ThinkWell, Chennai, Tamil Nadu, India
WHO, Geneva, Switzerland.
BMJ Glob Health. 2024 May 29;9(5):e015216. doi: 10.1136/bmjgh-2024-015216.
The interplay between devolution, health financing and public financial management processes in health-or the lack of coherence between them-can have profound implications for a country's progress towards universal health coverage. This paper explores this relationship in seven Asian and African countries (Burkina Faso, Kenya, Mozambique, Nigeria, Uganda, Indonesia and the Philippines), highlighting challenges and suggesting policy solutions. First, subnational governments rely heavily on transfers from central governments, and most are not required to allocate a minimum share of their budget to health. Central governments channelling more funds to subnational governments through conditional grants is a promising way to increase public financing for health. Second, devolution makes it difficult to pool funding across populations by fragmenting them geographically. Greater fiscal equalisation through improved revenue sharing arrangements and, where applicable, using budgetary funds to subsidise the poor in government-financed health insurance schemes could bridge the gap. Third, weak budget planning across levels could be improved by aligning budget structures, building subnational budgeting capacity and strengthening coordination across levels. Fourth, delays in central transfers and complicated procedures for approvals and disbursements stymie expenditure management at subnational levels. Simplifying processes and enhancing visibility over funding flows, including through digitalised information systems, promise to improve expenditure management and oversight in health. Fifth, subnational governments purchase services primarily through line-item budgets. Shifting to practices that link financial allocations with population health needs and facility performance, combined with reforms to grant commensurate autonomy to facilities, has the potential to enable more strategic purchasing.
权力下放、卫生筹资和公共财政管理进程之间的相互作用——或它们之间缺乏一致性——可能对一个国家实现全民健康覆盖的进展产生深远影响。本文探讨了亚洲和非洲七个国家（布基纳法索、肯尼亚、莫桑比克、尼日利亚、乌干达、印度尼西亚和菲律宾）的这种关系，强调了挑战并提出了政策建议。首先，国家以下各级政府严重依赖中央政府的转移支付，而且大多数国家都没有被要求将其预算的最低份额分配给卫生部门。中央政府通过有条件赠款向国家以下各级政府输送更多资金，是增加公共卫生筹资的一种有希望的方式。其次，权力下放使通过地理分割使人口资金池化变得困难。通过改进收入分享安排实现更大程度的财政均等化，在适用的情况下，利用预算资金为政府资助的医疗保险计划中的贫困人口提供补贴，可以弥合这一差距。第三，各级预算规划薄弱，可以通过调整预算结构、建设国家以下各级的预算编制能力以及加强各级之间的协调来加以改善。第四，中央转移的延迟以及审批和支付手续的复杂程序阻碍了国家以下各级的支出管理。简化流程并提高资金流动的可见度，包括通过数字化信息系统，有望改善卫生支出管理和监督。第五，国家以下各级政府主要通过项目预算来购买服务。将做法从与人口健康需求和机构绩效相联系的财政拨款转变，并对机构进行改革以赋予其相应的自主权，有可能实现更具战略性的采购。
