Reproductive health Service delivery Nutritional deficiencies Medical product Burundi 2013 Health Centres Infrastructure Hospitals Infrastructure Pharmacies and dispensaries Medical product Administrative services Governance process Preventive care Service delivery Other Other Cameroun 1995 – 1996 Public health and private pharmacy Medical product Public health institutions Service delivery Private for-profit providers Service delivery Traditional healers Service delivery 54 55 Framework Title Assessment criteria Kutzin et al 2010 Conceptual framework for analysing health financing systems and the effects of reforms Financial risk protection Equity in financing Equity in use of resources Transparency and accountability Quality Efficiency Fiscal constraint Doherty et al 2019 Critical assessment of domestic health financing options in East and Southern Africa Financial protection Equity in financing (progressivity) Health risk cross-subsidization Efficiency - revenue pooling Efficiency - ease of revenue collection Efficiency - potential to reduce cost escalation Sustainability – revenue-raising potential Macroeconomic feasibility and stability Sustainability – political/social acceptability Garand et al 2016 Performance evaluation framework for government-sponsored health insurance programmes Long-term effectiveness Net income ratio Subsidies/total revenue Incurred claims per capita Poverty outreach ratio Client value Incurred expense ratio Incurred claims ratio Mortality rates Out-of-pocket spending on health Quality Benefit coverage rate Compliant ratio Promptness of payment to providers McIntyre 2007 Learning from Experience: Healthcare financing in low- and middle-income countries Feasibility Equity Efficiency Sustainability 54 55 McIntyre & Kutzin (2016) Health financing country diagnostic: a foundation for national strategy development Fiscal context Overall level of government spending Scope for increasing revenue Budget deficit Government debt Extent of prepayment mechanisms Compulsory vs voluntary Equity in contributions Extent of pooling Extent of fragmentation Financial risk protection Efficiency Murray & Frenk (1999) A WHO framework for health system performance assessment Equity Efficiency Green 1992 An introduction to health planning in developing countries. Technical feasibility Revenue generating ability Effects on service provision Equity Participation in decision-making Effect on multisectoral Carrin & Vereecke 1992 Economic analysis of community financing schemes Allocative efficiency Technical efficiency Equity Hsiao (1992) International Conference on Macroeconomics and Health in Countries in Greatest Need. Session II: Health Care Finance. Equity Efficiency Cost containment Consumer choice Revenue raising potential Barnum & Kutzin (1993) Public hospitals in developing Countries. Resource Use, Cost, Financing Efficiency Equity Revenue collection Annex 3: Detailed health financing frameworks and framework elements identified in literature 56 57 Berman & Chawla (1995) Resource mobilization methodological guidelines Revenue mobilization capacity Efficiency Quality of care and patient satisfaction Public accountability and community participation Shaw & Griffin (1995) Financing health care in Sub-Saharan Africa through User Fees and Insurance. Revenue generating ability Efficiency Equity Public-private sector collaboration Nolan & Turbat (1995) Cost recovery in public health services in sub-Saharan Africa Revenue generation potential Efficiency Equity Creese & Kutzin (1995) Lessons from cost-recovery in health Revenue generation potential Efficiency Equity Criel 1998 District-based health insurance in sub-Saharan Africa Revenue generation ability Level of funding Reliability and stability of funds Administrative efficiency Displacement effects Ease of use Technical feasibility Social and political acceptability Flexibility of management System effects Impacts on demand Impacts on utilization Impact on supply (public vs private) Impact on quality of care Equity effects Horizontal equity Vertical equity Effects on community participation Participation in decision-making Public accountability World Bank (1975) Health Sector Policy Paper Efficiency World Bank (1987) A World Bank Policy Study. Financing Health Services in Developing Countries. An Agenda for Reform Efficiency Equity 56 57 World Bank 1993 Better health in Africa. 1-218. Washington Efficiency Equity Sustainability Impact on healthcare utilization Revenue generating ability WHO (1978) Financing of health services: report of a WHO study group Revenue-generating ability Allocative efficiency Technical efficiency WHO (1993) Evaluation of recent changes in the financing of health services: report of a WHO study group Impact on the level and reliability of funding Efficiency Quality of care Equity Viability Impact on health status Zschock (1979) Health care financing in developing countries Efficiency Equity Displacement effect Impact on health care Van Balen and Mercenier (1991) Financing of the health service contribution to primary health care. Contribution to continuity of care Social solidarity viability Griffiths and Mills 1983 Health sector financing and expenditure surveys Allocative efficiency Operational efficiency Revenue generation ability Political acceptability Reliability Flexibility Displacement effects Impact on health service utilization and provision Effects on the economy Hoare and Mills 1986 Paying for the health sector Efficiency Equity Effects on supply and provision of services Displacement effects Parker and Knippenberg (1991) Community cost-sharing and participation: a review of the issues Increase resources Responsible and empowered local communities 58 Stryckman (1996) Comparative analysis of cost, resource use and financing of district health services in sub-Saharan Africa and Asia Increase resources Responsible and empowered local communities Jowett et al (2020) Assessing country health financing systems: the health financing progress matrix Health expenditure is based predominantly on public/compulsory funding sources The level of public (and external) funding is predictable over a period of years The flow of public (and external) funds is stable and budget execution is high Fiscal measures are in place that create incentives for healthier behaviour by individuals and firms Pooling structure and mechanisms across the health system enhances the potential to redistribute available prepaid funds

Alignment of health financing with health systems goals for universal health coverage, health security, and addressing social determinants of health Technical brief

Alignment of health financing with health systems goals for universal health coverage, health security, and addressing social determinants of health Technical brief Alignment of health financing with health systems goals for universal health coverage, health security, and addressing social determinants of health: technical brief ISBN: 978-929023507-1 © WHO African Region, 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/ igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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All photos: ©WHO Designed in Brazzaville, Republic of Congo iii Contents Acknowledgements ......................................................................................................vi Abbreviations .............................................................................................................vii Executive summary ....................................................................................................viii 1. Background ............................................................................................................. 1 2. Methodology ............................................................................................................ 6 2.1 Inclusion and exclusion criteria ................................................................................................7 2.2 Search strategy ..........................................................................................................................7 2.3 Selection process .......................................................................................................................8 2.4 Data extraction...........................................................................................................................8 2.5 Data analysis ............................................................................................................................18 3. Findings ................................................................................................................... 9 3.1 Current focus of different sources of health funds in relation to the 13 health system elements .....................................................................................................10 3.2 Framework for assessing financing sources for health system elements ............................19 3.2.1 Efficiency .......................................................................................................................23 3.2.2 Equity .............................................................................................................................23 3.2.3 Sustainability .................................................................................................................23 3.2.4 Feasibility .......................................................................................................................23 3.2.5 Displacement.................................................................................................................24 3.3 Effectiveness of the current ways the 13 health system elements are financed from the four sources of funding ............................................................................................24 3.3.1 Government funding .....................................................................................................24 3.3.2 Out-of-pocket payments ...............................................................................................25 3.3.3 External funding ............................................................................................................25 3.3.4 Private financing ...........................................................................................................26 3.4 Perceptions on improving the targeting of the four sources of funds towards the 13 elements of the system for effective functioning .......................................................27 3.4.1 Human resources for health .........................................................................................37 3.4.2 Service delivery .............................................................................................................28 3.4.3 Infrastructure .................................................................................................................29 3.4.4 Information management systems ..............................................................................29 iv 3.4.5 Governance....................................................................................................................29 3.4.6 Medical products ...........................................................................................................29 3.5 Suggest more efficient methods for allocating current sources of funds to the 13 health system elements in order to maximize resource adequacy, efficiency and equity ...............................................................................................................30 4. Conclusion .............................................................................................................33 References .................................................................................................................35 Annex 1: List of reviewed literature ..................................................................................................42 Annex 2: Detailed summary of the different elements by country, according to the national health accounts .................................................................................................................49 Annex 3: Detailed health financing frameworks and framework elements identified in literature 55 List of figures Figure 1: Scope and relationships of health system elements .........................................................4 Figure 2: Literature selection flow diagram .....................................................................................10 Figure 3: Trends in contributions of health financing sources to total health expenditure in SSA 11 Figure 4: Absolute health expenditures by source in SSA................................................................11 Figure 5: Proportion of total health expenditure by health system function in SSA ......................12 Figure 6: Absolute total health expenditures by health system function in SSA ............................12 Figure 7: Share of, and absolute expenditure (in United States dollars) on health system functions from public sources of funding in SSA ..............................................................13 Figure 8: Share of, and absolute expenditure (in United States dollars) on health system functions from private sources of funding in SSA ...........................................................14 Figure 9: Share of, and absolute expenditure (in United States dollars) on health system functions from external/donor sources of funding in SSA .............................................14 Figure 10: Allocation of Global Fund Round 8 to health systems strengthening ............................15 Figure 11: Frequency of reporting expenditure for health system elements in NHA for the African Region .......................................................................................................19 List of tables Table 1: Summary of the different elements