Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa

Abstract

Background: The global focus on promoting Universal Health Coverage has drawn attention to the need to increase public domestic funding for health care in low- and middle-income countries. Objectives: This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends. Methods: Three case studies were conducted by different research teams using a common mixed methods approach. Quantitative data were extracted from official government financial reports and used to describe trends in general tax revenue, total government expenditure and government spending on the health sector and other sectors in the first decade of this century. Twenty-seven key informant interviews with officials in Ministries of Health and Finance were used to explore the contextual factors, actors and processes accounting for the observed trends. A thematic content analysis allowed this qualitative information to be compared and contrasted between territories. Findings: Increased tax revenue led to absolute increases in public health spending in all three territories, but not necessarily in real per capita terms. However, in each of the territories, the percentage of the government budget allocated to health declined for much of the period under review. Factors contributing to this trend include: inter-sectoral competition in priority setting; the extent of fiscal federalism; the Ministry of Finance’s perception of the health sector’s absorptive capacity; weak investment cases made by the Ministry of Health; and weak parliamentary and civil society involvement. Conclusion: Despite dramatic improvements in tax revenue collection, fiscal space for health in the three territories did not improve. Ministries of Health must strengthen their ability to motivate for larger allocations from government revenue through demonstrating improved performance and the relative benefits of health investments.

Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening

“…Chronic underfunding of public health has negatively influenced the ability of existing health systems in African countries to respond to healthcare needs [1], p. 249. In South Africa, despite increases in public healthcare utilisation due to the high burden of disease and increased patient load over the period 1997-2010, the public health sector fell from second to fourth in the list of spending priorities [2]. Consequently, major health system challenges occurred in this sector including negative staff attitudes, long waiting times, unclean facilities, medicine stock-outs, insufficient infection control and compromised safety and security of both staff and patients [3].…”

Government stakeholders’ perspectives on the family planning environment in three Nigerian cities: qualitative findings from the Nigerian Urban Reproductive Health Initiative (NURHI) Sustainability Study

“…Previous qualitative research has examined Nigerian government stakeholders' perspectives on FP programming and policies [18][19][20] and government stakeholders' perspectives on the long-term sustainability and financing of various health programs, including health systems strengthening and maternal and child health services [19,21,22]. Yet there has been little research on government stakeholders' perspectives on the FP environment and how actors influence the sustainability of programming efforts.…”

An unintended consequence of provider payment reform: The case of capitation grants in the National Health Insurance reform of Indonesia

“…In particular, the question of whether the expansion of the social health insurance programme, which causes inevitable increase in fiscal resources in the forms of tax revenues, grants, or subsidies, actually result in better financing capabilities of the government, is unsettling. For example, a recent comparative study of three countries in Africa (Kenya, Nigeria and South Africa) has concluded that the improvement of tax revenue collections in these countries did not improve the fiscal space for health due to other competing developmental priorities …”