16
16
June 2016
Documenting
good practices
and lessons
learnt
INNOVATIVE AND
DOMESTIC FINANCING
FOR HEALTH IN AFRICA
Acknowledgements 4
Foreword 5
Introduction 6
CASE STUDY ONE:
Health Trusts or Endowment Funds
The Zimbabwe AIDS Levy and Zimbabwe National AIDS ‘Trust Fund’ 8
CASE STUDY TWO:
Social Health Insurance
The Caisse Nationale de l’Assurance Maladie (CNAM) in Tunisia 11
CASE STUDY THREE:
Airline Levies
Airline Levies in Selected African Countries 16
CASE STUDY FOUR:
Consumption Taxes / Levies
The Alcohol Levy in Botswana 18
CASE STUDY FIVE:
Debt Swap Agreements
The Cote D’Ivoire’s Debt2Health debt swap agreement 19
CASE STUDY SIX:
Concessional Borrowing
Concessional Borrowing to Finance the health sector in Botswana 20
CASE STUDY SEVEN:
Estimate of revenue from innovative financing
Innovative Financing options for health in Tanzania 22
TABLE OF CONTENTS
Documenting good practices and lessons learnt
3
The African Union Commission extends its appreciation
to various resource persons who gave substantial input to
these case studies on innovative and domestic financing
for health in Africa. Special thanks to Paul Booth,
independent consultant, and Professor Alan Whiteside,
CIGI Chair in Global Health Policy Professor at Balsillies
School of International Aairs for doing the groundwork
on these case studies.
Member States Experts, Regional Economic Communities
and development partners reviewed these case studies
during the AWA Consultative Experts Meeting in June
2016 deserve special recognition.
The support from the Global Fund to Fight AIDS, TB and
Malaria and the United Nations Foundation facilitated
the development of this case studies contained in this
report. Special thanks to Amina Egal and Shu-Shu Tekle-
Haimanot.
The sta from the Department of Social Aairs of the
African Union Commission namely Ambassador Olawale
Maiyegun, Dr. Marie-Goretti Harakeye, Sabelo Mbokazi,
Tawanda Chisango, Dr. Adiel Kundaseny Mushi and Dr.
Sheila Tamara Shawa closely worked with the consultants
to finalise the case studies.
ACKNOWLEDGEMENTS
4 Documenting good practices and lessons learnt
Significant strides have been made in strengthening
health systems and in addressing AIDS, TB and Malaria
in African countries. While some targets have not
been reached there is a critical need to address the
remaining challenges. The African Union set bold and
ambitious targets to end the three biggest diseases on
the continent in the Catalytic Framework to end AIDS,
TB and Eliminate Malaria in Africa by 2030. Reaching
these targets will require Member States to expand their
fiscal space for health in line with the strong political will
that has continued to keep health high on the continent’s
development agenda.
Innovative financing mechanisms provide interesting
examples of leveraging on domestic resources for health.
However they are not the the sole panacea for Africa’s
health financing resource challenges. While the revenue
raised is small by comparison to domestic funding
requirements, innovative financing can provide a steady,
sustainable and equitable way of generating additional
resources for health. These mechanisms should be
used to complement traditional government revenue
generation in the short term while governments work
to expand their revenue base. It is expected that African
countries can learn from these case studies on health
nancing and consider
their adoption depending
on their context. The case studies presented in this
report contain selected country specific examples on
expanding the fiscal space for health in Africa. The compilation
complements a study on Innovative and Domestic Financing
for Health that was commissioned by the African Union to
provide practical models, challenges, lessons learnt and
their applicability.
Examples prese
nted include an AIDS levy, airline levies,
alcohol levies, Debt2Health Debt Swap Agreements and
concessional borrowing.
Dr. Mustapha Sidiki Kaloko
FOREWORD
Documenting good practices and lessons learnt 5
Africa’s long term development framework, Agenda
2063 provides clear priorities for Africa’s structural
transformation. However the achievement of the set
aspirations will to a greater extend be predicated on
domestic resource mobilisation as a key sources of
financing for the continent’s development agenda. This
collection of case studies selected from the five African
Union regions explores how selected countries are evolving
innovative and domestic financing models that seeks to
expand the fiscal space for health. However it should be
highlighted at the outset that these mechanisms are not
a panacea for domestic health financing in the long term
but rather as short term mechanisms to complement
traditional government revenue generation while the tax
base is being expanded.
These selected initiatives from the continent are
representative of continental eorts to fast track universal
health coverage aspirations set out in continental policies
and frameworks. While many of the 54 AU Member States
have not met the bold and ambitious health targets set by
its leaders since 2001 political commitment has remained
high. The failure to meet these targets often obfuscate
the fact that by far domestic resources contribute to
Africa’s health much more than external support.
Health thus continues to be prioritised by African
leaders in the context of many legitimate competing
priorities. Agenda 2063 places the objective of realising
“healthy and well-nourished citizens” among the first
of the seven aspirations towards the attainment of ‘the
Africa we want.’ Africa’s health frameworks for the next
fifteen years that include the overarching Africa Health
Strategy and the Catalytic Framework, to end AIDS, TB
and Malaria in Africa by 2030 translate this objective into
concrete actions plans and business models. However
meeting these targets will require significant investment
in health, yet this comes during a period of plateauing
development partner support. It is in this context that the
African Union Member States are in the short to medium
term looking at innovative mechanisms to expand the
fiscal space for health.
While domestic health financing focuses on increasing
the revenue base in a bid to increase resources allocated
to health, it is critical to ensure that income collection
and spending is progressive rather than regressive.
Furthermore, financially prudent economic management
requires that sources for the fiscal space be implemented
in combination and the degrees of implementation
be determined in accordance with the local economic
environment. Creating a balance between the primary
domestic sources of increase in fiscal space for health
includes prioritising health within the existing allocation
of government expenditure, generating additional
government revenue through innovative sources of
funding and eciency spending and investments within
the health sector. The case studies in this collection
illustrates eective ways of increasing domestic financing
for health through improved allocation and innovative
financing.