by country, according to the national health accounts ...................................................................................................................16 Table 2: Health financing frameworks identified in literature.........................................................20 vTable 3: Framework for assessing health financing sources ...........................................................22 Table 4: Performance of health financing sources against assessment criteria .............................24 Table 5: Public-private partnership models used in health in Africa (Whyle & Olivier, 2016) ........26 vi Acknowledgements The technical brief was developed under the stewardship of the Assistant Regional Director (ARD) Cluster in the WHO Regional Office for Africa. The Cluster coordinates and stewards cross- cutting technical functions of the WHO Regional Office for Africa. The brief was developed under the leadership of Dr Lindiwe Makubalo, the Cluster Director. Technical coordination was led by Dr Humphrey Karamagi, Team Lead of the Data, Analytics and Knowledge Management (DAK) Team. The assessment was conducted by independent experts from Member States, and included Edwine Barasa, David Njuguna and Herve Djossou. Internal appraisal was carried out by ULC, Professor Benjamin Musembi Nganda, Ms Diane Karenzi Muhongerwa, Mr Kingsley Addai Frimpong and Dr Juliet Nabyonga, and Aminata Binetou Wahebine Seydi DAK/ARD cluster. Coordination support from the regional office was provided by Solyana Ngusbrhan Kidane, DAK/ARD. vii Abbreviations CGH: common goods for health CASP: Critical Appraisal Skills Programme Gavi: Gavi, the Vaccine Alliance GHSA: Global Health Security Agenda GDP: gross domestic product HRH: human resources for health LMICs: low- and middle-income countries NCDs: noncommunicable diseases NGOs: nongovernmental organizations NHA: national health accounts OOPS: out-of-pocket spending PEPFAR: The U.S. President’s Emergency Plan for AIDS Relief PHC: primary health care PICO: participants, intervention, comparator and outcome PRISMA-ScR: preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews PFM: public financial management PPPs: public-private partnerships SDGs: Sustainable Development Goals SWAps: sector-wide approaches SSA: Sub-Saharan Africa THE: total health expenditure UHC: universal health coverage VAT: value-added tax WHO: World Health Organization viii Executive summary Health financing is critical to the attainment of universal health coverage. It ensures that funding is available and sets the right financial incentives to health providers for all individuals to access effective public health and personal health care. Currently, health financing focuses on complex and dynamic systems which interplay across 13 health system elements. However, there is a lack of detailed conceptualization on how the current health financing mechanisms interplay across those elements. This scoping review summarizes evidence on the potential for different funding sources for the specific elements of the health system. We included 119 articles in this review that employed a combination of conceptual studies (13%) and empirical studies (87%), published from 1975 to 2021. Moreover, 45% of the studies focused on service delivery, 13% on human resources for health, 5% on medical products and 3% on infrastructure and governance. Studies reporting multiple health system elements contributed 8% to the papers included. Health financing assessment frameworks were presented in 23% of these studies. Broadly, there was sufficient evidence to conclude that public sources were the dominant form of financing for the 13 health system elements. On the other hand, there was no preference to fund specific elements of the health system with any of the four funding sources. Additionally, global documentation on health expenditure does not track funding for all the dimensions that informed the conceptual framework of this scoping review. The available evidence tracks the spending for tangible elements of the health system and not the intangible ones. Sustainable policies for gradually exiting from donor funding for health are required, as dependence on humanitarian actors will continue to cripple countries’ ability to be self-sufficient and self-reliant. 11Background 2 3 “Ensure healthy lives and promote well-being for all at all ages” is the third of the 17 Sustainable Development Goals (SDGs) established by the United Nations in 2015 (UN, 2015). This third goal is attained by achieving multiple health and related targets across the SDGs (UN, 2015). These multiple targets are brought together in three interconnected themes: universal health coverage (UHC); health security (HSE); and coverage of health determinants (CHD). Universal health coverage is a global health priority, anchored in Sustainable Development Goal 3, target 3.8. It ensures financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all (UN, 2015). Global public health security includes proactive and reactive activities, which lower the risk and impact of acute public health events that endanger people’s health across geographical regions and international boundaries. Health security works at the individual and population levels. Individually, health security considers the risks and threats, as well as the underlying vulnerabilities to both communicable and noncommunicable diseases (NCDs). At the population level, health security overlaps State security. According to the current international liberal architecture, the relationship between health security and their realization is dependent on the citizen-State relationship. In this rendering, health security does not have a global guarantee; it is not itself a global public good (Frenk et al., 2014; Lisk, 2009). Determinants of health may be biological, behavioural, sociocultural, economic and ecological. Broadly, the determinants of health can be divided into four core categories, which are like the four pillars of a foundation: nutrition, lifestyle, environment and genetics. When any one of the pillars becomes weak, a support system is needed. The support system, which involves medical care, is considered the fifth determinant of health. Two of the determinants that have a significant influence on health are the environmental and social conditions in which people live. There is a large amount of empirical evidence showing that social inequalities, especially poverty, affect inequalities in health and well-being (Patwardhan et al., 2015). There is an increased commitment to improving health and achieving health equity through multisectoral approaches that address social, economic and environmental factors that influence health. In 2013, the review of social determinants and the health divide in the World Health Organization (WHO) European Region recommended developing more “partnerships at all levels of government that enable collaborative models of working, foster shared priorities between sectors and ensure accountability for equity” (Marmot et al., 2012). Health financing is the function of a health system that refers to how financial resources are used to ensure that the health system can adequately cover the collective health needs of every person. It deals with the mobilization, accumulation, efficient and effective allocation of funds to cover the health needs of the people, individually and collectively. It makes funding available and sets the right financial incentives to providers to ensure that all individuals access effective public health and personal health care. Besides, it is an enabling factor in the ability of countries to achieve universal health coverage by improving effective service coverage and financial protection (Kutzin, 2013). It is critical for achieving universal health coverage by raising adequate funds for health in ways that ensure that people can use the needed services and are protected from financial risk (WHO, 2018). By understanding financing of health systems and services, programmes and resources can complement the health financing already in place, advocate for more funding of priority areas and increase population access to available health services (Schieber et al., 2006). 2 3 Health systems differ widely across the globe in terms of their financing schemes. Funds are from four sources: government schemes, donors, out-of-pocket and private health insurance. Government schemes typically receive budget allocations out of the overall government revenue. Out-of-pocket spending (OOPS) is exclusively financed from household revenue. Donors give donations or additional income from investments or rentals. Resident financing schemes can also receive transfers from abroad as part of bilateral cooperation with foreign governments or other development partners. Social health insurance is usually financed out of social contributions payable by employees and employers. However, these schemes may also receive a varying proportion of their revenues from governmental transfers. The main sources of revenue for private health insurance are either compulsory or voluntary prepayments, which typically take the form of regular premium payments, as part of an insurance contract (Campos, 2018). Despite continued global agreement on the need to strengthen national health financing systems to develop sustainable and comprehensive policies, health financing in low- and middle-income countries (LMICs) and individuals’ access to essential health services depend on OOPS. Such access barriers contribute to a high burden of disease and preventable deaths. In addition, more than approximately 800 million people spend at least 10% of their income on health care through OOPS, which pushes millions of individuals further into poverty each year (Salari et al., 2019). This can be attributed to the cost-sharing policy in public hospitals (E. W. Barasa et al., 2017)”type”:”article- journal”,”volume”:”16”},”uris”:[“http://www.mendeley.com/documents/?uuid=329691b0- 3ef1-4431-895f-b91aa30d9cb0”]}],”mendeley”:{“formattedCitation”:”(E. W. Barasa et al., 2017, low health insurance coverage and low expenditure on health by the government (Mcintyre D, 2014). Strengthening of domestic financing is crucial to avoiding OOPS; and countries must increase their allocated spending on primary healthcare by at least 1% of their gross domestic product if the health targets of the 2030 Agenda for Sustainable Development are to be met. Besides, these different sources of funding are usually focused on the different elements of the health system. This scoping review is guided by a conceptual framework developed by the WHO Regional Office for Africa, to call for a shift from the focus on investment in the six building blocks (World Health Organization, 2007), to a focus on having complex, dynamic systems that allow for interplay across the 13 elements namely (Figure 1): • Three tangible hardware - health workforce, health products, health infrastructure. • Four tangible software - service delivery, governance processes, information system, and financial management system. • Six intangible software - values and norms, beliefs, practices, organizational culture, interests and networks, and relationships and power (Region, 2022). 4 5 The framework posits that a good system is one where the interplay among these elements allows the operationalization of the shifts needed to attain its expected results. The framework further proposes four capacities that a system needs to have, irrespective of the way it mixes and matches its constituent elements, for it to deliver on its results. These include the capacity to: • overcome barriers the population may face when accessing essential services; • ensure that the process of care provision is person-centred and effective; • engage with the beneficiaries, to ensure that what the system has provided is aligned to their own needs; and • anticipate, absorb, adapt and transform itself when facing a shock event, minimizing its impact. The framework asserts that the funding for any health system needs to focus on attaining these capacities. It is therefore crucial to repivot health system development in the WHO African Region to focus on the attainment of these capacities, to achieve the expected results in terms of universal health coverage, health security and coverage of health determinants. It is therefore important to explore whether these common allocations of health funds present the most appropriate way for using the resources, and where they could be put to better use. African countries are grappling with difficult economic conditions and large informal sectors that are difficult to draw into taxation systems or contributory health insurance. However, it is still possible for all countries to achieve UHC. This scoping review presents a typology of financing strategies for the 13 health system elements, their health financing options and lessons for African countries. The study findings will help them to put their financing options in the context of their institutional resources and Figure 1: Scope and relationships of health system elements 4 5 capacities, the efficiency and ease of their collection, their potential to avoid cost escalation and their political and social acceptability. The aim of this scoping review was to generate evidence on the most appropriate ways for utilizing resources to maximize resource adequacy, efficiency and equity in the WHO African Region. 6 7 2 Methodology 6 7 Design A scoping review was performed using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) checklist (Tricco et al., 2018). See appendix 4. This systematic review was not formally registered. 2.1 Inclusion and exclusion criteria This scoping review did not employ any time or geographical restrictions and included studies up to the time of the literature search (31 December 2021). The review included peer-reviewed articles: (a) that were published in the English language (b) reporting empirical research or conceptual papers on the financing of health system functions (c) that were open access. In addition, a thematic review of grey literature on health financing, including the WHO global health expenditure database was also conducted. The team ensured that all the evidence synthesized had undergone methodological and expert scrutiny. 