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Trends and Drivers of Government Health Spending in Sub-Saharan Africa, 1995–2015

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Trends and Drivers of Government Health Spending in Sub-Saharan Africa, 1995–2015 Research BMJ Glob Health: first published as 10.1136/bmjgh-2018-001159 on 13 January 2019. Downloaded from Trends and drivers of government health spending in sub-Saharan Africa, 1995–2015 Angela E Micah, Catherine S Chen, Bianca S Zlavog, Golsum Hashimi, Abigail Chapin, Joseph L Dieleman To cite: Micah AE, Chen CS, ABSTRACT Key questions Zlavog BS, et al. Trends and Introduction Government health spending is a primary drivers of government health source of funding in the health sector across the world. What is already known? spending in sub-Saharan Africa, However, in sub-Saharan Africa, only about a third of all 1995–2015. BMJ Glob Health National income and government fiscal space are health spending is sourced from the government. The ► 2019;4:e001159. doi:10.1136/ important determinants of how much a country’s objectives of this study are to describe the growth in bmjgh-2018-001159 government spends on health. government health spending, examine its determinants and explain the variation in government health spending Handling editor Seye Abimbola What are the new findings? across sub-Saharan African countries. ► Country choices irrespective of income level, gov- ► Additional material is Methods We used panel data on domestic government ernment fiscal space or population structure explain published online only. To view health spending in 46 countries in sub-Saharan Africa more of the level of government health spending ob- please visit the journal online from 1995 to 2015 from the Institute for Health Metrics served in a country. (http:// dx. doi. org/ 10. 1136/ and Evaluation. A regression model was used to examine bmjgh- 2018- 001159). ► Individual country characteristics such as good gov- the factors associated with government health spending, ernance or the perceived levels of corruption in the and Shapley decomposition was used to attribute the public sector are important factors for understanding Received 8 September 2018 contributions of factors to the explained variance in differences in government health spending across Revised 8 December 2018 government health spending. sub-Saharan African countries. Accepted 17 December 2018 Results While the growth rate in government health spending in sub-Saharan Africa has been positive overall, What do the new findings imply? there are variations across subgroups. Between 1995 ► For countries in sub-Saharan Africa, as the attention and 2015, government health spending in West Africa of the global health community focuses on ways to grew by 6.7% (95% uncertainty intervals [UI]: 6.2% to stimulate domestic government health spending, an http://gh.bmj.com/ 7.0%) each year, whereas in Southern Africa it grew by understanding of individual country sociopolitical only 4.5% (UI: 4.5% to 4.5%) each year. Furthermore, context will be most critical. per-person government health spending ranged from ► Interventions that find a way to promote coun- $651 (Namibia) in 2017 purchasing power parity dollars to try ownership of the health-related Sustainable $4 (Central African Republic) in 2015. Good governance, Development Goals may yield greater success in national income and the share of it that is government generating more spending on health from the gov- spending were positively associated with government ernment in support of the goals. on September 26, 2021 by guest. Protected copyright. health spending. The results from the decomposition, however, showed that individual country characteristics made up the highest percentage of the explained variation world. In 2015, government health spending in government health spending across sub-Saharan African made up 59.7% (59.2%–60.0%) of the total countries. health spending globally, although it was Conclusion These findings highlight that a country’s only 34.4% (33.5%–35.2%) in sub-Saharan policy choices are important for how much the health Africa.1 While the devastating effects of the sector receives. As the attention of the global health HIV/AIDS epidemic and other diseases © Author(s) (or their community focuses on ways to stimulate domestic drew a great deal of attention and external employer(s)) 2019. Re-use government health spending, an understanding that funding to the subregion starting from the permitted under CC BY. individual country sociopolitical context is an important Published by BMJ. mid-1990s, recent changes have led to a driver for success will be key. 2 Institute for Health Metrics plateauing of external resources for health. and Evaluation, University Additionally, estimates of the cost of attaining of Washington, Seattle, the health-related Sustainable Development Washington, USA Goals (SDGs) have led to a renewed sense Correspondence to INTRODUCTION of urgency to rally and leverage all possible 3 Dr Angela E Micah; Government health spending is the primary resource avenues. These circumstances have amicah@ uw. edu source of health funding throughout the revitalised an interest in understanding and Micah AE, et al. BMJ Glob Health 2019;4:e001159. doi:10.1136/bmjgh-2018-001159 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001159 on 13 January 2019. Downloaded from tracking domestic government health spending in low-in- countries with the lowest levels of government health come and middle-income countries, and in sub-Saharan spending globally. Therefore, such an analysis is timely Africa in particular, as government health spending, both and important because it will provide information on the per capita and as a per cent of the total health spending main drivers of government health spending that policy- in the region, remain among the lowest globally. makers may use to guide the development of strategies to While there is an extensive literature tracking the meet country-specific health goals and the global SDGs. growth and determinants of health spending in high-in- come countries, especially countries belonging to the Organisation for Economic Co-operation and Devel- METHODS opment, the literature focusing on the determinants Data of health spending in low-income and middle-income We used health spending data extracted from the Insti- countries is relatively limited.4–11 There are databases tute for Health Metrics and Evaluation’s Global Health from international agencies and research institutes that Spending database.12 These health spending estimates track and characterise cross-country estimates of health are based on health spending by source data obtained spending globally and government health spending from the WHO Global Health Expenditure Database, in particular.12–16 Also, there exist in the literature a national health accounts and project-level data on devel- few studies on the determinants of government health opment assistance for health.13 26 These data disaggre- spending in low-income and middle-income17–21 coun- gate total health spending into four mutually exclusive tries. The studies on government spending on health categories—domestic government health spending, have examined factors such as national income, govern- prepaid private spending, out-of-pocket spending and ment fiscal space, population structure, health burden development assistance for health—for 188 countries or disease prevalence, and health system characteristics. from 1995 through 2015. In this study, we limited the Findings from these studies show that national income data set to 46 countries in sub-Saharan Africa, which and government fiscal space are important determinants are listed in table 2. We define domestic government of government health spending.8–11 20 22 23 In several spending on health as the aggregate value of transfers studies, no statistically significant association is found from government domestic revenue allocated to health between government health spending and population purposes, social insurance contributions and compulsory structure.20 21 24 The findings on the association between prepayment. government health spending and health system charac- We extracted gross domestic product (GDP) and teristics have been mixed.20 25 The majority of existing general (all-sector) government spending (GGE) esti- studies have focused on quantifying the magnitude of mates from the same database. These data are based on the change in government health spending associated data obtained from the International Monetary Fund, with a change in each factor, but this evidence is not the World Bank, the United Nations, the Maddison indicative of how much of the cross-country and time Project and Penn World Tables database. Data from the http://gh.bmj.com/ variation in government health spending is explained by various sources were combined using regression methods each factor. This gap is important to fill because while the previously developed for producing a complete GDP estimated association between a factor and government time series.27 The GDP, GGE and health spending data health spending may be large, the size of the change in are all reported in inflation-adjusted 2017 purchasing the factor over time may be small, such that this factor power parity adjusted dollars. We extracted data on may actually contribute very little to explaining the vari- tax revenue mobilisation from the Organisation of on September 26, 2021 by guest. Protected copyright. ation in government health spending. A decomposition Economic Cooperation Global Revenue database and analysis of associated factors provides evidence on the data on perceptions of corruption in the public sector contributions of each factor
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