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

COVID-19等传染病暴发可改变低收入和中等收入国家卫生筹资的水平和构成，为实现全民健康覆盖的进展带来风险和机遇。在资源匮乏的情况下，COVID-19的经济后果可能会威胁到国内融资的可持续性，而捐助者增加对大流行防范的投资可能会使援助远离基本服务，并降低援助与国家系统的一致性和协调性。然而，事实证明，COVID-19等冲击也能创造机会，推动积极的系统转型，一些国家正在探索新的卫生筹资途径，以加强获得与COVID-19相关的医疗服务。目前尚不清楚COVID-19带来的变化是否以及如何转化为全民健康覆盖的进展。拟议的研究利用了世界卫生组织监测全民健康覆盖进展情况的框架。该框架确定了三个监测领域：融资安排；效率与公平的中间结果；全民健康覆盖的服务覆盖和负担得起的卫生支出目标。我们的研究将这一框架应用于五个财政分权程度和收入水平不同的撒哈拉以南非洲国家的国家和地方卫生融资评估：坦桑尼亚、马拉维、赞比亚、塞内加尔和塞拉利昂。我们的研究描述了COVID-19之前和之后卫生筹资安排的演变，以及与卫生筹资和全民健康覆盖目标的效率和公平性有关的进展。这项研究利用了常规的家庭调查、政府和捐助者支出信息系统以及世界卫生组织和经济合作与发展组织的全球数据。这项研究有六个主要目标。首先，我们将描述一段时间以来政府、捐助者和家庭筹集的卫生资金水平，以及与传染病相关的RMNCH资金水平。这项分析将确定与政府资助相比，这笔资金是更多还是更少地依赖于家庭自付医疗费用，以及这种情况是否随着COVID-19的发生而发生变化。该分析还将评估COVID-19后是否有资金从RMNCH转移。其次，我们将研究卫生援助、妇幼保健和传染病援助与国家系统的一致性和协调性趋势，以及自2019冠状病毒病以来的任何变化。第三，我们将按时间来源描述地方卫生供资水平，以确定地方单位供资的时间变化。第四，我们将衡量卫生筹资的效率，即资金在实现全民健康覆盖目标方面得到最佳利用而不浪费的程度。我们将研究为什么一些地方单位比其他单位效率更高，以及收入、每1000人拥有的卫生设施数量和卫生资金来源是否重要。第五，我们将评估筹资公平性：根据收入水平和新生儿和五岁以下儿童死亡率负担，政府和捐助者保健资金以及家庭自付捐款在次国家单位之间的分配情况。第六，我们将通过评估次国家单位中这些变量之间的关联程度，探索效率与全民健康覆盖目标之间的关系。因此，我们将测试全民健康覆盖框架，并确定效率和公平是否是全民健康覆盖取得进展的良好标志。该研究将利用“倒计时2030”伙伴关系广泛传播研究结果、分析冲击背景下全民健康覆盖卫生筹资的分析工具包；并在撒哈拉以南非洲进行培训。我们将通过与资深研究人员的培训和配对，培养团队中早期职业研究人员的技能。

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.