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From inequities to fairness and accountability
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When well designed and sufficiently resourced, PHC financing mechanisms play an essential role in promoting and reinforcing values of fairness, equity, and accountability within the overall healthcare system. Value-based payment mechanisms, for example, reinforce provider accountability for population-wide health outcomes, including for poor and vulnerable people. Sufficient pooled resource mobilization plays a redistributive role, leveraging social resources for equitable service coverage. Likewise, fair, inclusive, and transparent design of explicit health benefits packages creates an equitable entitlement across the entire population; providers and the government, in turn, can be held accountable for ensuring this package is, in fact, delivered.
In this section, we consider four elements of PHC financing for fairness and accountability that this report has not previously discussed: + Financing to break down demand-side access barriers
+ Pro-equity and accountability in intergovernmental transfers
+ Transparency and accountability in planning and budgeting
+ Community engagement in resource allocation.
For truly equitable access and utilization, all PHC services must be free at the point of service. There is broad consensus that financial barriers to PHC services in LMICs (such as user fees) should be removed (WHO 2016). Nevertheless, financing reforms that are not backed by mobilization of additional resources and careful planning to compensate for simultaneous revenue loss and costs associated with increased utilization can cause their own problems, for example, a shift to informal payments, patients’ forgoing services altogether, or ad hoc or implicit rationing (McPake et al. 2011). This further highlights the importance of defining an explicit benefits package, as well as a fair and inclusive priority-setting process appropriate for the local context.
Even when PHC is free at the point of service, some populations may still face financial or nonfinancial barriers to access services. These barriers could include migrants or refugees who fall between the cracks of empanelment strategies; marginalized populations who are socially stigmatized or fear
judgment or abuse from health care providers; rural populations geographically distant even from outlying PHC facilities; or groups where the opportunity cost of accessing services (for example, missed work and wages) may discourage utilization. Understanding the drivers of the nonutilization of PHC services is critical for developing targeted interventions to improve equity and fill gaps in financial protection (Amurao 2016).
Financing mechanisms are not a panacea, but some approaches can ease these broader inequities and demand-side access barriers. Conditional cash transfers, often targeting poorer groups, can improve financial access to care even when the conditions are not explicitly tied to health. Transfer payments are often used for out-of-pocket payments (where they exist), travel costs, or childcare (Lagarde, Haines, and Palmer 2014). Voucher programs, especially common for antenatal care or delivery, can also help vulnerable groups to receive free care. Evidence shows they are associated with positive impact on the use of maternaland child health services (De Brauw and Peterman 2020; Hunter et al. 2017; Lagarde, Haines, and Palmer 2009) and nutritional status (De Groot et al. 2017). However, it is hard to attribute positive effects to these incentives alone, since other components may also contribute (Glassman et al. 2013; Lagarde, Haines, and Palmer 2009). Accountability through intergovernmental transfers
In highly decentralized contexts, conditions on intergovernmental transfers can help create accountability for sufficient financing and/or quality delivery of PHC at subnational levels. In Kenya, for example, the share of the national government budget allocated to health was greatly reduced after the devolution of health care responsibility to the county level. To restore priority for health in country budgets, the central government established a UHC conditional grant; local authorities (counties) must direct at least 30 percent of the budget to health to receive the grant (Cotlear, Alawode, and Muchiri 2020). In Nigeria, a recent reform through the BHCPF finances PHC from the federal government through a statutory transfer, moving away from unconditional block grants that had left PHC underprioritized and facilities with little operational funding. The statutory transfer protects funding for PHC by transferring funds to facilities for a basic package of essential PHC services. The statutory transfer also overcomes the common problem of funds budgeted but not disbursed; subsidization of enrollment aims to reduce the financial barriers for the most vulnerable in a country where 70 percent of total health spending comes from out-of-pocket payments (Cotlear, Alawode, and Muchiri 2020; Hafez 2018). The disbursement of funds is subject to receiving financial reports showing the source and use of funds in alignment with the agreed purpose, improvements in monitoring, and quality assurance criteria.
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Similarly, specific financing mechanisms can ensure equitable nationwide resources for PHC, given regional variations in wealth or other relevant population characteristics. Italy, for example, earmarks 38.5 percent of the value added tax (VAT) for a national equalization fund to help regions with lower revenue-raising ability provide the core benefits package (Cashin, Sparkes, and Bloom 2017). The Philippines uses an earmark on the Sin Tax levied on alcohol and tobacco to fully subsidize the enrollment of the poorest 40 percent of the population in the National Health Insurance Scheme (Kaiser, Bredenkamp, and Iglesias 2016),which includes a benefits package for primary health care. Transparent, participatory, and accountable planning and budgeting
Improving the allocation of resources will require strong measurement and an understanding of existing performance challenges. Improved budget transparency and better expenditure data can provide a picture of country performance and identify necessary financing reforms. Data on the current level and distribution of health spending are most useful when combined with data on health outcomes, service coverage data, and financial protection, disaggregated across gender and equity markers, where possible (WHO 2019b). Recent global efforts have sought to measure PHC expenditure in a comparative and standardized manner, but implementation and capacity for a standardized methodology is still advancing. One limitation is that the current approach covers only a narrow definition of recurrent expenditure for PHC (WHO 2019b). Accordingly, continuous investment in data systems, by governments and donors, will be essential to guide PHC reforms.
A robust strategic planning process for PHC (articulating a vision and charting a plan for achieving that vision through measurable goals), coupled with strong government leadership, can help shift resource usage to PHC. For example, Turkey’s Health Transformation Program, launched in 2003, aimed to develop a universal PHC-based delivery system funded through a unified social insurance system. In addition to strong economic growth, a key contributor to success was the iterative planning, implementation, monitoring and evaluation, and refinement of the reform, which drove more spending to health generally and PHC specifically (Johanson 2015). This process allowed the country to adapt to common pitfalls; policies are not always implemented as planned and strategic plans are often wish lists. Over the course of a decade, the program led to improved health outcomes, increased health service utilization (for example, increased per capita outpatient physician visits