2.2 Search strategy The databases searched included Medline, Cochrane Library, PubMed, WHO database, World Bank database and Google Scholar search engines. In addition to the database search as outlined above, we also undertook the following to identify key evidence for the review: 1. Liaison with topic experts. 2. Citation searching on papers included and other key papers identified by topic experts. 3. Scrutiny of reference lists included in primary studies and relevant systematic reviews. 4. Scrutiny of recent reviews of services and guideline documents for relevant peer-reviewed evidence. The search strategy was structured as follows: • Population – studies reporting health systems financing globally • Intervention – health systems financing • Comparator - there was no comparator for this scoping review • Outcomes – there were main outcomes included. (a) Current focus of different sources of health funds in relation to the 13 health system elements (b) Framework for assessing financing sources for health system elements 8 9 (c) Effectiveness of the current ways in which the 13 health system elements are financed from the four sources of funding (d) Perceptions on how to improve targeting of the four sources of funds towards the 13 elements of the system for them to function effectively (e) Proposing more effective ways for channelling the current sources of funds to the 13 health system elements in order to maximize resource adequacy, efficiency and equity. The following search terms were employed: (“health financing” OR “financing” OR “funding”) AND (“health workforce” OR “human resources for health” OR Staff OR drugs OR medicine OR “medical products” OR “health infrastructure” OR “Service delivery” OR “governance” OR “information systems” OR “health investment” OR “Health system strengthening” OR “universal health coverage” OR “health security” OR “common goods for health”). Additionally, we specifically retrieved and reviewed the latest available national health accounts (NHA) reports for African countries. 2.3 Selection process We operationalized our inclusion criteria based on our PICO elements. Five reviewers (EB, HB, ND, HCK and SNK) participated in the design of the knowledge synthesis. Three reviewers (EB, HB and ND) participated in the development of the search strategy and the selection of eligible studies. HB searched for grey literature, ND searched for published literature while EB consolidated the findings for relevance. The study selection was done independently and checked by another (EB). 2.4 Data extraction Three reviewers (EB, HB and ND) participated in the data extraction. HB extracted data from the grey literature, ND extracted data from published literature while EB consolidated the findings. Full-text articles that fit the inclusion criteria were extracted for country, NHA year, health system elements financed, elements, title, assessment criteria, criteria definitions and criteria indicators, author, publication year focus, and the conceptual or theoretical nature of the study. The extracted data was entered into an excel matrix. All disagreements were re-examined jointly and appropriate corrections made for all studies included in the review. 2.5 Data analysis Four reviewers (EB, HB, ND, SNK and HCK) contributed to the analysis or interpretation of the data. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. In addition, a thematic review of grey literature on health financing, including the WHO Global Health Expenditure Database was also conducted. We also conducted a literature research and developed a five-criterion framework for assessing the alignment of health financing sources aimed at funding health system functions. We synthesized extracted data on health financing assessment frameworks, and integrated recurrent and relevant elements of multiple frameworks to develop a framework for assessing health financing sources. See table 2 below. The team ensured that all the evidence synthesized had undergone methodological and expert scrutiny. 8 9 3Findings 10 11 Selection of studies We identified a total of 1141 papers. Of these, 642 articles were excluded after the titles and abstracts had been screened. An assessment of the full-text formats of the remaining 499 papers resulted in a further 334 exclusions. A total of 165 studies were finally included in the review (Figure 2). Figure 2. Literature selection flow diagram Characteristics of included studies All included studies were published from 1975 to 2021. They were conceptual (13%) or empirical (87%) studies. With regard to the focus of the papers, 45% of the selected papers focused on service delivery, 13% on human resources for health, 5% on medical products and 3% on infrastructure and governance. Papers that focused on multiple health system elements contributed 8% to the total selected papers. Health financing assessment frameworks were presented in 23% of the selected papers. 3.1 Current focus of different sources of health funds in relation to the 13 health system elements Figures 3 and 4 present an analysis of the contribution of different financing sources to total health expenditure (THE) in sub-Saharan Africa (SSA) over a 20-year period, using data from the WHO database on global health spending. Several issues emerge from these analyses. First, private financing sources Id en ti fi ca ti on In cl ud ed Sc re en in g n= 13 1 Records identified (n=1141): Google Scholar (n=333), MEDLINE (n=683), PubMed (n=101), Cochrane library (n=14), WHO database=6, World bank database=4 Title and Abstract screening n=1,141 Records excluded n=642 Records excluded n=334 Full text screening n=499 Studies included in the review n=165 10 11 represent the largest proportion of total health spending, falling from 60% in 2000 to 51% in 2019. They remain a substantial contribution to total health spending in Africa despite countries’ commitment to progress. towards UHC by intensifying, among other things, prepayment health financing mechanisms. In second place we have public sources which experienced slight growth overall from 2000 to 2019, going from 35% to 40%. Third, donor funding increased between 2000 and 2013, but has stagnated since then. This situation is similar to health system financing and is considered globally (WHO, 2017). Fourth, the contribution of private sector financing appears to have declined, from 28% in 2000 to 21% in 2019. Figure 3. Trends in contributions of health financing sources to total health expenditure in SSA Figure 4. Absolute health expenditures by source in SSA An analysis of total health expenditure by health system functions reveals that the global health expenditure database tracks funding for only three of the 13 health system elements: governance; medical goods; and service delivery, which is disaggregated to preventive, curative, long-term, rehabilitative, ancillary and other healthcare services. Figures 5 and 6 outline the level of funding for each of these functions in SSA between 2016 and 2019. Findings show that service delivery received the greatest share of health sector funding in SSA during this period, followed by governance and administration, and lastly health commodities. 12 13 Figure 5. Proportion of total health expenditure by health system function in SSA Figure 6. Absolute total health expenditures by health system function in SSA 12 13 An assessment of expenditures on health system functions by funding sources in SSA reveals a similar pattern, with most of the funding allocated to service delivery, followed by governance and administration, and lastly health commodities (Figures 7, 8 and 9). The exception is private and out-of-pocket expenditure, where health commodities appear to come second to service delivery. It was not possible to separate private prepaid expenditures from out-of-pocket expenditures for this specific analysis (expenditure by health system functions) since the WHO health expenditure database does not provide that data to this level of disaggregation. Figure 7. Share of, and absolute expenditure (in US$) on health system functions from public sources of funding in SSA 14 15 Figure 8. Share of, and absolute expenditure (in US$) on health system functions from private sources of funding in SSA Figure 9. Share of, and absolute expenditure (in US$) on health system functions from external/donor sources of funding in SSA 14 15 Figure 10. Allocation of Global Fund Round 8 to health systems strengthening Two key messages emerge from this analysis of health expenditures in SSA. First, at the system level, there seems to be no preference to fund specific health system functions with specific funding sources. It appears that funding from all the four sources is allocated across all health system functions. This is in line with the expectations of a system that pools and allocates funds across health sector priorities. Even though the level of pooling of healthcare resources in SSA varies (McIntyre et al, 2018), and pooling mechanisms in SSA are characterized by substantial fragmentation (Diane McIntyre, 2008), these data show that health funding allocation in SSA benefits, to some degree, from pooling and allocation of resources across priorities. Second, a closer analysis of external funding reveals that the highly aggregated data masks important patterns. While external funding was initially focused on vertical service delivery, with little focus on horizontal health system strengthening, there has been a trend towards increased focus on health system strengthening (Nattrass et al., 2016). For instance, an analysis in 2013 showed that 37% of the Global Fund Round 8 funding was allocated to health systems strengthening (Warren et al., 2013). However, a deeper assessment of health system investments by the major external funders shows that the bulk of their health system spending was channelled to vertical disease programmes, with very little going to system-wide investments (Warren et al., 2013). For instance, 37% of the Global Fund funding was spent on health system strengthening, while approximately 62% was invested in disease-specific system support (Figure 6) (Warren et al., 2013). An assessment of external funding investments in broader health systems shows that there is a bias in allocation across health system elements. For instance, an analysis of the Global Fund Round 8 revealed that around 82% of health systems strengthening funding was allocated to service delivery, human resources, and medicines and technology, while governance, financing, and information building blocks received relatively low funding (Figure 10) (Moucheraud et al., 2016; Warren et al., 2013). Service delivery 31% Governance Financing Information Human Resources Medecines and Technology 5% 1% 23% 12% 28% 16 17 With regard to human resources for health, analyses of major external funders show that substantial investments are channelled to human resources for health. However, when overall external funding for health is assessed, funding for human resources was minimal, not going over 7% between 1990 and 2016 (Micah et al., 2018). This notwithstanding, external funding allocations for health have been increasing. For instance, between 1990 and 2016, development assistance for human resources for health increased by 15.7% each year (Micah et al., 2018). The most common external investment in human resources is short-term in-service training. There is relatively little investment in expanding pre-service training capacity, despite severe health worker shortages in developing countries (Vujicic et al., 2011). Third, global documentation of health expenditure does not track funding on all the 13 dimensions that informed the conceptual framework of this assignment. It tracks expenditure on health system tangible hardware (health commodities), and tangible software (governance and financial administration, and service delivery). Global tracking of funding emphasizes service delivery, and disaggregates service delivery expenditures further into curative, preventive, rehabilitative/ palliative care, and also tracks expenditures on the level of care, with a focus on primary health care (PHC). It does not, however, track expenditure on health security, making it difficult to assess the prioritization of health security by health systems. Global tracking of health expenditures is guided by the system of health accounts, that provides a systematic description of the financial flows related to the consumption of health care goods and services (OECD et al., 2017). It is apparent that the system of health accounts recognizes and includes both health system tangible hardware and tangible software elements. Expenditures on intangible elements of the health system are not tracked, which is not surprising, given the difficulty in tracking and quantifying such expenditures. This later finding is emphasized by an analysis of the format and reporting on country health expenditures in national health accounts (NHA). We analysed the latest NHA reports from 20 African countries. See Table 1 below. Table 1: Summary of the different elements by country, according to the national health accounts Reference in chronological order Assessment criteria Efficiency Equity Sustainability Feasibility Fungibility Others World Bank (1975) √ WHO (1978) √ √ Zschock (1979) √ √ √ • Impact on healthcare Griffiths and Mills 1983 √ √ √ √ • Impact on health service utilization and provision • Effects on the economy Hoare and Mills 1986 √ √ √ • Effects on supply and provision of services World Bank (1987) √ √ 16 17 Van Balen and Mercenier (1991) √ • Social solidarity • Contribution to continuity of care Parker and Knippenberg (1991) √ • Responsible and empowered local communities Hsiao (1992) √ √ √ Carrin & Vereecke 1992 √ √ Green 1992 √ √ • Effect on service provision • Participation in decision-making • Effect on multisectoral action Barnum & Kutzin (1993) √ √ √ World Bank 1993 √ √ √ √ • Impact on healthcare utilization WHO (1993) √ √ √ √ • Impact on health status Berman & Chawla (1995) √ √ • Accountability • Quality of care Shaw & Griffin (1995) √ √ √ • Public- private sector collaboration Nolan & Turbat (1995) √ √ √ Creese & Kutzin (1995) √ √ √ Stryckman (1996) √ • Responsible and empowered local communities Criel 1998 √ √ √ √ √ • Impact on demand • Impact on utilization • Impact on supply • Impact on quality of care • Impact on community participation • Accountability 18 19 Murray & Frenk (1999) √ √ √ • Effect on citizen participation • Effect on multisectoral action McIntyre 2007 √ √ √ √ Kutzin et al. 2010 √ √ √ • Financial risk protection • Quality • Transparency and accountability Garand et al 2016 √ √ √ • Financial risk protection McIntyre & Kutz- in (2016) √ √ √ • Financial risk protection • Extent of fragmentation Doherty et al. 2019 √ √ √ √ • Financial risk protection • Risk cross- subsidization Jowett et al. (2020) √ √ • Incentives for healthier behaviour by individuals and firms • Health expenditure is based predominantly on public/ compulsory funding sources The review of NHA reports reaffirms the observation that health expenditure tracking focuses on tangible hardware elements and some tangible software elements. Funding of intangible elements is not tracked. Compared to the global health expenditure databases, the NHA provides more disaggregation, especially of tangible hardware elements, as well as service delivery areas. NHA data also does not track health expenditures on health security. Figure 5 outlines the frequency of reporting different health system elements from the NHA reports that were assessed. 