INTRODUCTION
6 Documenting good practices and lessons learnt
Case Studies
Documenting good practices and lessons learnt
7
What is the health financing mechanism?
• An AIDS Levy – a 3% tax on the income of individuals, companies and trusts that is paid into the Zimbabwe National
AIDS Trust Fund (ZNATF) to finance activities of the national AIDS response.
Describe the mechanism?
• A financial endowment fund (or trust fund) is a donation of money or property to an institution that is tasked to
manage the financial asset in an investment fund. The initial endowment is invested so that it grows financially. This
enables the donation to have an impact over a longer period of time.
• Once the fund reaches a certain level of capitalisation a percentage of the investment can be accessed to fund
the operational costs or activities specific to the programme. The remaining funds are invested to augment the
endowment and to compensate for inflation.
• In a stricter sense the Zimbabwe AIDS Levy is technically not a trust fund or endowment as the revenue it generates
is spent as it is collected.
Introduced by Who, When and Where?
• The Zimbabwe National AIDS Trust Fund (ZNATF) – commonly known as the AIDS Levy – was established in 2000
through an Act of Parliament, the National AIDS Council of Zimbabwe Act.
• It is a local resource mobilisation initiative for Zimbabwe’s HIV response. The fund is one of the pathfinders in
domestic financing for health and its existence set an example for the recommendations (Article 50) of the AU
Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria (2012) that urges countries to
implement strategic investment approaches to health.
• The statutory levy is a 3% deduction from Pay as You Earn (PAYE) for individuals as well as 3% of income tax levied
on corporates.
• The levy is collected monthly by the Zimbabwe Revenue Authority (ZIMRA) and deposited into an account of the
National AIDS Council (NAC) for independent administration by ZNATF.
What is the rationale behind the tax levy?
• The burden of the AIDS epidemic had become severe and the resources available from government and other
players to address the challenges were limited.
• The Government of Zimbabwe faced with a worsening HIV & AIDS situation conceived the idea for AIDS levy in the
late 1990s.
• The AIDS Levy was established to finance the operations of key HIV and AIDS interventions through the National
AIDS Council (NAC).
• The fund was established as a “seed fund” into which donors were expected to contribute and augment available
national resources.
• The fund was founded partly due to the advocacy eorts of people living with HIV who lobbied for the establishment
of a dedicated AIDS-fund to meet their treatment and care needs.
How is it administered?
• In line with sound corporate governance principles the Fund is administered by the NAC board with clear stipulations
regarding its use to ensure that it is spent in a manner intended to achieve stated objectives.
• The board produces an annual work plan and budget which is then submitted to the Ministry of Health and Child
Care for approval. The Fund Administration also takes place under the guidelines and policies approved by the
Minister.
• The Fund has been decentralised through NAC structures at provincial, district and ward levels, where AIDS action
committees have been established. District AIDS Action Committees (DAACs) are the active components of the
decentralised structures where action plans have become the basis for disbursements of funds to ensure that the
response is tailor made to meet district needs.
CASE STUDY ONE:
HEALTH TRUSTS OR ENDOWMENT FUNDS
THE ZIMBABWE AIDS LEVY AND ZIMBABWE NATIONAL
AIDS ‘TRUST FUND’
8 Documenting good practices and lessons learnt
AIDS Levy Collections 2009-2013
The table below shows the AIDS levy collection for the period 2000 to 2014. However due to hyper-inflation experienced
between 2007 and 2008, the annual revenue collected was distorted.
Year Annual revenue
(million USD / ZIM $)
As % of NAC
expenditure
As % of GDP
2000 $793,903 (Zim $) 12.3% 0.3%
2001 $1,525,922 (Zim $) 11.4% 0.2%
2002 $2,835,887 (Zim $) 10.5% 0.2%
2003 $11,247,338 (Zim $) 12.6% 0.3%
2004 $92,622,847 (Zim $) 10.6% 0.4%
2005 $262,537,228 (Zim $) 8.5% 0.3%
2006 $5,648,585,976 (Zim $) 8.9% 0.3%
2007 $1,118,870,698,065 (Zim $) 15.2% 2.4%
2008 $347,482,953,678,240 (Zim $)
2009 $5,710,820 (USD $) 7.5% 0.1%
2010 $20,522,121 (USD $) 9.6% (estimate) 0.3% (est.)
2011 $26,459,054 (USD $)
2012 $32,640,678 (USD $)
2013 $34,236,005 (USD $)
2014 $35,5 million (USD $)
Funded activities
The pie chart below shows the allocation of the AIDS Levy between 2009 and 2012 to the following strategic activities:
antiretroviral medication (55%), prevention (11%), monitoring and evaluation and programme management (5%),
creating an enabling environment (4%), and administration and capital costs (25%). By law, 55% of the AIDS Levy is
allocated to the purchase of ARVs.
AIDS Levy budget allocations: 2009 – 2012
Analysis
• As of August 2015 about 815,000 of the country’s estimated 1,207,175 people living with HIV were enrolled on ART.
- 29% of these are domestically financed (195,000);
- Domestic funding for ART is pooled as follows: AIDS Levy (11%), Out-of-Pocket expenditure (13%), local NGOs
(4%) and for-profit companies (1%). The remaining 71% is donor funded [2012 National AIDS Spending Assessment
(NASA)];
- Although 55% of the AIDS Levy budget is allocated to ART, this is only sucient to purchase drugs for 11% of the
815,000 people on ART.
- The AIDS Levy generates only 15% of the country’s annual HIV funding needs.
