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      Health financing at district level in Malawi: an analysis of the distribution of funds at two points in time


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          There is growing attention to tracking country level resource flows to health, but limited evidence on the sub-national allocation of funds. We examined district health financing in Malawi in 2006 and 2011, and equity in the allocation of funding, together with the association between financing and under five and neonatal mortality. We explored the process for receiving and allocating different funding sources at district level. We obtained domestic and external financing data from the Integrated Financial Management Information System (2006–11) and AidData (2000–12) databases. Out-of-pocket payment data came from two rounds of integrated household budget surveys (2005; 2010). Mortality data came from the Multiple Indicator Cluster Survey (2006) and Demographic and Health Survey (2010). We described district level health funding by source, ran correlations between funding and outcomes and generated concentration curves and indices. 41 semi-structured interviews were conducted at the national level and in 10 districts with finance and health managers. Per capita spending from all sources varied substantially across districts and doubled between 2006 and 2011 from 7181 Kwacha to 15 312 Kwacha. In 2011, external funding accounted for 74% of funds, with domestic funding accounting for 19% of expenditure, and out of pocket (OOP) funding accounting for 7%. All funding sources were concentrated among wealthier districts, with OOP being the most pro-rich, followed by domestic expenditure and external funding. Districts with higher levels of domestic and external funding had lower levels of post-neonatal mortality, and those with higher levels of out-of-pocket payments had higher levels of 1–59 month mortality in 2006. There was no association between changes in financing and outcomes. Districts reported delayed receipt of lower-than-budgeted funds, forcing them to scale-down activities and rely on external funding. Governments need to track how resources are allocated sub-nationally to maximize equity and ensure allocations are commensurate to health need.

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          Most cited references33

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          Development assistance for health: past trends, associations, and the future of international financial flows for health.

          Disbursements of development assistance for health (DAH) have risen substantially during the past several decades. More recently, the international community's attention has turned to other international challenges, introducing uncertainty about the future of disbursements for DAH.
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            Health expenditures, health outcomes and the role of good governance.

            This paper examines the relationship between country health spending and selected health outcomes (infant mortality and child mortality), using data from 133 low and middle-income countries for the years 1995, 2000, 2005, and 2006. Health spending has a significant effect on reducing infant and under-5 child mortality with an elasticity of 0.13 to 0.33 for infant mortality and 0.15 to 0.38 for under-5 child mortality in models estimated using fixed effects methods (depending on models employed). Government health spending also has a significant effect on reducing infant and child mortality and the size of the coefficient depends on the level of good governance achieved by the country, indicating that good governance increases the effectiveness of health spending. This paper contributes to the new evidence pointing to the importance of investing in health care services and the importance of governance in improving health outcomes.
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              What level of domestic government health expenditure should we aspire to for universal health coverage?

              Global discussions on universal health coverage (UHC) have focussed attention on the need for increased government funding for health care in many low- and middle-income countries. The objective of this paper is to explore potential targets for government spending on health to progress towards UHC. An explicit target for government expenditure on health care relative to gross domestic product (GDP) is a potentially powerful tool for holding governments to account in progressing to UHC, particularly in the context of UHC's inclusion in the Sustainable Development Goals. It is likely to be more influential than the Abuja target, which requires decreases in budget allocations to other sectors and is opposed by finance ministries for undermining their autonomy in making sectoral budget allocation decisions. International Monetary Fund and World Health Organisation data sets were used to analyse the relationship between government health expenditure and proxy indicators for the UHC goals of financial protection and access to quality health care, and triangulated with available country case studies estimating the resource requirements for a universal health system. Our analyses point towards a target of government spending on health of at least 5% of GDP for progressing towards UHC. This can be supplemented by a per capita target of $86 to promote universal access to primary care services in low-income countries.

                Author and article information

                Health Policy Plan
                Health Policy Plan
                Health Policy and Planning
                Oxford University Press
                January 2018
                27 October 2017
                27 October 2017
                : 33
                : 1
                : 59-69
                [1 ]Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK,
                [2 ]Chancellor College, University of Malawi, Zomba, Malawi P.O. Box 280 and
                [3 ]Malawi National Statistics Office, Malawi
                Author notes
                Corresponding author. Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. E-mail: josephine.borghi@ 123456lshtm.ac.uk
                © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 29 August 2017
                Page count
                Pages: 11
                Funded by: UNICEF 10.13039/100006641
                Funded by: Bill and Melinda Gates Foundation 10.13039/100000865
                Original Articles

                Social policy & Welfare
                sub-national,health financing,malawi,district,equity,child health
                Social policy & Welfare
                sub-national, health financing, malawi, district, equity, child health


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