18 19 3.2 Framework for assessing financing sources for health system elements In this section, we present a framework for assessing the alignment of health financing sources with the objectives of funding health system functions. We synthesized extracted data on health financing assessment frameworks, and integrated recurrent and relevant elements of multiple frameworks to develop a framework for assessing health financing sources. Table 2 outlines the frameworks and individual elements of those frameworks. Figure 11. Frequency of reporting expenditure for health system elements in NHA for the African Region 20 21 Table 2. Health financing frameworks identified in literature Author of the framework Individual criteria of the framework Efficiency Equity Sustainability Feasibility Fungibility Other elements Kutzin et al 2010 √ √ √ • Financial risk protection • Quality • Transparency and accountability Doherty et al 2019 √ √ √ √ • Financial risk protection • Risk cross- subsidization Garand et al 2016 √ √ √ • Financial risk protection McIntyre 2007 √ √ √ √ McIntyre & Kutz- in (2016) √ √ √ • Financial risk protection • Extent of fragmentation Murray & Frenk (1999) √ √ √ • Effect on citizen participation • Effect on multisectoral action Green 1992 √ √ • Effect on service provision • Participation in decision-making • Effect on multisectoral action Carrin & Vereecke 1992 √ √ Hsiao (1992) √ √ √ Barnum & Kutzin (1993) √ √ √ Berman & Chawla (1995) √ √ • Accountability • Quality of care Shaw & Griffin (1995) √ √ √ • Public- private sector collaboration Nolan & Turbat (1995) √ √ √ Creese & Kutzin (1995) √ √ √ 20 21 Criel 1998 √ √ √ √ √ • Impact on demand • Impact on utilization • Impact on supply • Impact on quality of care • Impact on community participation • Accountability World Bank (1975) √ World Bank (1987) √ √ World Bank 1993 √ √ √ √ • Impact on healthcare utilization WHO (1978) √ √ WHO (1993) √ √ √ √ • Impact on health status Zschock (1979) √ √ √ • Impact on healthcare Van Balen and Mercenier (1991) √ • Social solidarity • Contribution to continuity of care Griffiths and Mills 1983 √ √ √ √ • Impact on health service utilization and provision • Effects on the economy Hoare and Mills 1986 √ √ √ • Effects on supply and provision of services Parker and Knippenberg (1991) √ • Responsible and empowered local communities Stryckman (1996) √ • Responsible and empowered local communities Jowett et al (2020) √ √ • Incentives for healthier behaviour by individuals and firms • Health expenditure is based predominantly on public/compulsory funding sources 22 23 The review revealed that there is substantial literature that discusses and/or applies criteria for the assessment of health financing mechanisms. While some authors were explicit about proposing assessment frameworks, others were implicit in the sense that they applied a set of criteria without formally proposing them as part of a framework for health financing assessments. Further, frameworks and criteria typically focused on the entire health financing function rather than the revenue mobilization function, which is the focus of this work. Drawing on this review, specifically focusing on recurrent themes and suitability of criteria to assess funding sources, we propose a framework for assessing funding sources. The framework comprises five criteria and 10 indicators (Table 3). These five criteria have been selected based on their recurrence in the health financing frameworks reviewed. See Table 2 above. Table 3. Framework for assessing health financing sources Criteria Definition Criteria indicators Efficiency An efficient health financing source maximizes revenue collection and enhances technical and allocative efficiency of the health system Indicator 1: Proportion of administrative costs for revenue collection Indicator 2: Revenue generation potential of the funding source Indicator 3: Extent to which the funding sources can be flexibly allocated across priorities Feasibility A feasible health financing source has political support and is aligned with the system’s capacity to implement the health financing mechanism Indicator 4: Level of political acceptability and support Indicator 5: Level of administrative ease of revenue collection Sustainability A sustainable health financing source maintains predictable levels of funding over the medium to long term Indicator 6: Whether revenues from the source are projected to remain at the same level or grow over the long term (Revenue growth rate by funding sources) Equity An equitable health financing source enhances equity in financial contributions and use of health services Indicator 7: Level of progressivity of financial contributions Indicator 8: Extent of risk cross-subsidization Indicator 9: Effect on financial risk protection Displacement A health financing source has a displacement effect when it causes a reduction or reallocation of other sources of funding to other priorities Indicator 10: Whether the funding sources have a displacing effect on other sources of revenues 22 23 3.2.1 Efficiency There are two aspects of efficiency. Allocative efficiency is the capacity to finance healthcare based on the effectiveness of public programmes in meeting its strategic objectives. It requires proper arrangements within line ministries for sector policy formulation and sufficient technical capacity within spending agencies to select the most cost-effective programmes, projects, and activities. Technical efficiency refers to the ratio of resources financed to the output produced. It is achieved when maximum outcomes are achieved for a given level of inputs and no other combination of inputs can achieve a higher outcome (Diamond & Potter, 1999). An efficient health financing source maximizes the levels of funding while minimizing the costs associated with revenue mobilization (Hoare & Mills, 1986; Diane McIntyre, 2007). Such a funding source has a high revenue generation potential (Diane McIntyre, 2007). When fund collection costs are kept at a minimum, high net revenues are available to allocate to health system functions. 3.2.2 Equity The International Association for Equity in Healthcare Services defines equity as “the lack of systematic and potentially removable differences in one or more aspects of health in a population and its economic, social and geographical subgroups” (Black & Mooney, 2002). Equity in health financing can be defined in terms of vertical equity (unequal treatment of un-equals in a fair sense) and horizontal equity (equal treatment for equal need) (Wagstaff & Van Doorslaer, 1993). An equitable health financing source is therefore progressive in the sense that financial contributions as a share of income increases as the socioeconomic status rises. An equitable health financing source will hence be characterized by risk-cross subsidization and will also provide financial risk protection to avoid exposing households to catastrophic expenditure or impoverishment. 3.2.3 Sustainability Sustainability is the capacity of a government to finance its desired expenditure programmes, to service any debt obligations and to ensure its solvency (Heller, 2005). Expenditure and revenue should be aligned in a way that maximizes the attainment of health system objectives, subject to the requirement of fiscal balance, which in turn depends upon what is going on in other areas of government spending, and on the value to be had from spending on health, relative to the value to be had from spending elsewhere (Thomson et al., 2009). 3.2.4 Feasibility The feasibility of health financing sources refers to the political and operational ease of fund mobilization. A feasible health financing source has political support from relevant actors in the health system. In addi- tion, the health system needs to have the capacity to operationalize revenue generation for the funding source. Administrative capacity includes technical skills, information systems and mechanisms for enforc- ing collection. 24 25 3.2.5 Displacement The displacement criterion refers to the extent to which the health financing source has an additive effect on overall health resource mobilization efforts. That is, every dollar mobilized through this source results in an additional dollar in net resource mobilization, rather than displacing some funds from other sources. 3.3 Effectiveness of the current ways the 13 health system elements are financed from the four sources of funding In this section, we use the five-criterion framework developed in section 3.2 to assess the suitability of funding sources and arrangements for health system elements. A summary of this assessment is provided in Table 4. Table 4. Performance of health financing sources against assessment criteria Source of funding/assessment criteria Efficiency Equity Sustainability Feasibility Displacement effect Public sources + + + + - Private sources - - - - ND Out-of-pocket funding - - - - ND External funding ND - - + + + enhances – reduces ND - no data on criteria 3.3.1 Government funding There is consensus that public expenditure on health is a key determinant of the achievement of UHC. It has been proposed that for countries to achieve UHC, their public spending on health, as a share of their gross domestic product (GDP) will need to be at least 5% (Diane McIntyre et al., 2017). Countries must raise sufficient funds and reduce their reliance on direct payments to finance services, in order to improve efficiency and equity. The extent to which public spending on health aligns with health system goals is dependent on the financing arrangements. Public funding can be mobilized through taxation or social health insurance contributions. Improving the efficiency of revenue collection will increase the funds that can be used to provide services or buy them on behalf of the population. The mobilization of revenues for the health sector through taxation is more efficient, and sustainable compared to social health insurance contributions (Diane McIntyre, 2007; Diane McIntyre et al., 2018). While generation taxation is typically progressive and hence equitable, indirect taxes such as value-added tax (VAT) have mixed effects. For instance, while VAT was found to be progressive in Ghana (Diane McIntyre et al., 2018), it was regressive in Kenya (Munge & Briggs, 2013). Social health insurance contributions have been found to be inefficient and unsustainable in mobilizing health sector resources in SSA, as well as inequitable (E. Barasa et al., 2021). The feasibility and sustainability of social health insurance in SSA is compromised by high informality and poverty (E. Barasa et al., 2021). 24 25 3.3.2 Out-of-pocket payments Out-of-pocket payments are fragmented and hence inefficient (Kutzin & Sparkes, 2016). OOPS are regressive and do not cross-subsidize risk (Diane McIntyre, 2007). They are also responsible for catastrophic health expenditures and impoverishment. OOPS are therefore inequitable as a source of funding. OOPS have had negative implications on equity. 