55%
25%
11%
5%
4%
Antiretroviral medication
Administration and capital costs
Prevention
Monitoring and evaluation, program management
Creating an enabling environment
Documenting good practices and lessons learnt
9
Challenges
• The cabinet directive that 55% of funds be allocated to the purchase of ART is a strategic move in ensuring access to
medicines. This has however resulted in very limited resources being allocated to prevention and other interventions.
In 2014 the Levy collected $35.5 million and only $5.68 million (16%) was spent on prevention.
• While the AIDS levy has provided an alternative source of domestic financing for health it generates a small proportion
of the country’s funding requirements. The amount is very minimal in light of the huge financial investment required
for HIV interventions and other health responses.
• In spite of this the AIDS levy accounted for 11.38% ($311,9 million in 2015) of the total budget of the Ministry of Health
and Child Care. The AIDS Levy amounted to 0.82% of the total government budget ($4,340 million). However due
to the insucient amount of funds raised from the AIDS levy, the country still remains donor dependant for its
response.
• Funds may be aected by prevailing circumstances such as hyperinflation as experienced during the 2006 – 2008.
Furthermore in dicult times, authorities may place demands on the Fund for services from other ministries and
sectors.
• The AIDS Levy is seen as everyone’s fund, as such this leads to increased demands on the fund.
• The tax is only levied on individuals in formal employment (70% of Zimbabwe’s productive population are employed
in the informal sector) and companies. This means that wages and profits from the informal sector which account
for a huge proportion of the productive population is not levied.
• By financing the response, the NAC role of Coordination vs. Implementation becomes complex.
Conclusions
• The Zimbabwe AIDS Levy is considered as a regional best practice by SADC and UNAIDS for increased domestic
financing for health. It is a resourceful approach to ensuring self-sustainability and reducing aid dependency in the
HIV response.
• The AIDS levy sustained NAC activities through Zimbabwe’s 2007 to 2008 economic crisis, an indication that it
can be sustainable regardless of the prevailing circumstances. In spite of hyper-inflation and decreasing external
funding, Zimbabwe continued to accelerate enrolment onto ART, which reached 59% of those eligible by the end of
2010.
• The sustainability of the AIDS levy is demonstrated by its endurance over fourteen years.
Lessons Learnt
• Self-financing of the HIV response allows government to have greater autonomy in determining its priorities and
areas of focus.
• The AIDS Levy is a visible commitment on the part of government and its citizens to address national challenges.
• Transparency in managing the AIDS levy serves as a basis for attracting donor funds for other interventions.
Transparency on the utilisation of the fund is also essential for the policy makers, implementers and the populace.
• Periodic media updates on the utilisation of the Fund’s helps to promote accountability.
• Political commitment is important for mobilisation of resources to the Fund and implementation of desired
interventions.
• Whenever an additional tax burden is placed on workers, careful planning is required, including to solicit acceptance,
support and participation.
10 Documenting good practices and lessons learnt
What is the health financing mechanism?
• The Tunisian National Health Insurance Fund is a mandatory payroll contribution rate of 6.75% of earnings.
• Health care in Tunisia is financed through a combination of social health insurance, general government revenue,
private insurance and out-of-pocket payments.
• The CNAM contributory system has enabled the expansion of health insurance to 71% of the population.
• By law, the government guarantees free or subsidised health care services to low-income groups through two public
medical aid schemes- the free health care scheme and a reduced-fee plan.
What is the role of Social Health Insurance (SHI)
• Social Health Insurance (SHI) is one of several social protection mechanisms that address the equity of the financial
burden of health care. SHI increases access to health services for the underprivileged. SHI pools health risks across
all those who are insured and finances this through a combination of contributions from members, employers and
government.
• SHI ensures that access to health care is available to all, regardless of wealth, employment status, health condition
or geographic location.
• The primary objectives of social health insurance are:
- To provide health care that avoids large out-of-pocket expenditure;
- To increase appropriate utilisation of health services;
- To improve the health status of individuals.
Introduced by Who, When and Where?
• Social Health Insurance is primarily provided by the state, although several NGOs provide SHI at community level in
developing countries.
• SHI began in Germany in 1883 as a means to displace private financing for health in Western Europe during the late
19th century. It was adopted extensively in the Americas in the 20th century.
• The introduction of SHI is in line with the recommendations (Article 50) of the AU Roadmap on Shared Responsibility
and Global Solidarity for AIDS, TB and Malaria (2012) on strategic investments to health approaches.
The re-emergence of Social Health Insurance
• The low total health expenditure in many countries makes it dicult for governments to provide a minimum package
of health services to its population.
• Private expenditure, particularly out-of-pocket expenditure, fills the gap. But experience of critical illness results in
catastrophic outcomes for poor households.
• A heavy dependence on out-of-pocket expenditure also makes the financial cost a major barrier to accessing health
care. As a result, health service utilisation tends to be higher among the rich compared to the poor.
• Many countries are finding it increasingly dicult to adequately finance health care where the main source of
funding for health services is general tax revenue. This has led international policy makers to recommend SHI as an
alternative health financing mechanism.
• In 2005, the World Health Assembly passed a resolution in support of the strategy of mobilising more resources for
health through risk pooling to increase access to health care for the poor and deliver quality health care in all its
member states, particularly low income countries.
What is the problem that Social Health Insurance seeks to address?
• The question at the heart of healthcare financing is how national health financing systems can provide sucient
financial risk protection against the costs of healthcare for the whole population.
• SHI falls within the concept of risk-pooling where all individuals and households in a society share the financing
of total healthcare costs. In such cases, the larger the degree of risk-pooling in a health financing system, the less
people will have to bear the financial consequences of their own health risks, and the more they are likely to have
access to the care they need.
CASE STUDY TWO:
SOCIAL HEALTH INSURANCE
THE CAISSE NATIONALE DE L’ASSURANCE MALADIE (CNAM)
IN TUNISIA
Documenting good practices and lessons learnt
11
Social Health Insurance in Tunisia
In 2004, Tunisia reformed the health sector by creating Caisse Nationale d’Assurance Maladie (CNAM) through a merger
of health insurance and health benefits provided through the National Social Security Fund (CNSS) and National Pension
and Welfare (CNRPS). The reforms also enabled health services to be accessed through the private sector.
