raising revenues while managing expenditure growth: a ... · health financing policy, who fiscal...
TRANSCRIPT
Joseph Kutzin, Coordinator
Health Financing Policy, WHO
Fiscal Space, Public Financial Management, and Health
Financing
26-28 April 2016, Montreux, Switzerland
Raising revenues while
managing expenditure
growth: a balancing act for
sustainability and transition
2 |
1. Sustainability: two sides of the coin
Domestic revenue
mobilization (DRM)
Expenditure
management
More Money for Health
More Health for the Money
3 |
Growing attention to financial sustainability
and transition from aid
Recognition of limits of donor funding, especially given
global financial / economic situation
– Refining how aid is targeted, e.g. Development Continuum,
Equitable Access Initiative
– Addis Ababa Action Agenda: strengthen domestic tax systems,
crack down on tax avoidance, illicit flows
4 |
Response of global health community has
largely focused on revenues
Targets like $86/capita or 5% of GDP
Growing number of health programs and partners
exploring the same issues
– Domestic resource mobilization, “innovative financing”, donor
funding, investment cases…
– …for sustainability of their program (HIV/AIDS, NCDs, NTDs,
nutrition, RMNCAH, TB, malaria,…)
Although many are explicit about integrating with overall
health financing strategy (e.g. GFF, HIV strategy)
5 |
Some concerns
Insufficient differentiation between global advocacy and
how to approach finance/revenue issues at country level
– Global “gaps” may be useful for fundraising, but not clear that
this is a useful way to engage national finance ministries
– We can’t (or shouldn’t) be arguing that every important disease
needs its own tax and revenue stream
Sustainability is not only a revenue question; we have to
think about managing expenditures better
– “Can’t just spend your way to UHC”
6 |
Clarity on policy objectives
Health financing and related reforms should improve…
– Equity in the use of services relative to need
– Quality
– Financial protection
– Health outcomes
– Equity in funding the system
– Efficiency (in organization, service delivery, administrative
arrangements, …)
– Transparency and accountability
7 |
Interpreting “sustainable health financing”
from a health policy perspective
Fiscal sustainability applies to the public sector as a whole
– Changing resource allocation priorities can change extent to
which something can be “sustained”
– So it’s a bit slippery at the level of one sector, and even more so
for sub-sectors
Concept is not useful without reference to what you are
trying to achieve
– If budget balance per se is an objective, then just cut the budget
– So what are we trying to sustain? Sustainability is not
meaningful without reference to policy objectives
B A
Le
vel of goal att
ain
ment
Level of resource inputs
maximum attainable for
given resource input level
Adapted from P. Travis
An efficiency agenda is central to the ability of
governments to sustain progress on their
coverage goals
9 |
3. Bringing a “UHC perspective” to these
issues
10 |
What a “UHC lens” can bring to these
issues
Unit of analysis is the system, not the program or single
disease
– Assess progress at level of population, not for “scheme
members” or program beneficiaries
On revenue side, see health as part of overall public sector
– Focus on overall tax/revenue strengthening efforts
– Avoid fragmentation and “intra-competition”
Similarly with efficiency, need a whole system, whole
population unit of analysis
11 |
An opportunistic approach to “transition”
What’s real: many countries can expect a decline in aid
Therefore, countries need to:
– Strengthen domestic resource mobilization
– Improve efficiency to get more from the money they spend on
health
Whereas in those countries not experiencing transition…
– strengthen DRM and improve efficiency
Let’s use the momentum attached to transition to
reinvigorate efforts to do what we should be doing anyway
12 |
Essential to be clear on what are we trying
to sustain
Neither “health programs” nor even “health systems”
– These are means, not ends
Aim of policy is to improve performance (mix of health
system goals, as e.g. embodied in UHC) to the extent
possible subject to the constraint of living within our budget
Therefore, what we want to sustain is increased effective
coverage of priority interventions
13 |
Messages and implications for action
UHC implies a system-level unit of
analysis
Transition and sustainability is not
only about revenues; efficiency matters
Efficiency ≠ cost cutting: must ensure
accountability for results
Addressing inefficiencies
requires country-specific approach