3.3.3 External funding Considerable external funding has been channelled to low- and middle- income countries (LMICs) over the past 30 years (Fitzmaurice et al., 2017). There is overwhelming evidence that this funding has had a significant impact on expanding access to critical health services in LMICs (Ejughemre, 2013). For instance, assessments have shown the huge impacts that Gavi, the Vaccine Alliance has had on expanding access to immunization (Ikilezi et al., 2020), PEPFAR on HIV/AIDs , and the Global Fund on HIV/AIDS, tuberculosis (TB), and malaria (Yu et al., 2008). Beyond the positive impact on expanding access to care, external funding has been characterized by several attributes of concern. First, external funding has predominantly been channelled to vertical programmes (Desai et al., 2010; Ejughemre, 2013; Mounier-jack et al., 2010; Rudge et al., 2010). While there is evidence that verticalization has contributed to the success of specific disease programmes (malaria, HIV/AIDS, TB, immunization), it has had unintended effects, with implications for the efficiency of health systems (Mwisongo & Nabyonga-orem, 2016). Vertical programmes have compromised the coordination of overall health systems because they have typically not been well integrated with the rest of the system (Desai et al., 2010; Mounier-jack et al., 2010; Mwisongo & Nabyonga-orem, 2016; Rudge et al., 2010), resulting in duplication of functions such as procurement, monitoring and evaluation, information systems and drained health workers from other services, because of added financial incentives for health workers in these donor-funded programmes (Yu et al., 2008). The fragmented and vertical funding arrangements are exacerbated challenges by governments to track their resources (Mwisongo & Nabyonga-orem, 2016). The terms of external funding also often means that donors influence public health priorities, sometimes at odds with local priorities (Mwisongo & Nabyonga-orem, 2016). For instance, an assessment of the Global Fund rounds 1 to 7 funding found that investments in human resources or health were not coordinated with the rest of the system (Bowser et al., 2014). Further, external funding has been fragmented, with little coordination across different donors. While there have been efforts to coordinate donor funding at the country level through the sector-wide approaches (SWAps) (Sweeney & Mortimer, 2016), and at the global level through initiatives such as the Health Systems Funding Platform, the extent to which these initiatives have been successful is debatable (Brown et al., 2013; Hill et al., 2011; Moucheraud et al., 2016; Stierman et al., 2013). The narrow focus, combined with the poor integration and coordination of external funding has therefore compromised the efficiency of health systems (Bowser et al., 2014; Moucheraud et al., 2016). Further, there is evidence that when external funds are concentrated in urban areas, they have contributed to maldistribution of health workers. Financing salaries and incentives of health workers has, in some cases, made an important contribution to country efforts to increase staffing and improve retention. However, health workers, attracted by financial (allowances) and nonfinancial (training) incentives, move to health facilities in urban areas that are donor funded, resulting in inequities in the distribution of health workers (Brugha et al., 2010). For example, 26 27 countries employed a variety of mechanisms, including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers, using Global Fund financing (Bowser et al., 2014). There are also concerns about the sustainability of external funding. While historically, external funding has played a significant role in financing LMIC health systems, there are plans by major donors such as Gavi and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to progressively exit as countries graduate to middle-income status (Gilbert et al., 2019). This means that donor funding cannot be considered sustainable in the long term. Finally, donor funding has been shown to have a displacement effect on public expenditure on health. An analysis of financial flows data spanning 119 countries and 16 years showed that US$ 1 year-on-year increase in development assistance for health channelled to governments leads to a US$ 0.62 decrease in domestic government spending on healthcare (J. L. Dieleman & Hanlon, 2014). 3.3.4 Private financing Private funding is mobilized through multiple mechanisms, including private health insurance, delivery of funding through the private sector, corporate philanthropy or social responsibility initiatives, and public private partnerships. Private insurance has been shown to mobilize limited resources for healthcare, achieve limited population coverage because of the challenge of scaling up voluntary contributions in LMICs that are characterized by high poverty and informality and hence too inefficient and unsustainable to be equitable (E. Barasa et al., 2021). Public-private partnerships (PPPs) have been used as a mechanism to leverage private sector resources to further public health goals (Whyle & Olivier, 2016). Table 5 outlines the common models of public-private partnerships used in health in Africa (Whyle & Olivier, 2016). Table 5. Public-private partnership models used in health in Africa (Whyle & Olivier, 2016) Model Definition Public-private partnership Long-term contractual arrangements for the development, financing and/or provision of public infrastructure (and sometimes services), in which risk and management responsibility are shared. Six sub-types of PPPs are: private finance initiative; public-private integrated partnership; Alzira model; franchise; co-location PPP; and global PPP Social marketing The social marketing approach uses commercial sector marketing and communication approaches to “sell” products of a high social or public health value, or to bring about behaviour change among a target population. Commonly, social marking programmes use community-based organizations, nongovernmental organizations (NGOs), or public sector facilities to distribute products. They often involve product subsidy to ensure affordability and rely on external funding. Sector-wide approach A ministry of health-led formal, sustained cooperative agreement with civil society and donors in which all parties are obligated to pool available resources and work together in accordance with jointly approved and negotiated sectoral national strategies and expenditure frameworks to improve population health outcomes and facilitate national development. Public-private mix (PPM) approach A PPM approach consists of initiatives to increase collaboration and improve relationships among all forms of health care providers for a particular disease Voucher programmes A public authority delegates responsibility for the provision or management of a service on behalf of the State in exchange for a fee, using a contract that specifies the type, quantity and time period of the services to be provided. 26 27 Dual practice regulation The development and enforcement of regulations, policy and other mechanisms to prevent or control public sector health providers working in the private sector. Financing Public financing of privately delivered health services through grants to providers or public insurance, covering private sector services. Private finance initiative or (DBFO) This is a long-term contract in which the design, building financing and nonclinical operation of a facility, in accordance with public authority requirements, is contracted to a private consortium. Public-private integrated partnership A long-term partnership between the State and a private consortium in which contracted services include infrastructure, nonclinical operations and clinical operations delivered to a specified segment of the population. Alzira model The Alzira model is characterized by a contractual arrangement that combines the building of facilities with the operating of nonclinical services and clinical services, including primary care provision for a defined population in return for capitated payment. Franchise The public authority uses contracting arrangements to harmonize the activities of a network of providers, supporting the providers through branding and bulk drug purchasing, while strictly controlling the quality, quantity and package of services provided, and disallowing cream-skimming Co-location public- private partnership A long-term partnership through which a portion of a public hospital’s premises is granted for use by a private provider, sharing infrastructure and support services but operating as distinct facilities, in return for payment and specified benefits to the public party Global public- private partnership (GPPP) A collaborative relationship, transcending national boundaries, in which both government and nongovernment entities provide financing and participate in decision-making through a mutually agreed upon and well-defined division of labour, so as to achieve a shared goal. All partners contribute and benefit equally. GPPPs are commonly three-way partnerships comprising international donors, recipient governments and NGOs or corporations. PPPs in the health sector have focused mostly on health system functions. For instance, PPPs have been used to develop human resource capacity through training programmes (Sirili et al., 2019; Vian et al., 2007), to finance hospital care (Sadeghi et al., 2016) and healthcare commodities (Shrivastava et al., 2019). There are mixed findings on the impact of PPPs within the health sector. While they have been shown to be successful in scaling up the provision of services such as laboratory services (Shrivastava et al., 2016) and in delivering essential commodities (Shrivastava et al., 2019), some PPPs have been shown to be unsustainable, inefficient (Metsing, 2008; Vian et al., 2015), and inequitable (Marten & Sullivan, 2020). A key challenge with PPPs in Africa is the weak regulatory and policy environment, such that quite often, PPP arrangements are informal. Another challenge is the capacity of government to negotiate and structure PPPs whose terms are aligned with health system goals or public goods. This contributes to the inappropriate distribution of risk and reward, leading to moral hazards (Kamugumya & Olivier, 2016; Nuhu et al., 2020). 3.4 Perceptions on improving the targeting of the four sources of funds towards the 13 elements of the system for effective functioning 3.4.1 Human resources for health First, donors should work with governments to understand how national and donor policies could impact programme sustainability, integration and coordination, so as to maximize human resources for health (HRH) investments and improve health outcomes. Innovative financing mechanisms should work for both the health system and the overall health workforce. Better 28 29 coordinated financing of HRH training and activities will lead to less duplication, lower costs for training programmes and strengthen national training programmes that focus on long-term, pre-service training rather than short-term, in-service training. Quantifying the impact of donor activities on health systems and health outcomes will require a coordinated effort with current tracking, monitoring and health management information systems (Bowser et al., 2014) (Micah et al., 2018). To this end, some of the existing initiatives, such as the International Health Partnership and the Health Systems Funding Platform, may present viable and timely approaches for the three agencies to pursue more effective HRH-related financing efforts in low and middle-income countries (Vujicic et al., 2011). Second, there is a need to establish a policy to support resource mobilization for increasing health worker training at the county level, as well as the number of health workers, based on proper assessment and forecasting. This is to determine: the cadres to be supported, based on county, regional and national needs; and the number of beneficiaries eligible for funding each year. A framework would then be put in place for revolving the funding, to ensure sustainability and grow funds, such that all health disciplines are supported at all levels of training (Hughes & Mann, 2020; Lu et al., 2020; Milo et al., 2021; Okech, 2016). Third, greater investment by donors and governments in the basic pre-service training of nurses, clinical officers, medical assistants and doctors is required (Brugha et al., 2010). (Sablah, 2019) recommend that the Government of Ghana and the Global Fund should increase dialogue, intensify health education and cooperate to enhance health personnel capacity. The Government should further regulate health staff transfers and increase health budget allocation to promote health development in the country. 3.4.2 Service delivery Donors should be more attentive to domestic resource constraints and integrate fully with existing health systems and address these constraints up front to limit possible negative effects on the delivery of other health services (Grépin, 2012). Moreover, it would be extremely desirable to carry out a mapping of the areas and sectors where government needs support from the NGOs. There on, it would be better to define clear roles and responsibilities of the parties, the nature and timeline of deliverables, and a clear plan for scaling up and sustainability (Ejaz et al., 2011). There is also a need for allocative efficiency of public spending on primary health care (PHC). Benefits can be differentiated among recipient countries, depending on: (a) the political will to improve both financing and delivery of PHC services in the recipient country; (b) harmonization or at least strong synergies of external and domestic spending on PHC; and (c) allocation of spending to PHC services most relevant to reducing the country’s burden of disease (Shaw et al., 2015). Global-health initiatives should have a proactive and balanced investment approach, so as to concurrently strengthen PHC systems, achieve programme targets, and sustain the gains in resource-poor settings (Assefa et al., 2018). Second, there is a need to invest in increased coverage of prepaid health financing mechanisms as it would reduce overreliance on potentially catastrophic and impoverishing out-of-pocket payments (Sambo et al., 2013). Safety nets for the poor are also needed to reduce the burden of spending by households (Sidze et al., 2013). Policy interventions aimed at financial risk pooling mechanisms are crucial to reducing the intensity and impact of OOP payments among vulnerable households (especially those living with severe mental disorders), and supporting the goal of universal health coverage (Hailemichael et al., 2019). 28 29 Third, governments need to track how resources are allocated sub-nationally to maximize equity and ensure that allocations are commensurate with health needs (J. Borghi et al., 2018; Klugman, 2004). Also, countries and international partners should pay more attention to the efficiency in the use of the available resources, as savings can go a long way in decreasing the funding gaps and increasing the impact (Ithibu & Amendah, 2019). Resource tracking at country and donor levels will help hold countries and donors to account for their commitments (J. O. Borghi et al., 2006; Mookherji et al., 2015). 