• CNAM is responsible for managing public health insurance plans, occupational disease pay-outs, injury compensation
and granting of sickness benefits.
• CNAM purchases health services from public and private providers, in one of the following three ways:
- Public sector: Outpatient care in public health facilities (including polyclinics outside of urban areas). About 75%
of CNAM beneficiaries chose to receive treatment in the public sector.
- Private sector: Outpatient care in private health facilities, following referral by a General Practitioner. Payment is
via CNAM, topped up with user co-payments.
- The reimbursement system: Inpatient and outpatient services accessed through a network of contracted care
providers, with payment reimbursed by CNAM (at set rates).
Introduced by Who, When?
• CNAM was created through legislation in 2004.
• The entity is administered by a board of directors and is subject to supervision by the Minister of Social Security.
Genesis of CNAM Social Health Insurance
• Tunisia introduced insurance coverage by first providing medical health insurance for civil servants and formal sector
employees and gradually extending this to additional groups.
• At the same time, the country placed strong emphasis on prevention programmes.
• The health system was dentralised from hospital-centred tertiary health services mainly in large urban areas to
extending coverage in geographically accessible primary health facilities that were physically and financially
accessible for the entire population.
• Finally, private providers were gradually incorporated into the health care delivery system.
What is the problem that this mechanism seeks to address?
Health financing reform in Tunisia was aimed at overcoming the following three key challenges:
1. High Household Out-of-Pocket (OOP) expenditure on health (including catastrophic health expenditure) for the
underprivileged:
- Despite success eorts in expanding the coverage of social health insurance (the free, subsidised and CNAM
health insurance schemes) the Tunisian healthcare system is still largely funded through direct out-of-pocket
payments;
- Still, 41% of health expenditure is borne directly by households as OOP expenditure;
- It estimated that the poorest households spend an average of 10% percent of their total OOP expenditure on
health services. This rises to 68% of OOP for the poorest 10% of the population.
2. The declining quality of the health care system (services, outcomes and infrastructure).
3. Significant investment required in order to address inequalities between urban and rural areas in health outcomes,
spending and in the distribution of health services.
Delivery System
Health care in Tunisia is delivered through public, parastatal, and private facilities. The public health system predominates
in service provision with 87% of all beds and over 55% of medical personnel found in public hospitals. However 40% of
CNAM expenditure (1138 million Tunisian Dinars) was spent in the private sector in 2009. This shows that the private
sector still plays a significant role in health service delivery.
12 Documenting good practices and lessons learnt
Coverage
About 99% of the Tunisian population has health care coverage, provided through various means that include the following:
- Approximately 71% through mandatory social security schemes (including CNAM). Some patients who can aord,
top up their social health schemes with private insurance;
- Approximately 7% is provided through free medical services;
- An estimated 21% is financed through reduced charges.
Financing Agents and Flows of Funds (2010)
Health care in Tunisia is financed through a combination of social health insurance, general government revenue and
private sector insurance as shown in the table below.
- Social Health Insurance (CNAM) rose from 27.7% in 2010 to approximately 30% in 2015. Government continues its
eorts to increase this share and CNAM accounts for an increasingly greater year-on-year share.
- The State through general government revenue accounts for 23.8% of the financial contribution.
- Out of pocket expenditure spending by households accounts for 41.2%, which is a larger proportion compared to
the other two financing agents.
- However, the past 5 years have seen a 4% reduction in OOP since 2010, down to 37% in 2015.Other forms of private
insurance accounts for 7%.
Spending on health care (2006 to 2012)
External resources (donor) account for less than 1% of the total health expenditure in Tunisia. Government spending on
health constitutes 7.3% of total governmental expenditure, an increase on the 6.3% spent in 2010.
Total Health Expenditure (THE) – public and private – as a percentage of GDP has grown from 3.2 % in 1980 to 7% in
2010. Total Health Expenditure has increased by an average of 12% annually between 1980 and 2008. The graph below
shows trends in health spending in Tunisia between 2008 and 2012.
Sources
Central Government
(21.0%)
MOH (covering FMAP)
(23.8%)
Public Providers (30.0%)
By Volumes,
66.0% of total volume
Outpatient: 92.0%
Inpatient: 8.0%
Private Providers (52.7%)
By Volumes,
34.0% of total volume
Outpatient: 84.0%
Inpatient: 16.0%
Para-Public Providers
(0.4%)
Private Pharmacies
(16.9%)
Public Enterprises
(14.1%)
Private Incurers / Mutuals
(7.0%)
Private Firms
(13.6%)
Other Ministries
(Defende/Interior)
(0.4%)
Out-of-pocket payments
(41.2%)
External
(0.1%)
Social Health Insurance
(27.7%)
Households
(51.2%)
Agents Providers
Documenting good practices and lessons learnt
13
Analysis
- Despite the mandatory payroll contribution rate of 6.75%, Social Health Insurance (including CNAM) provides
only 30% of Tunisia’s Total Health Expenditure (THE). Since 2011 the government of Tunisia has demonstrated
commitment to increase the contribution of SHI to Total Health Expenditure.
- In 2010, the Ministry of Public Health contributed an additional 23.8% towards Total Health Expenditure. This
amount was used to finance free and subsidised social health insurance (FMAP) provided to those not able to pay
CNAM contributions.
- In 2015 these two contributions combined contributed only 54% of total health expenditure (2015). This places
great pressure on households and exposes them to the risk of catastrophic health expenditure.
- At 37%, household out-of-pocket expenditure makes up the largest share of total health expenditure.
