The Challenge of Non-Communicable Diseases and Road Traffic ...

An Overview 53
some NCD prevention [79]. Many African LMIC
are heavily reliant on external financing. External
resources for health as a percentage of THE in 2010
ranged from 2 percent in Mauritius and Equatorial
Guinea to 63.8 percent in Malawi. External financing
is volatile and uncertain, and a big issue for SSA
is the fungibility of government spending and donor
spending. There is evidence of a strong substitution
effect, with donor funding for health substituting for
health financing by recipient governments, the effect
being largest in low-income countries [368]. Donor
funding for NCDs is negligible, comprising only
about 2-3 percent of overall development assistance
for health in 2007.
Some LMIC – notably Rwanda and Ghana – have
made significant progress in developing financing
systems towards universal coverage, although fragmentation
and sustainability can be a continuing
problem. Many people have little financial protection
against the high costs of health care. More than
half (51 percent) of THE in the WHO African Region
is private health expenditure (global average
37.1 percent) of which more than half (55.6 percent)
is out-of-pocket, ranging from 8.1 percent in
the Seychelles to 90 percent in Guinea-Bissau [367].
WHO estimates that if the proportion of THE that is
out-of-pocket is below 15-20 percent, the incidence
of financial catastrophe caused by such expenses is
negligible: in 2010, only 7 SSA countries were below
the threshold of 15 percent [369-370]. Only 5-10
percent of people in SSA are covered by social protection
in the event of lost wages during illness or
pregnancy [371].
Available resources must be used efficiently and
equitably to realize potential gains in health outcomes.
A study of Tanzania, Ghana and South Africa
found that although overall health care financing was
progressive in all three countries, the distribution of
service benefits favored richer people, despite illness
burden being greater amongst lower-income groups,
and access to necessary services was the main challenge
to universal coverage [372].
Responses
Many countries have embraced the goal of “universal
health coverage”, aiming to ensure equitable
access to effective health services (promotion, prevention,
treatment, and rehabilitation) when needed
and without incurring financial hardship for the
whole population. To achieve this, countries need a
health-financing system that raises sufficient funds,
protects people from financial impoverishment associated
with health care costs, and uses resources
efficiently [371, 373]. This requires balancing tradeoffs
among the populations, services, and costs that
can realistically be covered.
Moving towards universal health coverage, as for
example in Ghana, South Africa, and Tanzania, requires
less-fragmented financing arrangements, less
reliance on out-of-pocket payments at the point of
service, increased financial protection for people in
the informal sector, and more equitable allocation of
public resources [374].
Ways of raising additional resources for health include
better revenue collection, increasing the share
of government budgets for health, and more innovative
means such as increasing excise taxes on tobacco
and alcohol. As African countries with rich endowments
of natural resources largely do not have good
human development outcomes, including in health,
natural resource wealth-management should consider
both the long-term requirements for economic
growth when these revenues dwindle, as well as the
immediate need to increase public investment in
health, education, and social protection to cut poverty,
reduce inequality, and build human capital as
a key contributing factor to diversified growth over
the medium and longer terms [375]. International
aid may need to be restructured to better align incentives
and goals. Performance- or results-based financing
(RBF) which links funding to performance
has been promoted as a means of achieving this. It
has been used for example by the Global Fund in
HIV, TB, and Malaria programs [376] and the World
Bank as a way of incentivizing health workers and
health providers towards the achievement of health
goals. Overall, the evidence for the effectiveness of
these strategies in improving health care and health
in LMIC is mixed, and results depend on the design
of the intervention; for example, who receives payments,
the size of the incentives, the targets and how
they are measured, additional funding and support,
and contextual factors [377]. Rigorous evaluation of
a randomized study in Rwanda demonstrated large