okore a. okorafor health economics unit, university of cape town, south africa
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Equitable Financing of Primary Health Care under a Fiscal Federal System: Swimming Against the Tide?. Okore A. Okorafor Health Economics Unit, University of Cape Town, South Africa. Background. Equity a major focus of health policy in post-apartheid South Africa - PowerPoint PPT PresentationTRANSCRIPT
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Equitable Financing of Primary Health Care under a Fiscal Federal System:
Swimming Against the Tide?
Okore A. Okorafor
Health Economics Unit, University of Cape Town, South Africa
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Background
Equity a major focus of health policy in post-apartheid South Africa Equitable distribution of financial resources (geographic)
Major shifts in resource distribution experienced between 1996 and 1996 - Centrally controlled allocation process
Slow-down in progress towards equitable distribution from 1996 Adoption of a fiscal federal system - provincial autonomy in
determining allocations to health services
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Objective
What is the implication of fiscal federalism on equity in health care financing? Case - PHC
Process of intergovernmental transfers Criteria for the size of transfers Intergovernmental arrangements and behaviour of sub-national
governments Community involvement Stakeholder influences / interests
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Methods
Qualitative Analysis Document reviews Interviews with government officials
Quantitative Trend in health spending (Equity) Deprivation index as proxy for level of “need” for health care Regression analysis used to assess relationship between expenditure
and health care needs
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Theoretical predictions for fiscal federalism and equity
Fiscal federalism: government system with different levels of government, each with fiscal authority and functions
Why fiscal federalism: Efficiency and welfare gains – assigning responsibility for each type of
public expenditure to the level of government that most closely represents the beneficiaries of these outlays
Democracy – greater representation of the community in decision making processes. Result of evolution towards a more democratic society
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Theoretical predictions for fiscal federalism and equity
Context: SNG is tasked with the responsibility for providing and financing the service (exclusively or jointly with other level of government)
Greater SNG autonomy in determining allocation to service creates greater scope for inequities Size of SNG own revenue relative to expenditure budget Nature and mix of transfers to SNG (Specific/General purpose) Differences in local preferences Constitutional provisions
Differences in SNG capacity
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Theoretical predictions & International Evidence
Equity best achieved if there is significant influence on resource distribution from the centre
Australia: PHC is responsibility of states and territories States and Territories generate ~ 40% of expenditure budget Transfers for health sector to states and territories in the form of SPGs Commonwealth has substantial influence in amount of resources allocated
to each state/territory
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
International Experience
Canada PHC responsibility of provinces Provinces generate most of expenditure requirements National legislation ensures that quality and quantity of services provided
in each province is comparable India
PHC responsibility of state States generate about 30% of budget expenditure Transfers for health to states in form of general purpose grants States have full autonomy in determining recurrent budget for PHC
Inequities in distribution of PHC resources
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
International Experience
Nigeria Local governments responsible for PHC LGs dependent on transfers from centre – GP grants Lack of accountability to state or federal government LGs have full autonomy in determining PHC expenditure
Inequities in distribution of PHC resources
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Primary Health Care
PHC approach Equity, Sustainability Acceptability Efficiency Active participation of the community that is being served
(decentralisation) Delivery through a district health system (decentralisation)
Parallels with fiscal federalism
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Results from the South Africa Case
Slow-down in progress towards equitable financing in health sector due to Provincial autonomy Lack of capacity to cope with the pace of reallocations
Provinces have maintained autonomy in decision making around the financing of health and PHC (except for few health programmes that are funded through SPG)
Inequity in distribution of PHC allocations; but trend since 2000 shows shifts towards a more equitable distribution.
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Province Ranking % change in per capita PHC 2001/02 – 2007/08
Limpopo 9 88.0%
Eastern Cape 8 75.3%
KwaZulu Natal 7 33.5%
Mpumalanga 6 132.4%
North West 5 17.7%
Free State 4 66.7%
Gauteng 3 -22.7%
Northern Cape 2 91.1%
Western Cape 1 -4.45%
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
How?
Overwhelming political support for equity at all levels of government. No single unit can be credited with movement towards equity
Economic growth – increasing health budget
Key constraints Lack of absorptive capacity in areas of greater need Historical approach to budgeting Inter-agency relations Efficiency concerns becoming more pronounced!!
Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009
Conclusion
Trend in decentralisation within health systems PHC approach also subscribes to a district health system – decentralisation PHC approach subscribes to equity and universal coverage
Possible trade-off between decentralisation and equity. Possible trade-off between efficiency and equity
Challenge 1: Enough autonomy for SNGs to respond to the preferences and needs of communities, but sufficient central influence to ensure that people are not disadvantaged based on location.
Challenge 2: Develop sufficient capacity of all areas to effectively utilise resources allocated to them