- However social health insurance reform since 2011 has seen OOP expenditure reduce from 42.5% in 2011 to 37% in
2015. Yet it remains a significant burden on households.
Challenges
- Health expenditure is considered to be ‘catastrophic’ if it constitutes more than 10% of household expenditure.
Catastrophic health expenditure (CHE) aects all socio-economic groups, but tends to be more concentrated
among the lower-income groups and those who are supposed to benefit from free or subsidised care.
- This case study has thus shown that the Tunisian social health insurance covers (CNAM and FMAP) do not provide
protection from CHE for all. Thus extending coverage of social health insurance will not necessarily lead to better
financial protection in health.
- To ensure protection from CHE, there is need to reinforce eective, rather than the nominal, coverage of social
protection mechanisms – particularly among lower-income groups.
OOP expenditure results from accessing care in the private sector due to overcrowding or drug shortages in the
public sector. This calls for the strengthening of the public health systems to prevent the population from having
to seek private care.
- While private healthcare providers help to overcome challenges in service delivery of the public health sector,
40% of CNAM expenditure which is quite a significant portion of the social health insurance budget is spent in the
private healthcare sector.
- Notably, the majority of CNAM beneficiaries (75%) seek care in the public healthcare system. While the private
health care delivery system constitutes only 13% of beds and 45% of medical personnel it received approximately
40% of CNAM expenditure in 2009.
US$0
20122006
Government Expenditures
2007 2008 2009 2010 2011
Tunisia: Trends in Health Spending
External Resources
Out of Pocket Expenditures
US$1,000
US$1,500
US$500
US$2,000
US$2,500
14 Documenting good practices and lessons learnt
Lessons Learnt
- Domestic financing for health requires political commitment and leadership. If a country is committed to
substantively expand its finance health coverage, this can be achieved. However, without political will and
leadership this can be a very daunting task.
- Strengthening of primary health delivery system and expanding PHC access to communities has contributed to
the Tunisian achievements.
- The success in Tunisia shows that it is possible to move quickly towards the goal of universal health coverage by
establishing an appropriate financing mechanism and changing consumer behaviour.
- The transparency of CNAM has been critical to its public acceptance and success.
- The dimensions of large-scale mandatory health insurance reform should not be underestimated when initially
implemented. Coverage expansion is complex and entails extensive, long-term financial commitments.
- The paradigm shift from focusing on ‘social security’ to ‘health insurance’ has enabled various agents in the
country to have a dialogue on the appropriate funding mix regarding primary health funding.
- The extensive growth of the private sector and the manner of its integration into the national healthcare delivery
system contributed to the significant growth in household OOP health expenditure. This growth and integration
could have been managed better.
- Regulatory and administrative capacity is critical to the successful expansion of health care coverage and must be
backed up by a commitment to provide access to quality health care services. The development of management
capacity within public hospitals and the promotion of participatory management will drive hospital performance
improvements.
- The development of Health Management Information Systems (HMIS) is essential. Tunisia has invested heavily in
information technology but continues to face extensive HMIS demands.
- The Tunisian experience has shown that it is not easy to increase the payroll contribution rate. The aim to reach
the ideal contribution rate should be gradual in order to avoid mistakes and mitigate negative repercussions of
any increases.
Conclusions
- SHI oers an important component of health financing as demonstrated by CNAM, however it faces formidable
challenges in providing coverage to populations with unreliable or limited incomes. These includes those working
in the informal sector and subsistence agriculture. Enrolling these populations requires substantial government
subsidies, which in turn are subject to fiscal constraints. Increasing health funding levels through the creation of
compulsory insurance contributions (SHI) faces the same macroeconomic constraints as do increasing general tax
revenues (Kutzin, 2001).
- While often viewed as a means to inject new resources into the health sector, the introduction of SHI typically leads
to the creation of new organisations for pooling funds, paying providers, and in some cases, even for providing
services. While this results in new revenues it also results in new costs, administrative and regulatory challenges
(Kutzin, 2001 and Carrin and James, 2004). The costs of collecting revenues can also be substantial both in the
informal and formal sector where non-enrolment and evasion are commonplace (Carrin and James, 2004).
- SHI can also have negative labour market eects, including formal sector workers moving into the informal sector
(Wagsta, 2007). Due to all these challenges, there need to increase public funding for health and to reduce OOP
health expenditure.
Documenting good practices and lessons learnt
15
Introduction
The 2008 High Level Taskforce on Innovative International Financing for Health Systems recommended that among
possible new sources of financing for health, countries should “extend the mandatory solidarity levy on airline tickets
to more countries.” Airline levy entails a small tax (commonly $1-2 for economy class passengers and $10 for business
class passengers) that is added to the price of outbound airplane tickets. In 2006 France became the first country to
implement an airline levy. The tax is intended to generate a stable and predictable source of revenue for supporting
developing countries in their eorts to achieve their development goals. In African countries that implement the tax,
the revenue generated is commonly used to fund domestic HIV responses. Since 2006, more than 30 countries have
introduced an airline levy. Many of the advanced economies who apply the airline levy use part of the revenue to finance
national contributions to international development. Between 2008 and 2013 approximately 50% of UNITAID funding
was derived from airline levies.
Implementation modalities
- The implementation of the ‘airline levy’ is coordinated by UNITAID – an International Drug Purchase Facility –
hosted at the WHO in Geneva.
- However, the decision to implement, the management of implementation and revenue collection is done at
country level.
What is the problem that this mechanism seeks to address?
- At the international level the airline levy provides sustainable funding to UNITAID to tackle ineciencies in markets
for medicines and diagnostics. This includes bringing new drugs to the market, ensuring the lowest possible prices
for drugs and diagnostics and preventing drug stock-outs.
- The fund is used to fund programmes for AIDS, Tuberculosis and Malaria in developing countries. In principle,
all levies represent a small fraction of the cost of travel and are not expected to negatively impact on passenger
trac volumes.
