'Highlight' Health financing for universal health coverage in the era of shocks, monitoring risks and opportunities in Sub-Saharan Africa

Infectious disease outbreaks, such as COVID-19 can alter the levels and composition of health financing in low and middle income countries presenting risks and opportunities for progress towards universal health coverage (UHC). The economic consequences of COVID-19, can threaten the sustainability of domestic financing in low resource settings, and increased donor investment for pandemic preparedness could risk displacing aid away from essential services, and reduce the alignment and harmonisation of aid with country systems. However, shocks, such as COVID-19, have also been shown to create moments of opportunity which can drive positive system transformation, with a number of countries now exploring new avenues for health financing to enhance access to COVID related care. It is currently unclear, whether and how the changes brought about by COVID-19 have translated into universal health coverage (UHC) progress. The proposed research draws on the World Health Organization framework for monitoring progress towards UHC. The framework identifies three areas for monitoring: financing arrangements; intermediate outcomes of efficiency and equity; and UHC goals of service coverage and affordable health expenditures. Our research applies this framework to assess health financing at the national and subnational levels in five Sub-Saharan African countries with varied degrees of fiscal decentralisation and income levels: Tanzania, Malawi, Zambia, Senegal and Sierra Leone. Our research describes the evolution of health financing arrangements before and after COVID-19, and progress in relation to efficiency and equity of health financing and UHC goals. This research draws on routine household surveys, government and donor expenditure information systems, and global data from the World Health Organzaition and the Organisation for Economic Cooperation and Development. The research has six main objectives. First, we will describe levels of health funding raised by government, donors and households, and the level of RMNCH funding relative to infectious diseases over time. This analysis will determine whether this funding is more or less reliant on household out-of-pocket payments for health care as compared to funding from government and if this has changed with the onset of COVID-19. This analysis will also assess whether there is displacement of funds away from RMNCH post COVID-19. Second, we will examine trends in the alignment and harmonisation of aid for health, RMNCH and infectious diseases with country systems and any changes since COVID-19. Third, we will describe the levels of subnational health funding by source over time to identify temporal variation in funding across subnational units. Forth, we will measure the efficiency of health financing, the degree to which funds are optimally used in terms of UHC goals, without wastage. We will examine why some subnational units are more efficient than others, and whether income, the number of health facilities per 1000 population and sources of health funding matter. Fifth, we will assess financing equity: the distribution of government and donor health funding and household out of pocket payment contributions across subnational units in relation to the income level and burden of neonatal and under five mortality. Sixth, we will explore the relationship between efficiency and UHC goals, by assessing the level of association between these variables across subnational units. We will thus test the UHC framework, and determine whether efficiency and equity are good markers of progress towards UHC. The research will use the Countdown2030 partnership to widely disseminate findings, analytical toolkits for analysing health financing for UHC in the context of shocks; and undertake training within Sub-Saharan Africa. We will develop skills among early career researchers in our team, through training and pairing with senior researchers.