3.4.3 Infrastructure First, there is an urgent need for countries to develop health policies that address inequities and health financing models that optimize the use of health resources and strengthen health infrastructure (Sambo et al., 2013). Second, further research needs to be carried out to determine the sustainability of the gains made in the health system infrastructure as a result of donor funds and to also to evaluate the effectiveness of donor-funded health system infrastructure in comparison to nonfunded health system infrastructure (OMONDI, 2015). 3.4.4 Information management systems The donor-supported programme needs to integrate parallel reporting systems with the district health information system to make it more flexible, reliable, and robust (Atun et al., 2011). In addition, coordinated efforts are needed towards strengthening monitoring and evaluation systems, thereby allowing countries to collect and use data to design, plan, implement, analyse, evaluate and manage their health programme (Jain & Zorzi, 2017). 3.4.5 Governance Future work will need to explore how donor financing of civil society influences policy agenda- setting and institutional innovations for increased civic participation in health governance and accountability to citizens (Gómez & Atun, 2012). 3.4.6 Medical products Tracking changes in health financing patterns across time and benchmarking against global trends is vital to addressing missed opportunities, ensuring access to medicines and high quality services, and pursuing universal health coverage (J. Dieleman et al., 2017). In Tajikistan, out-of- pocket expenditure, especially for drugs, has increased over time, and varies substantially across geographical areas and economic status. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies for improving access of patients to services (Schwarz et al., 2013). Finally, government engagement with private health facilities, particularly pharmacies, is quite limited. Improving engagement will help governments with limited resources to better take advantage of the private sector capacity to meet access and equity objectives (Sood et al., 2011). 30 31 3.5 Methods for allocating current sources of funds to the 13 health system elements in order to maximize resource adequacy, efficiency and equity Drawing on this review, below are several proposals for aligning health financing sources with the goals of financing health system elements: • Mind-set shift: Mindsets orient an individual to a particular set of associations and expectations. They influence decision-making under uncertainty and allow individuals to solve problems efficiently. Shifting mindsets is crucial to communication and advocacy efforts for UHC. Besides, a mindset shift that is centred on strengthening ecological thinking about health might create space for changes to policies that affect the social determinants of health. Also, a mindset shift is critical to enabling national governments to share responsibility and to demonstrate the importance of having the security of a robust health system, beyond the health ministries, to include multiple stakeholders, such as the private sector and indeed, the population at large. • Updating frameworks for health expenditure tracking: Health expenditure tracking aims to empower actors and increase accountability, transparency and responsiveness in health systems, to advance towards universal health coverage. Most health expenditure tracking exercises are guided by the system of health accounts (SHA). While the conceptualization of health systems has evolved over time, health expenditure tracking frameworks have not kept pace. As a result, it is difficult to track budgets and expenditures for most system software and for important functions such as health security and other public and common goods for health. We recommend that health expenditure tracking frameworks are updated to reflect relevant health system software, and public and common goods for health, including health security. Moreover, it is crucial to develop, test and improve financial systems to track resources and ensure adequate and timely reimbursement for public health emergency preparedness. • Improved coordination of sources of funding (globally and locally): While there are continuing efforts to coordinate external funding to LMICs at the global and national level, evidence shows that those global efforts have mostly failed, while gaps exist with national efforts. There is a need for coordination of donor funding at both these levels, and alignment of these funding approaches with local priorities. Roadmaps to UHC should consider the complex and changing needs of different contexts. Tailored, country-specific plans and coordination mechanisms that aim to build and finance health systems that are adaptable for unforeseen changes like global pandemics, will help accelerate progress along the path toward UHC. Moreover, health security and emergency preparedness can be achieved by providing joint support to accelerate progress on UHC in countries facing conflicts and protracted crises by improving disease outbreak coordination at the local level, ensuring continuity of service provision to affected populations and areas and strengthening primary health care. • Integration: The case for integration is even stronger now, given plans by donors to transition. Donors and LMICs will need to make concrete plans for integrating vertical programmes into the broader health system, to improve efficiency and ensure the sustainability of these service delivery areas. Moreover, the social determinants of health are vital to the equitable pursuit of healthy lives and health services delivery for all. There is a need to expressly incorporate 30 31 social determinants of health into the framework for monitoring UHC, through integration. Integration disaggregates UHC indicators to reflect the social gradient and the complexity of social stratification. Also, through integration, we can connect health indicators, both outcomes and coverage, with the social determinants of health and policies within and outside of the health sector. Failure to integrate health services increases the risk of going down a narrow route that limits the right to health coverage of services and financial risk protection. • Donor transition plans: In terms of integration, LMICs will need to develop pragmatic and feasible donor transition plans. These donor transition plans must be anchored on three broad principles that guide health financing reforms to accelerate progress towards universal health coverage. The first is to move towards a predominant reliance on public funding sources. The second is to reduce fragmentation in pooling, to enhance the redistribution capacity of these prepaid funds. The third is the move towards strategic purchasing, which seeks to align funding and incentives with promised health services. Such plans will need to be country driven, pragmatically aligned to country fiscal capacity and accompanied by efficiency measures such as integration and feasible co-financing commitments. Countries will need to honour these commitments to avoid disruption to the gains made. Also, emergency programming has short funding cycles that do not facilitate medium- to long- term strategic planning. This complicates efforts to build programme ownership and capacity among the affected populations, and prolongs the use of expensive emergency-oriented programme strategies. Consequently, there is a need to focus on resilience programming that links emergency and development responses under the framework of supporting a programme that will enable communities to withstand future shocks. • Scale-up prepayment financing mechanisms: LMIC countries will need to continue the shift from out-of-pocket payment mechanisms to prepayment mechanisms. The case for this shift cannot be belaboured. Increased prepayment and pooling result in efficiency gains; for example, from enhanced bargaining power of purchasers. Moreover, people do not forego health care and no longer need to sell assets or borrow to meet health payments. This means that they can cover health costs while continuing to spend and invest in other areas. This contributes to reducing poverty and inequities, while spurring economic growth. These UHC gains allow health indicators to improve steadily while regional disparities decline, thereby helping to consolidate a country’s social stability. • Tax funding: There is overwhelming evidence that tax-funded mechanisms are more feasible, equitable, efficient and sustainable than contributory health insurance, for instance. LMIC countries with high poverty and informality should prioritize tax funding as a foundation for UHC financing reforms. Increased general taxation financing has been associated with increased health service coverage and improved financial protection. The tax reforms will have to be ambitious and concern all types of taxes. Those directly related to health, such as excise duties on products harmful to health and UHC contributions should lead in financing the health sector. Other taxes, with their impact on increasing tax revenues for the general State budget, will also help improve funding for the sector. 32 33 • Policy and regulatory framework for public private partnerships: Public-private partnerships have become a popular way for governments to engage private actors in the delivery of health services, to increase quality and provide better value for money. Most governments have been exploring PPPs with the intention of achieving universal health coverage, either by expanding the coverage of services, which have conventionally not been available or are in short supply in the public sector, or by providing better access to certain services in specific under-served regions. The COVID-19 crisis also revealed that the government departments and public sector bodies are not sufficiently equipped to effectively respond to public health emergencies. The private sector has made major contributions and rapid and innovative solutions by working in partnership with the public sector to strengthen some existing services and develop new ones. In the long term, it is crucial to assess whether the introduction of such partnerships creates or exacerbates social and health inequalities. While PPPs may offer an alternative for mobilizing additional resources for the health sector, governments will need to lead the way, and develop effective policy and regulatory frameworks to guide their formation and implementation in the health sector. Fund software: Evidence shows that health system software elements play as important a role in health system performance as health system hardware. There is a need to invest in improved service delivery by ensuring UHC of essential health care services, paying particular attention to vulnerable populations. Also, governments should work on reducing risk factors to health, and address social determinants of health and health inequalities. Finally, they should strengthen capacity in health information and financial system management for evidence- based policy-making, and as part of health system reforms. • Incentivize and nurture health system intangibles: The public recognition given to health system intangibles is valuable in creating a culture of quality improvement, which is critical to achieving UHC and meeting the health-related SDGs. The success and value of UHC depend on its ability to provide quality services to all people, everywhere. Alongside the need to fund health system software elements, is the importance to incentivize and nurture health system intangibles, given the difficulty in directly funding them. Ways of doing that include explicitly recognizing them as important, including them as part of performance management for staff and health system organizations, and funding efforts to develop their capacities in soft skills and emotional intelligence training, and coaching and mentoring health system leaders and managers. 32 33 4Conclusion 34 35 The current focus of different funding sources for the 13 health system elements is skewed, with public sources being the significant contributor and the private sector lagging behind. This points to opportunities for more balanced investments. Moreover, no distinction is made between which funding sources should be used for specific health system functions. It appears that funding from all four sources is allocated across all the health system functions. Besides, global documentation of health expenditure does not track funding on all the 13 health system elements that informed the conceptual framework of this work. 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Globalization and Health, 4(1), 1–10. 