Where is the airline levy implemented?
- In Africa the following countries have implemented airline levies: Benin; Burkina Faso; Cameroon; Central African
Republic; Democratic Republic of the Congo; Cote d’Ivoire; Gabon; Guinea; Liberia; Madagascar; Mali; Mauritius;
Morocco; Namibia; Niger; Sao Tome and Principe; Senegal; South Africa and Togo. Other African countries
considering a similar mechanism include Chad, Kenya, Mozambique and Nigeria.
- Outside of Africa, Brazil, Chile, Cyprus, France, Luxembourg, Norway, Republic of South Korea, Spain and United
Kingdom also implement the levy.
How is it administered/implemented?
- Following the adoption of the levy through domestic legislation, airlines are instructed to collect and declare
funds generated from the tax.
- Generated revenue is then transferred to the national treasury, usually through the Ministry of Transport or the
Civil Aviation Authority.
- The tax is not applied to the airline but to passengers when they purchase their tickets (as a component of all
applicable airport taxes). It is levied on all passenger flights originating from countries that impose it.
What are the advantages of airline levy as a source of innovative financing?
- Economically neutral, equitable and transparent.
- Research has shown that it has no negative eect on air trac, airline jobs or profitability.
- Administratively simple and cost eective.
- Positive reception among passengers and tax payers – the levy is relatively a small amount and therefore it is not
felt by the clients.
CASE STUDY THREE:
AIRLINE LEVIES
AIRLINE LEVIES IN SELECTED AFRICAN COUNTRIES
16 Documenting good practices and lessons learnt
How much does it generate globally?
Over 70% of UNITAID’s long-term financing, approximately $250 million annually, comes from the airline levy in the
participating countries. The table below shows the contribution of participating countries between 2006 and 2012.
Members –
Africa
Domestic
flights
International
flights
Contributions:
2006 – 2012
Contributions:
2012
Cameroon €1 €4 $1,430,000 $412,000
Congo €40 (business class only) $1,090,000
Guinea $49,000
Madagascar €1 (business and 1st class) $30,000 $3,000
Mali
$928,000
Mauritius $8,741,000 $1,790
Niger
$281,000
Documenting good practices and lessons learnt
17
- Alcohol Levy also known as a “sin tax” is charged on the sale of alcoholic beverages.
- Funds collected finance programmes that seek to minimise the eects of alcohol abuse, public education,
rehabilitation and law enforcement measures.
What is the problem that the mechanism seeks to address?
- Alcohol abuse causes 2.5 million deaths worldwide (2010). Many of these could be prevented by reducing alcohol
consumption.
- Alcohol (and tobacco) are under-taxed in low- and middle-income countries while their consumption is growing.
The evidence shows strongly that increasing tax on alcohol and tobacco improves public health.
Evolution of the alcohol levy as a health financing mechanism
- The alcohol levy was introduced in November 2008 at a rate of 30% through the Levy on Alcoholic Beverages
Fund Order.
- During World AIDS Day 2008, a month after the alcohol levy was introduced, Botswana’s President Ian Khama
stated that “The continued abuse of alcohol is one of the greatest obstacles to Botswana’s Vision 2016 ideal of an
HIV free nation by 2016.”
- The levy was subsequently raised in 2010 to 40%, then 45% in 2013 and 55% in January 2015.
- The levy on alcoholic beverages is one component of a multi-faceted approach that, together, seeks to regulate
the availability, price, and marketing of alcohol in order to reduce consumption, especially heavy drinking.
- The policies and activities of the levy are managed by the Alcohol Levy Implementation Committee housed in the
Ministry of Health.
- Funds collected from this tax are used to support, among other things, public education and rehabilitation
programmes as well as law enforcement measures to combat alcohol abuse.
Why an alcohol levy- What is the situation in Botswana?
- Despite key successes, Botswana still has one of the world’s highest HIV burden.
- Donor funds peaked in 2008 but have been in decline since then.
- 70% of the national AIDS programme is funded by the Government.
- The ART programme has more than 90% coverage. This has resulted in a significant reduction in AIDS-related
deaths but with a huge financial investment.
- Only 10% of total expenditure in the AIDS response is allocated to prevention eorts resulting in interventions
lagging behind.
- Responding to the AIDS epidemic requires a predictable commitment of resources over the long term. At the
same time, there are many diverse health and development needs that compete for the same resources.
- Lifelong ART treatment requires long term sustainable financing mechanisms. The alcohol levy is part of eorts to
identify alternative sources of financing that contribute to the financial sustainability of the AIDS programme.
- The Government of Botswana considered a range of alternative financing options, and concluded that a levy on
alcohol was the least regressive, least distortionary and a measure linked at least in part to causation.
What results can the alcohol levy achieve?
- Since the introduction of the alcohol levy, US$79 million has been collected.
- Resources from the alcohol levy are distributed as follows, 45% to Ministry of Youth, Sport and Culture, 10% to the
Ministry of Health and 45% to the Government Consolidated Fund.
How was it implemented?
- High-level political commitment and visionary leadership was key in successful implementation.
- Extensive research prior to implementation including a report on the impact of the alcohol levy, comparison to
other interventions as well as consistent reviews to monitor its impact were undertaken.
- Legislative revision such as amendment of the Road Trac Act, separating the Trade and the Liquor Act in to two
Acts and drafting of the Traditional Beer Regulations provided a legal framework for the implementation of the
new measures.
CASE STUDY FOUR:
CONSUMPTION TAXES / LEVIES
THE ALCOHOL LEVY IN BOTSWANA
18 Documenting good practices and lessons learnt
What is the health financing mechanism or innovation?
- Debt2Health is an arrangement that enables developing countries to redirect debt repayments to domestic
investments in health.
