Using costing to facilitate policy making towards Universal Health Coverage: findings and recommendations from country-level experiences.

As countries progress towards universal health coverage (UHC), they frequently develop explicit packages of health services compatible with UHC goals. As part of the Disease Control Initiative 3 Country Translation project, a systematic survey instrument was developed and used to review the experience of five low-income and lower-middle-income countries-Afghanistan, Ethiopia, Pakistan, Somalia and Sudan-in estimating the cost of their proposed packages. The paper highlights the main results of the survey, providing information about how costing exercises were conducted and used and what country teams perceived to be the main challenges. Key messages are identified to facilitate similar exercises and improve their usefulness. Critical challenges to be addressed include inconsistent application of costing methods, measurement errors and data reliability issues, the lack of adequate capacity building, and the lack of integration between costing and budgeting. The paper formulates four recommendations to address these challenges: (1) developing more systematic guidance and standard ways to implement costing methodologies, particularly regarding the treatment of health systems-related common costs, (2) acknowledging ranges of uncertainty of costing results and integrating sensitivity analysis, (3) building long-term capacity at the local level and institutionalising the costing process in order to improve both reliability and policy relevance, and (4) closely linking costing exercises to public budgeting.

Identifying Major Health-System Challenges in Developing Countries Using PERs: Equity is the Elephant in the Room.

Despite an unprecedented increase in official development assistance to health in the last 25 years, there is no systematic way to assess dominant patterns in health-system challenges and opportunities in developing countries. Developing a new global instrument for and by donors and development partners would be resource-intensive and cumbersome. In this article, we demonstrate that Public Expenditure Reviews (PERs) can be used to reveal such patterns. PERs are analytical reports financed and conducted by the World Bank that have been used for years to identify and prioritize country-specific health sector reform needs. In order to extend their use beyond the country level, a reading instrument is developed in the form of a questionnaire to systematically identify the different themes addressed in each PER. All PERs published over a period of ten years are reviewed for health sector content. A new database is created with data on 70 PERs, spanning 61 countries. Analysis of the data reveals dominant themes globally, patterns across development levels, and some regional variations. Our main finding is that issues related to equity strongly dominate and are relevant across all regions and income groups. In addition, the article highlights the usefulness of PERs beyond providing country-specific information. Without losing the country-focus and flexibility of PERs, thoughtful and minor investments in how Health PERs are conducted can create a relatively cheap and strongly operational instrument for building global knowledge bases on health sector needs and challenges.

The Case for Public Financing of Environmental Common Goods for Health.

Safeguarding the continued existence of humanity requires building societies that cause minimal disruptions of the essential planetary systems that support life. While major successes have been achieved in improving health in recent decades, threats from the environment may undermine these gains, particularly among vulnerable populations and communities. In this article, we review the rationale for governments to invest in environmental Common Goods for Health (CGH) and identify functions that qualify as such, including interventions to improve air quality, develop sustainable food systems, preserve biodiversity, reduce greenhouse gas emissions, and encourage carbon sinks. Exploratory empirical analyses reveal that public spending on environmental goods does not crowd out public spending on health. Additionally, we find that improved governance is associated with better performance in environmental health outcomes, while the degrees of people's participation in the political system together with voice and accountability are positively associated with performance in ambient air quality and biodiversity/habitat. We provide a list of functions that should be prioritized by governments across different sectors, and present preliminary costing of environmental CGH. As shown by the costing estimates presented here, these actions need not be especially expensive. Indeed, they are potentially cost-saving. The paper concludes with case examples of national governments that have successfully prioritized and financed environmental CGH. Because societal preferences may vary across time, government leaders seeking to protect the health of future generations must look beyond electoral cycles to enact policies that protect the environment and finance environmental CGH.

Common Goods for Health: Economic Rationale and Tools for Prioritization.

This paper presents the economic rationale for treating Common Goods for Health (CGH) as priorities for public intervention. We use the concept of market failure as a central argument for identifying CGH and apply cost-effectiveness analysis (CEA) as a normative tool to prioritize CGH interventions in public finance decisions. We show that CGH are consistent with traditional lists of public health core functions but cannot be identified separately from non-CGH activities in such lists. We propose a public finance decision tree, adapted from existing health economics tools, to identify CGH activities within the set of cost-effective interventions for the health sector. We test the framework by applying it to the 2018 Disease Control Priority (DCP) list of interventions recommended for public funding and find that less than 10% of cost-effective interventions unconditionally qualify as CGH, while another two-thirds may or may not qualify depending on context and form. We conclude that while CEA can be used as a tool to prioritize CGH, the scarcity of such analyses for CGH interventions may be partly responsible for the lack of priority given to them. We encourage further research to address methodological and resource challenges to assessing the cost-effectiveness of CGH intervention packages, in particular those involving large investments and long-term benefits.

Son preference in Indian families: absolute versus relative wealth effects.

The desire for male children is prevalent in India, where son preference has been shown to affect fertility behavior and intrahousehold allocation of resources. Economic theory predicts less gender discrimination in wealthier households, but demographers and sociologists have argued that wealth can exacerbate bias in the Indian context. I argue that these apparently conflicting theories can be reconciled and simultaneously tested if one considers that they are based on two different notions of wealth: one related to resource constraints (absolute wealth), and the other to notions of local status (relative wealth). Using cross-sectional data from the 1998-1999 and 2005-2006 National Family and Health Surveys, I construct measures of absolute and relative wealth by using principal components analysis. A series of statistical models of son preference is estimated by using multilevel methods. Results consistently show that higher absolute wealth is strongly associated with lower son preference, and the effect is 20%-40% stronger when the household's community-specific wealth score is included in the regression. Coefficients on relative wealth are positive and significant although lower in magnitude. Results are robust to using different samples, alternative groupings of households in local areas, different estimation methods, and alternative dependent variables.

Immunization in India 1993-1999: wealth, gender, and regional inequalities revisited.

Previously published evidence from the 1992-1993 Indian National Family and Health Survey (NFHS) on the state of childhood immunization showed the importance of analyzing immunization outcomes beyond national averages. Reported total system failure (no immunization for all) in some low performance areas suggested that improvements in immunization levels may come with a worsening of the distribution of immunization based on wealth. In this paper, using the second wave of the NFHS (1998-1999), we take a new snapshot of the situation and compare it to 1992-1993, focusing on heterogeneities between states, rural-urban differentials, gender differentials, and more specifically on wealth-related inequalities. To assess whether improvements in overall immunization rates (levels) were accompanied by distributional improvements, or conversely, whether inequalities were reduced at the expense of overall achievement, we use a recently developed methodology to calculate an inequality-adjusted achievement index that captures performance both in terms of efficiency (change in levels) and equity (distribution by wealth quintiles) for each of the 17 largest Indian states. Comparing 1992-1993 to 1998-1999 achievements using different degrees of "inequality aversion" provides no evidence that distributional improvements occur at the expense of overall performance.