42 43 Annex 1: List of reviewed literature Author and publication year Title Focus Type of study World Bank (1975) Health sector policy paper Health financing framework Conceptual WHO (1978) Financing of health services: report of a WHO study group Health financing framework Conceptual Zschock (1979) Health care financing in developing countries Health financing framework Empirical Griffiths and Mills 1983 Health sector financing and expenditure surveys Health financing framework Empirical Hoare and Mills 1986 Paying for the health sector Health financing framework Empirical World Bank (1987) A World Bank policy study. Financing health services in developing countries. An agenda for reform Health financing framework Conceptual Van Balen and Mercenier (1991) Financing of the health service contribution to primary health care Health financing framework Empirical Parker and Knippenberg (1991) Community cost-sharing and participation: a review of the issues Health financing framework Empirical Green 1992 Financing health care. An introduction to health planning in developing countries Health financing framework Conceptual Hsiao (1992) International Conference on Macroeconomics and Health in Countries in Greatest Need. Session II: Health Care finance Health financing framework Conceptual Carrin & Vereecke 1992 Economic analysis of community financing schemes. Health financing framework Empirical World Bank 1993 Better health in Africa Health financing framework Conceptual Barnum & Kutzin (1993) Public hospitals in developing countries. resource use, cost, financing Health financing framework Empirical WHO (1993) Evaluation of recent changes in the financing of health services. Report of a WHO study group Health financing framework Empirical Berman & Chawla (1995) Resource mobilization. Methodological guidelines. Health financing framework Conceptual Creese & Kutzin (1995) Lessons from cost-recovery in health Health financing framework Conceptual Shaw & Griffin (1995) Financing health care in sub-Saharan Africa through user fees and insurance Health financing framework Empirical Nolan & Turbat (1995) Cost recovery in public health services in sub- Saharan Africa Health financing framework Empirical Stryckman (1996) Comparative analysis of cost, resource use and financing of district health services in sub-Saharan Africa and Asia Health financing framework Empirical Criel 1998 District-based health insurance in sub- Saharan Africa Health financing framework Empirical 42 43 Murray & Frenk (1999) A WHO framework for health system performance assessment Health financing framework Conceptual Mayhew et al 2002 Donor dealings: the impact of international donor aid on sexual and reproductive health services Service delivery Empirical Mwapasa & Kadzandira 2004 Global health initiatives and health care delivery: the case of the Global Fund to Fight AIDS, Tuberculosis and Malaria Service delivery Empirical Blecher et al 2006 Health care financing: core health issues All Conceptual Hernandez et al., 2006 Measuring expenditure for the health workforce: evidence and challenges Human resources for health Empirical Borghi et al 2006 Mobilising financial resources for maternal health Service delivery Empirical Powell-Jackson et al 2006 Countdown to 2015: tracking donor assistance to maternal, newborn, and child health Service delivery Empirical McIntyre 2007 Learning from experience: Healthcare financing in low- and middle-income countries Health financing framework Empirical Puri et al 2008 Examining out-of-pocket expenditures on reproductive and sexual health among the urban population of Nepal Service delivery Empirical Yu et al 2008 Investment in HIV/AIDS programmes: does it help strengthen health systems in developing countries? Service delivery Empirical Embrey et al 2009 How AIDS funding strengthens health systems: progress in pharmaceutical management. Medical products Empirical Baker 2009 The Long and Tortured Road to Adequate, Sustained, and Spendable Domestic and Donor Financing for Health Service delivery Empirical Gordon et al 2009 Fuel, beds, meals and meds: out-of-pocket expenses for patients with cancer in rural Queensland Service delivery Empirical McCoy et 2009 Global health funding: how much, where it comes from and where it goes Service delivery Empirical Perkins et al 2009 Out-of-pocket costs for facility-based maternity care in three African countries Service delivery Empirical Brugha et al., 2010 Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia. Human resources for health Empirical Rudge et al 2010 Critical interactions between Global Fund- supported programmes and health systems: a case study in Papua New Guinea. All Empirical Edström et al 2010 The pipers call the tunes in global aid for AIDS: The global financial architecture for HIV funding as seen by local stakeholders in Kenya, Malawi and Zambia Governance Empirical Kutzin et al 2010 Conceptual framework for analysing health financing systems and the effects of reforms Health financing framework Conceptual Brugha et al., 2010 Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia Human resources for health Empirical Evans et al 2010 Health systems financing and the path to universal coverage Medical products Conceptual 44 45 Schäferhoff et al 2010 Financing maternal and child health — what are the limitations in estimating donor flows and resource needs? Service delivery Empirical Zere et al 2010 Health financing in Malawi: Evidence from National Health Accounts. Service delivery Empirical Atun et al 2011 Critical interactions between the Global Fund-supported HIV programmes and the health system in Ghana All Empirical Vujicic et al., 2011 GAVI: The Global Fund and World Bank support for human resources for health in developing countries Human resources for health Empirical Esser et al 2011 Does global health funding respond to recipients’ needs? Comparing public and private donors’ allocations in 2005–2007 Service delivery Empirical Gomez et al 2012 The effects of Global Fund financing on health governance in Brazil Governance Empirical Grepin et al 2012 HIV donor funding has both boosted and curbed the delivery of different non-HIV health services in sub-Saharan Africa Service delivery Empirical Tibebe et al 2012 Examining out of pocket payments for maternal health in rural Ethiopia: paradox of free health care un-affordability Service delivery Empirical Ejughemre 2013 Donor support and the impacts on health system strengthening in sub-Saharan Africa: assessing the evidence through a review of the literature All Empirical Warren et al 2013 Global health initiative investments and health systems strengthening: a content analysis of global fund investments. All Empirical Mussa et al 2013 Vertical funding, non-governmental organizations, and health system strengthening: perspectives of public sector health workers in Mozambique. Human resources for health Empirical Feng Zhao et al, 2013 Investing in human resources for health: the need for a paradigm shift Human resources for health Conceptual Mohanty et al 2013 Out-of-pocket expenditure on institutional delivery in India Service delivery Empirical Rahman et al 2013 Out-of-pocket expenses for maternity care in rural Bangladesh: a public-private comparison Service delivery Empirical Schwarz et al 2013 Out-of-pocket expenditures for primary health care in Tajikistan: a time-trend analysis. Service delivery Empirical Sidze et al 2013 Reproductive health financing in Kenya: an analysis of national commitments, donor assistance and the resources tracking process Service delivery Empirical Vassal et al 2013 Financing essential HIV services: a new economic agenda Service delivery Empirical Sambo et al 2013 Health financing in the African Region: 2000–2009 data analysis Services Empirical Grepin et al 2014 China’s role as a global health donor in Africa: what can we learn from studying under- reported resource flows? All Empirical 44 45 Bowser et al., 2014 Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening Human resources for health Empirical Shi et al 2014 Time trends and determinants of pharmaceutical expenditure in China (1990–2009). Medical products Empirical Omondi et al 2015 Effect of HIV/Aids donor funding on health system infrastructure in Siaya county health facilities, Western Kenya All Empirical Shaw et al 2015 Donor and Domestic Financing of Primary Health Care in Low Income Countries. All Empirical Mookherji et al 2015 Tracking Global Fund HIV/AIDS resources used for sexual and reproductive health service integration: case study from Ethiopia. Service delivery Empirical Shukla et al 2015 Out-of-pocket expenditure on institutional delivery in rural Lucknow Service delivery Empirical Moucheraud et al 2016 PEPFAR Investments In Governance And Health Systems Were One-Fifth Of Countries’ Budgeted Funds, 2004-14. Governance Empirical Garand et al 2016 Performance evaluation framework for government-sponsored health insurance programmes Health financing framework Conceptual McIntyre & Kutzin (2016) Health financing country diagnostic: a foundation for national strategy development Health financing framework Conceptual Atun et al 2016 Innovative financing for HIV response in sub- Saharan Africa Service delivery Empirical Govil et al 2016 Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India Service delivery Empirical Issac et al 2016 Out of pocket expenditure to deliver at public health facilities in India: a cross sectional analysis Service delivery Empirical Luboga et al 2016 Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level Service delivery Empirical Nattrass et al 2016 Changing donor funding and the challenges of integrated HIV treatment Service delivery Empirical Odekunle et al 2016 The impact of the US President’s emergency plan for AIDS relief (PEPFAR) HIV and AIDS programme on the Nigerian health system. service delivery Empirical Rout et al 2016 Out of pocket expenditure on surgical and nonsurgical conditions in Odisha Service delivery Empirical Servan-Mori et al 2016 A Performance Analysis of Public Expenditure on Maternal Health in Mexico. Service delivery Empirical Doherty et al 2019 If donors woke up tomorrow and said we can’t fund you, what would we do?” A health system dynamics analysis of implementation of PMTCT option B+ in Uganda All Empirical Ministère de la santé 2017 General accounts and health expenditures for malaria, HIV/AIDS and tuberculosis Governance Empirical 46 47 Stenberg et al 2017 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. Human resources for health Empirical Shen et al., 2017 Incentives to change: effects of performance-based financing on health workers in Zambia human resources for health Empirical Marty et al 2017 Taking the health aid debate to the subnational level: the impact and allocation of foreign health aid in Malawi Infrastructure Empirical Dieleman et al 2017 Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries Service delivery Empirical Lohman et al 2017 District Health Officer Perceptions of PEPFAR’s Influence on the Health System in Uganda, 2005-2011. Service delivery Empirical Lu et al 2017 Does foreign aid crowd out government investments? Evidence from rural health centres in Rwanda. Service delivery Empirical Zakumumpa et al 2017 Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria Service delivery Empirical Zakumumpa et al 2017 Alternative financing mechanisms for ART programmes in health facilities in Uganda: a mixed-methods approach Service delivery Empirical Mor et al 2018 Funding the Training of Future Health Services Researchers Human resources for health Empirical Micah et al., 2018 Donor financing of human resources for health, 1990–2016: an examination of trends, sources of funds, and recipients Human resources for health Empirical Oluwashina Afees Noah 2018 Effectiveness of External Financing for Health Infrastructure in Sub-Saharan African Countries Infrastructure Empirical Lukas Roth et al 2018 Expanding global access to essential medicines: investment priorities to sustainably strengthen medical product regulatory systems Medical products Empirical Borghi et al 2018 Health financing at district level in Malawi: an analysis of the distribution of funds at two points in time Service delivery Empirical Goli et al 2018 Out-of-pocket expenditure on maternity care for hospital births in Uttar Pradesh, India Service delivery Empirical Samia et al 2018 Assessing out-of-pocket expenditures for primary health care: how responsive is the Democratic Republic of Congo health system to providing financial risk protection? Service delivery Empirical Doherty et al 2019 Critical assessment of domestic health financing options in East and Southern Africa Health financing framework Empirical Mamdoo, 2019 Financing of medical products in South Africa Medical products Empirical Abdulmalik et al 2019 Sustainable financing mechanisms for strengthening mental health systems in Nigeria Service delivery Empirical Ithibu et al 2019 Domestic financing for HIV, TB and malaria in Global Fund High Impact Asia countries Service delivery Empirical 46 47 Kaiser et al 2019 Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study Service delivery Empirical Kanmiki et al 2019 Out-of-pocket payment for primary healthcare in the era of national health insurance: Evidence from northern Ghana Service delivery Empirical Mishra et al 2019 Out-of-pocket expenditure and distress financing on institutional delivery in India Service delivery Empirical Okungu et al 2019 Sustainability, equity and effectiveness in public financing for health in Uganda: an assessment of maternal and child health services Service delivery Empirical Yohannes et al 2019 Catastrophic out-of-pocket payments for households of people with severe mental disorder: a comparative study in rural Ethiopia Service delivery Empirical Jowett et al (2020) Assessing country health financing systems: the health financing progress matrix Health financing framework Empirical Lu et al., 2020 Development assistance for community health workers in 114 low-and middle- income countries, 2007–2017 Human resources for health Empirical Okunogbe et al., 2020 Global Fund financing and human resources for health investments in the Eastern Mediterranean Region Human resources for health Empirical Hughes et al 2020 Financing The Infrastructure Of Accountable Communities For Health Is Key To Long- Term Sustainability: A legal and policy review to identify potential funding streams specifically for accountable communities for health infrastructure activities Infrastructure Empirical Atim et al 2020 An assessment of domestic financing for reproductive, maternal, neonatal and child health in sub-Saharan Africa: potential gains and fiscal space Service delivery Empirical Gartaula et al 2020 Out of Pocket Expenditure on Health Service Delivery at a Tertiary Care Women’s Hospital: A Descriptive Cross-sectional Study Service delivery Empirical Ikilezi et al 2020 Effect of donor funding for immunization from Gavi and other development assistance channels on vaccine coverage: evidence from 120 low- and middle- income recipient countries