This Outcome Statement summarizes the main recommendations from the Primary Health Care (PHC) Financing Forum for Eastern and Southern Africa (ESA) held on 21-23 March 2023 in Kigali, Rwanda through the Harmonization for Health in Africa (HHA) platform. The Forum was attended by 130 senior officials mainly from ministries responsible for finance and health, civil society organizations, development partners and regional and global institutions supporting PHC within the region.
The forum provided a platform for the participants to review and discuss progress, challenges, and opportunities to improve resource mobilization and financing to support more efficient and effective delivery of PHC services. The ultimate objective is to ensure increased and equitable access to quality and comprehensive health care services.
Importantly, by the end of this workshop, each government delegation has developed an action plan to improve PHC financing that reflects country-specific context and priorities. The expectation is that the country specific action plans will be further discussed, revised, and validated by the relevant government officials and partners within each country. The participating governments recognized the importance of investing in PHC as a key strategy for achieving Universal Health Coverage.
The below recommendations were agreed upon to improve PHC financing and spending.
1. Regular measurement and monitoring of PHC services and spending
Sustainable investments in PHC starts with a shared understanding of the meaning and functional boundaries of PHC. This will help in prioritizing, optimizing and sequencing PHC interventions. Delegates agreed that comprehensive and regular monitoring and measurement of PHC services, inflows, and expenditures by each government at all levels of care, including at the community level, is critical.
- Facilitate the development of national consensus, using a whole of government and whole of society approaches on the national definition as well as functional and programmatic boundaries of PHC to guide planning, budgeting, resource mobilization, and expenditures.
- To ensure evidence-based decision-making, develop robust mechanisms for tracking inflows, allocations, and expenditures on PHC based on national definitions while drawing guidance from international approaches and good practices. This may include elaboration of the PHC expenditures as part of national health accounts, or the use of programme-based budgeting or budget tagging.
- Make timely information about PHC financing and expenditures publicly available to improve transparency, accountability, and public participation in decision-making.
- Strengthen national and local data and information systems as well as quality assurance, monitoring and evaluation of PHC plans and budgets.
2. Increasing resources to invest in PHC services
Domestic public revenue is the most sustainable way to finance the provision of quality PHC services for all. Strengthening domestic revenue mobilization for the health sector including during emergencies and other shocks, as well as strategic allocation of available resources will continue to be a policy priority of governments in Eastern and Southern Africa. However, considering fiscal space constraints and recurring shocks, external financing may be used as supplementary funding especially in low and lower-middle income countries where government revenue is limited, debt distress is rising, and macro-economic volatility is high.
- Facilitate costing of a nationally defined PHC package and other health sector interventions to inform resource mobilization and annual budgeting.
- Recommit to increasing public investments in PHC to match estimated need as per the costed plans and also to meet the 2001 Abuja Declaration for governments to allocate at least 15 per cent of their budgets to the health sector.
- Strengthen the engagement of PHC stakeholders including local authorities, civil society organizations, and private sector in policy processes related to revenue raising, pooling and strategic purchasing of health services in general and PHC in particular.
- Develop policies to reduce fragmentation across resource pools in the health sector and ensure pooled funds are directed towards PHC.
- Crowd in domestic public financing including through progressive taxation, public-private partnerships for health and where feasible through mechanisms such as taxes on alcohol, tobacco, and sugar-sweetened beverages and earmarking the funds where such mechanisms do not risk reduction in other sources of revenue.
- Design robust PHC financing mechanisms such as provider payment schemes, capitation, performance/ results-based financing and direct facility financing so that resources are channeled to the most marginalized and hard-to-reach areas.
- Strengthen mechanisms for financing PHC services during emergencies considering recurrence of shocks such as health emergencies, droughts, cyclones, and conflict.
- Explore external financing opportunities including but not limited to concessional loans, grants, Special Drawing Rights (SDRs), and debt-for-health swaps as supplementary financing. Such external funding should be aligned with the national health priorities, delivered through pooled funding mechanisms and made on-budget as much as possible.
- Wherever possible and as needed conduct cost-benefit and other relevant analyses to demonstrate the impact of PHC investment on the health system and the economy.
3. Enhancing efficiency, effectiveness, and equity of PHC spending
Sustainable investment in PHC is not just a question of more inflows, it is also about better use of all available domestic and external resources. By better emphasizing efficiency, value for money and equity in PHC spending, there is significant scope to increase coverage, quality, and impact of resources especially on the most vulnerable populations.
- Explore opportunities created by budgeting approaches such as programme/ output/ performance-based budgeting to improve allocative efficiency and ensure all elements of the PHC framework receive a fair share of available resources.
- Strengthen measures to ensure that the health workers needed to support PHC are available, with the required capacity and are well motivated. This should include community health workers who help in the delivery of PHC especially in underserved communities.
- Address bottlenecks that limit timely flow of funds to service delivery points and optimize relevant structures to ensure timely and efficient disbursement of funds.
- Periodically assess PHC budget implementation bottlenecks, especially in supply and procurement, and take measures to improve budget credibility and execution.
- Strengthen mechanisms for strategic purchasing including appropriate mix of provider payment mechanisms.
- Review or strengthen intergovernmental fiscal transfer mechanisms in decentralized settings and use health resource allocation formulae to improve equity in resource allocation within countries.
- Strengthen health sector governance systems for improved accountability, transparency, and public participation in PHC financing and spending at national, sub-national and local levels.
- Ensure other sectors like water, sanitation, education, and agriculture, which contribute to quality PHC get a fair share of available resources.
- Institutionalize mechanisms for bringing more value for the money invested in health, including regular diagnostics to assess and improve cost-efficiency and effectiveness in procurement and delivery of PHC services.
4. The enabling environment for investing more and better in PHC services
Comprehensive national and health sector policies and plans that put the right level of priority on PHC as well supportive institutional frameworks underpinned by robust public financial management (PFM) systems are key enablers for improved funding, budgeting, and spending on PHC services.
- Regularly update national and health sector policies and plans to ensure they are oriented towards PHC, and they are costed to inform annual budgets and medium-term expenditure frameworks.
- Strengthen sub-national health systems, including on data and information, planning, forecasting and costing, supply and procurement, as well as reporting and accountability to enable last mile delivery.
- Strengthen partnerships and harmonization for PHC comprehensive approach, including measures for the strategic involvement of the private sector in PHC, including through enhancing the capacities of relevant ministries and departments to design, regulate, monitor, and evaluate public private partnership on health, and create clear and sustainable incentives to attract private investments in PHC.
- Foster a whole of government and whole of society approaches to PHC planning, budgeting and service delivery including through national multi-stakeholder dialogues and co-creation of interventions.
- Seize opportunities offered by regional and global institutions to share insights and lessons learned and continue advocating for improved public investment in PHC.