- ‘Debt swap’ / ‘debt conversion’ was introduced to the health sector in 2007 by the Global Fund. Under individually
negotiated agreements, creditors relinquish a part of their rights to repayment of loans from a beneficiary country,
on the condition that the beneficiary country invests the freed-up resources into programmes approved by (and
performance managed by) the Global Fund.
- The Global Fund facilitates the negotiation of the ‘debt swap’ agreement. Since funds are disbursed through the
existing Global Fund performance-based system no new governance structure or administration is required for
Debt2Health reallocations.
- Debt2Health is an attempt to overcome weakened donor financing following the financial recession by bringing
together donors who might be struggling to meet their ODA promises and poorer countries who have considerable
outstanding debt so as to generate domestic funding for health. The diagram below illustrates the modalities for
the implementation of the Debt2Health Debt Swap Agreement.
Debt2Health debt swaps were piloted in Indonesia, Kenya, Pakistan and Peru.
- Germany has pioneered Debt2Health, with arrangements amounting to almost €120 million across Indonesia
(€50 million), Pakistan (€40 million), Côte d’Ivoire (€19 million) and Egypt (€6.6 million).
- Anything entitled to funding from the Global Fund can be financed through Debt2Health.
Côte d’Ivoire’s Debt2Health Debt Swap Agreement.
- The Global Fund facilitated negotiations between Côte d’Ivoire and Germany in 2010, making it the first African
country to benefit from Debt2Health. Under the agreement, Germany cancelled Côte d’Ivoire’s debt obligations
worth €19 million ($27 million). Côte d’Ivoire in turn invested half of this amount (€9.5 million) in national
programmes to combat HIV/AIDS.
- Côte d’Ivoire was required to transfer this €9.5 million amount to the Global Fund (in the form of cash or as a
promissory note).
The criteria for a country to qualify for Debt2Health are as follows:
• High disease burden
• Liquidity to invest in the counterpart fund
• An adequate mix of potentially convertible debt
• Good past performance of Global Fund grants
• Demonstrated need
• Potential and capacity for scale-up
• Potential for involvement of civil society
CASE STUDY FIVE:
DEBT SWAP AGREEMENTS
THE COTE D’IVOIRE’S DEBT2HEALTH DEBT SWAP AGREEMENT
The Debt2Health Mechanism in Action
Under Debt2Health, a creditor government (the “Creditor’) writes o a certain amount of debt owed by a
developing country with high debt and high disease burden (the “beneficiary”). The Beneficiary subsequently
makes the counterpart payment to the Global Fund. The Global Fund then disbyrses these funds to prevention,
treatment and care services for those in most need.
Creditor
Global Fund
Beneficiary
Debt cacellation
Counterpart
payment(s)
Funding of grants based on
performance based funding system
Documenting good practices and lessons learnt
19
The innovative financing mechanism in action
- The HIV/AIDS response in Botswana had, prior to 2008, been heavily focussed on providing HIV treatment and as
a result less focus was accorded to prevention.
- To address the gap in prevention the country sought technical and financial assistance from the World Bank to
help the country transition from an emergency response to a broader, more strategic and sustainable response.
- As an upper middle-income country, however, Botswana is excluded from access to the World Bank’s highly
concessional IDA lending programme.
- The government of Botswana negotiated a loan of US$50 million from the IBRD to finance the strengthening of
HIV prevention eorts as part of the Botswana National HIV/AIDS Prevention Support Project (BNAPS).
- In an attempt to improve the terms of a proposed IBRD loan the government of Botswana requested that part of
the loan involve a “buy-down” using donor funds.
- The IBRD loan “buy-down” mechanism was developed to increase the flexibility and concessionality of funding for
projects where it is justified by global public good or cross-border externalities.
- A “buy-down” combines a loan to a developing country with a donor commitment to pay (“buy down”) part or
all of the loan, with the “buy-down” component performance managed and debt “bought” only if predetermined
objectives are achieved
- In essence, the IBRD loan can become a grant if the loan is used to achieve negotiated results but will remain a
repayable loan where satisfactory results are not achieved.
What is the health financing mechanism?
- A concessional loan is a credit extended on terms substantially more generous than market loans. The
concessionality is achieved either through low interest rates below those available on the market (typically 1% to
7%). This can also be provided through generous lending terms such as grace periods, repayment terms and up-
front fees, or through a combination of the two.
- The loans are typically provided over long repayment periods of between 10 and 40 years and are commonly
provided by multilateral financial institutions. They are provided directly to national governments and usually for
the purpose of financing large-scale programmes in a particular sector such as health, infrastructure and education.
- The ‘concession’ component of the loan also commonly includes providing a proportion of the ‘loan’ in the form
of a grant. Under new terms recently negotiated by OECD member states (October 2015), concessional loans may
only be considered as Ocial Development Assistance (ODA) if at least 45% of the loan is provided in the form of
a grant.
- The ocial OECD definition of concessional lending in fact classifies giving by any of the major regional
development banks (African Development Bank, Asian Development Bank, and the Inter-American Development
Bank) and from the IMF and World Bank as concessional lending – with concessionality defined on the basis
of each institution’s own classification of concessional lending. [International Monetary Fund: External Debt
Statistics: Guide for Compilers and Users, June 2003 (2013 edition)].
- The World Bank provides concessional loans through dierent lending mechanisms depending on a recipient
country’s creditworthiness and income level. Loans to low-income countries are provided through the International
Development Association (IDA) – which is vested with the authority to provide financing at lower interest rates
and at more generous payment terms. Loans to middle-income countries are managed by the International Bank
for Reconstruction and Development (IBRD).
- During the most recent fiscal year (which ended June 30, 2015), IDA commitments totalled $19 billion (including
IDA guarantees), of which 13 percent was provided on grant terms. IDA has averaged $19 billion annually over the
three previous financial years. Since 1960, IDA has provided $312 billion to 112 countries.
- The IMF as well as Regional Development Banks have similar lending policies and mechanisms.
