Financing multisectoral engagement

152

primary care.17 Such dual programs will eventually be more widely offered in other countries and to other health professionals. A fundamental concern is to customize them to local needs and ensure their accessibility and relevance to people who work in PHC or who aspire to do so. Available tools include tuition support, options for on-the-job and on-line degree acquisition, and tangible benefits in compensation and career advancement.

+ Last and perhaps most important, countries need to build capacities for multisectoral stewardship at the highest policy level. This first involves understanding the training and other requirements for doing so effectively, a question that remains unresolved, despite recurrent efforts in many countries with varied approaches and uneven results. Top-level multisectoral stewardship also needs to be mirrored through the successive levels of the health system down to the local administrative level and the PHC front lines. Relevant skills—including intersectoral dialogue, advocacy, and communication—must be embedded within health worker training curricula.

The current context may provide an opportunity to launch ambitious reforms in this respect. Along with the global systemic disruption caused by COVID19, the era of the Sustainable Development Goals (SDGs) is one in which the complex interplay between health and development progress in other sectors has again come to the fore. There is growing acknowledgment of how action in other sectors influences health, and now there is an acute awareness that what happens in health can swiftly and overwhelmingly affect countries’ economic performance and every other part of life (Bennett et al. 2020; Hussain et al. 2020).

Valuing multisectoral benefits in resource allocation

The case for multisectoral action to strengthen PHC is clear. Only through multisectoral action can the PHC platform cohesively target the social determinants of health across sectors like education, nutrition, agriculture, housing, transport, and environment (Anaf et al. 2014; Public Health Agency of Canada 2007; Public Health Agency of Canada and WHO 2008).Capitalizing on the synergies across health and other sectors, however, will require governments to use new ways of promoting and financing win-win measures that can spur progress on multiple development goals at once (Marmot etal. 2008). Agrowing body of literature on frameworks can be used to guide governments

governments on multisectoral investment in health to support stronger PHC platforms (De Leeuw 2017; Glandon et al. 2018; McGuire et al. 2019; Rasanathan et al. 2017; Rasanathan et al. 2018).

Win-win taxes, such as those on products that harm health (notably tobacco, alcohol, sugary drinks, and salt in processed food), offer a clear example of an effective multisectoral investment. Such taxes provide one of the most cost-effective (and often cost-saving) approaches to reduce health-damaging product consumption, improve population health and individual productivity, and lower future medical treatment costs. These measures complement the promotive/preventive aspects of the PHC platform while making medium-term health financing more sustainable (Bloomberg Philanthropies 2019). Although earmarking funds on the expenditure side requires careful consideration of the trade-offs (Cashin, Sparkes, and Bloom 2017; World Bank 2017c) in some countries, these taxes have contributed directly to PHC. For example, the Philippines’ influential Sin Tax on alcohol and tobacco uses an earmark to fully subsidize the enrollment of the poorest 40 percent of the population and senior citizens in the National Health Insurance Scheme (Kaiser, Bredenkamp, and Iglesias 2016), which includes a benefits package for primary health care. In the first three years of earmark tax implementation, the budget for the Department of Health tripled (Kaiser, Bredenkamp, and Iglesias 2016).

Countries can also consider joint financing of specific interventions that further the PHC agenda: this modality typically involves one or more nonhealth sectors investing in health, based on evidence that the investment will also benefit its own sector. This financing model tends to be intervention specific. For example, a randomized controlled trial of school-based deworming treatment, partially supported by the education budget, reduced school absenteeism by one-fourth and was far more cost-effective than alternative mechanisms to boost school attendance (McGuire et al. 2019).

Similarly, voluntary, school-located programs, which often involve a partnership that includes joint financing between a local school system and a health department, have successfully increased the uptake for several vaccines (Cawley, Hull, and Rousculp 2010; Lindley et al. 2008).

Governments can also explore integrative financing by pooling or aligning resources across sectors to better link PHC coordination and other service provision. For example, Canada and New Zealand have implemented various jointly financed integrated health and social care sector models for older adults with complex health needs who live in community settings.

153

154

The evidence suggests that these programs have several positive multisectoral outcomes: they meet the elderly population’s social and health needs, lead to better health outcomes, and reduce costly and often inappropriate hospital and long-term residential care (Béland et al. 2006; Parsons et al. 2012). Joint financing can take place at various levels (national, regional, local) when two or more budget holders contribute to a single pool for spending on preagreed services or interventions, or by aligning resources to ensure joint monitoring of spending and performance but separate management of resources (McGuire et al. 2019).

Ministers of health can be at the center of the intersectoral dialogue, together with the ministry of finance, as they work together to identify and finance such interventions, breaking down the silos typical of more traditional decision-making on resource allocation. In LMICs, this approach marks a departure from a situation where the health sector often struggles to make the case for investing in health, sometimes because of a failure to highlight nonhealth benefits that might raise other sectors’ interest in health gains (De Leeuw 2017; Rasanathan et al. 2017). Cost-benefit analysis captures human welfare improvement benefits across all sectors in monetary terms. Thus, it may help make a more effective case for intersectoral partnership than cost-effectiveness analysis, which is conducted in individual sectors and can undervalue benefits beyond the health sector (Angevine and Berven 2014). Intersectoral priority setting can also increase the quality and quantity of public spending and ensure both value for money and equity (Dercon and O’Connell 2018).

Finally, with strong ministry of finance leadership, governments can facilitate a whole-of-government approach to proactively tackle the structural, social, and behavioral determinants of health (Davies et al. 2014; Stubbs et al. 2014; World Bank 2019a). This approach can make traditional governmental decision-making mechanisms more reflective of social diversity by promoting greater engagement of the private sector, civil society, communities, and individuals in health-related actions (WHO 2018e). The World Bank’s Human Capital Project consistently highlights the potential benefits of the whole-of-government approach (box 4.6).

New Zealand offers an illustrative example of an operationalized whole-ofgovernment approach. The country passed a “Well-being Budget” in 2019, whereby all ministries were asked to frame their funding requests based on how that funding would help improve intergenerational well-being. In addition, the budget statement explicitly recognizes that, while Maori and Pacific peoples account for only 22 percent of the population, they make up over 60 percent of avoidable hospitalizations; many admissions could