Service delivery Empirical Nomura et al 2020 Tracking Japan’s development assistance for health, 2012-2016 Service delivery Empirical Vannakit et al 2020 Fast-tracking the end of HIV in the Asia Pacific Region: domestic funding of key population- led and civil society organisations Service delivery Empirical Zhao et al 2020 Development assistance for health and the Middle East and North Africa Service delivery Empirical Milo et al., 2021 Building a sustainable financial resource base to support health workforce training Human resources for health Empirical Boyce et al 2021 Global Fund contributions to health security in ten countries, 2014-2020: mapping synergies between vertical disease programmes and capacities for preventing, detecting, and responding to public health emergencies. Infrastructure Empirical 48 49 Ikilezi et al., 2021 Estimating total spending by source of funding on routine and supplementary immunisation activities in low-income and middle-income countries, 2000–17: a financial modelling study Medical products Empirical Kairu et al 2021 Examining health facility financing in Kenya in the context of devolution Service delivery Empirical Nomura et al 2021 Tracking Development Assistance for Health: A Comparative Study of the 29 Development Assistance Committee Countries, 2011–2019 Service delivery Empirical 48 49 Annex 2: Detailed Summary of the different elements by country, according to the national health accounts Country NHA year Health system elements financed Element Kenya 2015 Curative inpatient care Service delivery Curative outpatient care Service delivery Medical goods (non-specified by function) Medical product Preventive care Service delivery Health system financing administration Governance processes Governance Governance process Fixed capital formation Infrastructure Others Other Rehabilitative care Service delivery Other healthcare services Service delivery Ghana 2010 Curative care services (drugs, consumables) Service delivery Health administration and health insurance Governance process Capital formation for health care provider institutions Infrastructure Research and development in health Information systems Environmental health Service delivery Medical goods dispensed to outpatient Medical product Liberia 2015 Inpatient curative care Service delivery Outpatient curative care Service delivery Medical goods dispensed to outpa- tients Medical product Public health programmes Service delivery General government administration of health Governance process Technical Assistance Service delivery Capital formation for health care provider institutions Infrastructure Education and training Staff Research and development in health Information systems Environmental health Service delivery 50 51 Mauritius 2018 Gross capital formation (Infrastructure, machinery and equipment) Infrastructure Curative care, rehabilitative care, long-term care Service delivery Rehabilitative care Service delivery Medical goods (non-specified by function) Medical product Governance, and health system and financing administration Governance process Public health programmes Service delivery Mozambique 2006 Hospitals Infrastructure Ambulatory health service provider Service delivery Curative care service Service delivery Gross capital Infrastructure Personnel education and training on health Staff Retail sales and other medical material providers Medical product Public health programmes management and administration Governance process General health and insurance administration Governance process Institution providing health service Service delivery Namibia 2013 Public health programmes management and administration Governance process Governance, and health system and financing administration Governance process Inpatient curative care Service delivery Outpatient curative care Service delivery Medical goods Medical product Capital formation Infrastructure Rwanda 2006 Inpatient curative care Service delivery Outpatient curative care Service delivery Prevention and public health programmes Service delivery Pharmaceuticals and nondurables Medical product Health administration Governance process Capital formation Infrastructure 50 51 Seychelles 2013 Inpatient Service delivery Outpatient Service delivery Dental care Service delivery Pharmaceutical Medical product Health administration Governance process Capital formation Infrastructure Prevention and public health Service delivery Sierra Leone 2013 Machinery and equipment Infrastructure Infrastructure Infrastructure Information, education and counselling programme Staff Inpatient Service delivery Outpatient Service delivery Governance and administration Governance process Ancillary service Service delivery Tanzania 2010 Facilities development Infrastructure Curative inpatient care Service delivery Curative outpatient care Service delivery Medical goods (equipment and pharmaceutical products) Medical product Prevention and public health programmes Service delivery Governance, health system and financing administration Governance process Capital formation Infrastructure Others Other Sudan 2018 Government administration of health and social health insurance administration Governance process Health providers of preventive care Service delivery Infrastructure Infrastructure Unspecified health care providers Service delivery Eastern and Southern Africa 1998 Providers of pharmaceuticals and medical supplies Medical product Public health programmes Service delivery Outpatient care centres Service delivery Management of the health system Governance process Infrastructure Infrastructure 52 53 Zambia 2018 Health care system administration and financing Governance process Hospitals Infrastructure Ambulatory healthcare Service delivery Retailers and other providers of medical goods Medical product Preventive care Service delivery Medical goods (non-specified by function) Medical product Uganda 2012-2014 Infrastructure Infrastructure Ambulatory health care Service delivery Retailers and other providers of medical goods Medical product Preventive care Service delivery Health care system administration and financing Governance process Inpatient curative care Service delivery Outpatient curative care Service delivery Machinery and equipment Infrastructure Benin 2014-2015 Infrastructure Infrastructure Staff Staff Ambulatory health care Service delivery Retailers and other providers of medical goods Medical product Preventive care Service delivery Health care system administration and financing Governance process Inpatient curative care Service delivery Outpatient curative care Service delivery Machinery and equipment Infrastructure Ethiopia 2010 – 2011 Outpatient services Service delivery Inpatient Service delivery Public health programmes Service delivery Communicable disease prevention Service delivery Maternal and child health Service delivery General health administration Governance process Capital formation in the health sector Infrastructure Investment in construction Infrastructure Equipment and vehicle purchase Infrastructure Education, training and research Staff 52 53 Egypt 2007–2008 Pharmaceuticals and private clinics Infrastructure MOH facilities Infrastructure Public facilities Infrastructure Outpatient curative care Service delivery University hospitals Service delivery Primary health care Service delivery Tertiary care Service delivery Botswana 2013 – 2014 Hospitals Infrastructure Health centres Service delivery Curative care Service delivery Prevention and planning services Service delivery Management and administration Governance process Reproductive health Service delivery Nutritional deficiencies Medical product Burundi 2013 Health Centres Infrastructure Hospitals Infrastructure Pharmacies and dispensaries Medical product Administrative services Governance process Preventive care Service delivery Other Other Cameroun 1995 – 1996 Public health and private pharmacy Medical product Public health institutions Service delivery Private for-profit providers Service delivery Traditional healers Service delivery 54 55 Framework Title Assessment criteria Kutzin et al 2010 Conceptual framework for analysing health financing systems and the effects of reforms Financial risk protection Equity in financing Equity in use of resources Transparency and accountability Quality Efficiency Fiscal constraint Doherty et al 2019 Critical assessment of domestic health financing options in East and Southern Africa Financial protection Equity in financing (progressivity) Health risk cross-subsidization Efficiency - revenue pooling Efficiency - ease of revenue collection Efficiency - potential to reduce cost escalation Sustainability – revenue-raising potential Macroeconomic feasibility and stability Sustainability – political/social acceptability Garand et al 2016 Performance evaluation framework for government-sponsored health insurance programmes Long-term effectiveness Net income ratio Subsidies/total revenue Incurred claims per capita Poverty outreach ratio Client value Incurred expense ratio Incurred claims ratio Mortality rates Out-of-pocket spending on health Quality Benefit coverage rate Compliant ratio Promptness of payment to providers McIntyre 2007 Learning from Experience: Healthcare financing in low- and middle-income countries Feasibility Equity Efficiency Sustainability 54 55 McIntyre & Kutzin (2016) Health financing country diagnostic: a foundation for national strategy development Fiscal context Overall level of government spending Scope for increasing revenue Budget deficit Government debt Extent of prepayment mechanisms Compulsory vs voluntary Equity in contributions Extent of pooling Extent of fragmentation Financial risk protection Efficiency Murray & Frenk (1999) A WHO framework for health system performance assessment Equity Efficiency Green 1992 An introduction to health planning in developing countries. Technical feasibility Revenue generating ability Effects on service provision Equity Participation in decision-making Effect on multisectoral Carrin & Vereecke 1992 Economic analysis of community financing schemes Allocative efficiency Technical efficiency Equity Hsiao (1992) International Conference on Macroeconomics and Health in Countries in Greatest Need. Session II: Health Care Finance. Equity Efficiency Cost containment Consumer choice Revenue raising potential Barnum & Kutzin (1993) Public hospitals in developing Countries. Resource Use, Cost, Financing Efficiency Equity Revenue collection Annex 3: Detailed health financing frameworks and framework elements identified in literature 56 57 Berman & Chawla (1995) Resource mobilization methodological guidelines Revenue mobilization capacity Efficiency Quality of care and patient satisfaction Public accountability and community participation Shaw & Griffin (1995) Financing health care in Sub-Saharan Africa through User Fees and Insurance. Revenue generating ability Efficiency Equity Public-private sector collaboration Nolan & Turbat (1995) Cost recovery in public health services in sub-Saharan Africa Revenue generation potential Efficiency Equity Creese & Kutzin (1995) Lessons from cost-recovery in health Revenue generation potential Efficiency Equity Criel 1998 District-based health insurance in sub-Saharan Africa Revenue generation ability Level of funding Reliability and stability of funds Administrative efficiency Displacement effects Ease of use Technical feasibility Social and political acceptability Flexibility of management System effects Impacts on demand Impacts on utilization Impact on supply (public vs private) Impact on quality of care Equity effects Horizontal equity Vertical equity Effects on community participation Participation in decision-making Public accountability World Bank (1975) Health Sector Policy Paper Efficiency World Bank (1987) A World Bank Policy Study. Financing Health Services in Developing Countries. An Agenda for Reform Efficiency Equity 56 57 World Bank 1993 Better health in Africa. 1-218. Washington Efficiency Equity Sustainability Impact on healthcare utilization Revenue generating ability WHO (1978) Financing of health services: report of a WHO study group Revenue-generating ability Allocative efficiency Technical efficiency WHO (1993) Evaluation of recent changes in the financing of health services: report of a WHO study group Impact on the level and reliability of funding Efficiency Quality of care Equity Viability Impact on health status Zschock (1979) Health care financing in developing countries Efficiency Equity Displacement effect Impact on health care Van Balen and Mercenier (1991) Financing of the health service contribution to primary health care. Contribution to continuity of care Social solidarity viability Griffiths and Mills 1983 Health sector financing and expenditure surveys Allocative efficiency Operational efficiency Revenue generation ability Political acceptability Reliability Flexibility Displacement effects Impact on health service utilization and provision Effects on the economy Hoare and Mills 1986 Paying for the health sector Efficiency Equity Effects on supply and provision of services Displacement effects Parker and Knippenberg (1991) Community cost-sharing and participation: a review of the issues Increase resources Responsible and empowered local communities 58 Stryckman (1996) Comparative analysis of cost, resource use and financing of district health services in sub-Saharan Africa and Asia Increase resources Responsible and empowered local communities Jowett et al (2020) Assessing country health financing systems: the health financing progress matrix Health expenditure is based predominantly on public/compulsory funding sources The level of public (and external) funding is predictable over a period of years The flow of public (and external) funds is stable and budget execution is high Fiscal measures are in place that create incentives for healthier behaviour by individuals and firms Pooling structure and mechanisms across the health system enhances the potential to redistribute available prepaid funds