- The IMF provides concessional loans to low-income country member governments through the Poverty Reduction
and Growth Facility (PRGF). In 2012 the IMF adopted a strategy to establish an annual concessional lending
capacity of SDR 1¼ billion ($2 billion).
CASE STUDY SIX:
CONCESSIONAL BORROWING
CONCESSIONAL BORROWING TO FINANCE THE HEALTH SECTOR
IN BOTSWANA
20 Documenting good practices and lessons learnt
What are the advantages of concessional borrowing?
- Predictable and stable funding (a set amount is disbursed over a set number of years).
- Allows countries to gradually assume financial responsibility over a long period of time.
- Low transaction costs (low interest rates and up-front fees).
- Quick implementation (from application to approval can take between six months to two years.
What are the disadvantages of concessional borrowing?
- Must compete with other funding priorities at a national and multilateral level.
- The World Bank and ADB has funded infrastructure, energy, and public sector/ governance programmes more
than health.
Results of the IBRD loan “buy-down” in Botswana
- The IBRD loan for BNAPS leveraged a US$20 million contribution from the European Union Commission (EC) to
achieve a performance-based “buy-down” of part of the loan.
- The EC approved an additional $20 million in its next four-year Economic Development Framework (EDF-10,
2010-2014) to finance the buy-down of this IBRD loan. The financial impact of this amount eectively enabled
Botswana to access a zero-interest project loan to finance BNAPS and to receive roughly $3million toward the
principle repayment.
- The release of the additional $20 million from the EU was triggered by meeting performance objectives within
the project time frame. The performance objectives agreed upon were a subset of the project’s performance
indicators derived from the M&E framework, with funds scheduled for release based on the results of IBRD mid-
term and end-term reviews.
- The recently released BAIS IV sero-survey indicates positive progress with respect to improvements in access to
HIV testing services, knowledge levels, among other key areas.
- Botswana provided pathfinder learning on the innovative performance-based buy-down mechanism for other
IBRD countries in the region – including for the governments of Swaziland and Lesotho who thereafter adopted
similar loan “buy-downs” for their HIV/AIDS response.
Documenting good practices and lessons learnt
21
Introduction to health financing in Tanzania
• The United Republic of Tanzania is a low-income economy (a GNI per capita of $1,045 or less).
• 60% of Tanzania’s response to AIDS, TB and Malaria is sustained through external funding.
• Canada and Denmark are two of the largest bilateral donors of the country’s HIV & AIDS response, but have both
announced the withdrawal of funding by the year 2015.
• Tanzania is also the second largest recipient of the Global Fund grants.
- There is no GFATM commitment to health financing beyond the 2015 deadline.
- This led the Global Fund in 2013 to urge Tanzania “to fast-track eorts to establish a multimillion-dollar health
trust fund aimed at sustaining the country’s campaign to fight HIV & AIDS, tuberculosis and malaria.”
• Analysis by the Tanzania Commission for AIDS (TACAIDS) show that foreign assistance for HIV has declined by
nearly 50%, and is projected to decline further.
Tanzania’s ability to increase domestic financing for health through Innovative Financing?
• As part of its eort to implement Universal Health Coverage the Government of Tanzania commissioned Oxford
Policy Management to prepare an analysis of how the country could finance the introduction of UHC.
• The report – Fiscal Space and Innovative Financing for the Tanzania Health Sector
1
– includes an analysis of the
potential contribution of five innovative sources of financing to meet the financing gap that would make a minimum
package of UHC possible.
- Two financing gaps were considered: a ‘minimum funding gap’ and a ‘wider financing gap’
• The table below summarises the resources that could be available from each of these alternative funding mechanisms
each year on average for the next ten years.
- Were the Government of Tanzania to implement a combination of a Remittances Levy, Airtime Levy, Alcohol Levy
and Airline Levy as well as to implement private sector mainstreaming the total funding that this would generate
would amount to only 4% of the ‘minimum funding gap’ and 2.9% of the ‘wider financing gap’ – an amount of USD
$246 million per year.
- The combination of these levies “would be insucient to fill any of the financing gap”.
- This is prior to consideration of whether it is politically or technically feasible to institute these types of taxes on
the Tanzanian economy.
Potential Revenues from innovative financing for Health (10-year average)
$ Millions As a % of the ‘Wider
Financing Gap’
As a % of the ‘Minimum
Financing Gap’
Alternative Funding Sources (USD) $ 246 million -4.0% -2.9%
Alternative Funding Sources (TzSh) $ 461,173 million -4.0% -2.9%
Earmarked Taxation (million TzSh) 385,092 -3.3% -2.4%
Remittances Levy 2,084 -0.02% -0.01%
Airtime Levy
68,785 -0.6%
-0.4%
Alcohol Levy 256,381 -2.2% -1.6%
Airline Levy
57,842 -0.5%
-0.4%
Mainstreaming
76,080 -0.7%
-0.5%
Private sector mainstreaming
76,080 -0.7%
-0.5%
• The report identifies that eciency improvements alone could generate at least twice as much (‘minimum funding
gap’) and possibly three times as much (‘wider financing gap’) ‘fiscal space’
- Tanzania can move from operating at 70% eciency to 82% eciency by 2024/25.
- Doing so would close the health financing gap by 10%.
• Thus the priority for Tanzania should be on strengthening general government taxation and to pursue eciency
improvements, although some innovative financing interventions can prove complementary.
CASE STUDY SEVEN:
ESTIMATE OF REVENUE FROM INNOVATIVE FINANCING
INNOVATIVE FINANCING OPTIONS FOR HEALTH IN TANZANIA
1 Oxford Policy Management: Fiscal Space and Innovative Financing for the Tanzania Health Sector. December 2014.
Available at: http://apps.who.int/health_financing/events/2_opm_fiscal_space_tanzanian_health_sector.pdf
22 Documenting good practices and lessons learnt