The global movement toward universal health coverage (UHC) is accompanied by requests for large increases in government health spending in some countries. This combined with the global economic situation and stagnant economic growth across many low- and middle-income countries make it more critical than ever to place health financing discussions firmly in the context of macroeconomic and fiscal realities. Unfortunately, there is often a disconnect in decision making, with key fiscal decisions made in the absence of a clear understanding on the one hand of the potential consequences for the health sector, and on the other, the consequences for the country’s macroeconomic and fiscal position of increasing or reallocating government spending. Constructive health financing policy dialogue aims to reach a common understanding between health sector leaders and central budget authorities about policy objectives for the health sector and the resources needed to achieve those objectives, how much priority will be given to health in the government budget, and how the health sector will be held accountable for using funds effectively. This common understanding should be built on a realistic picture of the country’s macroeconomic and fiscal context, the constraints and competing priorities in the budget-setting process. When ministries of health and ministries of finance have a common understanding of macroeconomic and fiscal constraints, discussions can focus productively on using funds within the potential health resource envelope in the most effective way to achieve health system objectives. This guidance note outlines the key components of the macroeconomic, fiscal, and public financial management context that need to be considered for an informed health financing discussion at the country level. The guidance note is organized around four sets of questions that are key to placing the health financing dialogue in the context of a country’s macroeconomic and fiscal context. Each section points to measures, resources, and analytical tools that are available to assist in answering these questions for a specific country. The guidance note draws on case studies from 11 countries moving toward or sustaining universal health coverage conducted as part of the Japan†“World Bank Partnership Program on UHC as well as from other country examples.

This manual is one in a series of methodological studies developed for the Office of International Health, U.S. Department of Health, Education, and Welfare, to foster health planning by host country personnel in less developed countries. It originally appeared in May, 1978 under the title "An Approach to the Study of Health Sector Financing in Developing Countries: A Manual." The present revised and updated version of the manual was completed in April, 1979. This manual presents an action-tested procedure for appraisal of health sector financing which may be used, with some local adaptations, to examine health sector financial resources. The guidance presented in the text of the manual, combined with the prototype data collection and tabulation arrangement in Appendix A, are sufficiently detailed to lead a host country health planner or financial specialist through the assessment process. For successful completion of such an evaluation, it is anticipated that a senior-level economist or public finance specialist would be available to assist the analyst, both in initial design and final interpretation of the results.

This paper examines the relationship between public financial management (PFM), the financing of health interventions, and health outcomes. Specifically, the paper econometrically tests whether the effect of PFM on under-five (U5) mortality depends on the relevance of public sector health financing. Employing OLS on a sample of 215 observations indicates that a one-unit increase in PFM quality is associated with a reduction in the U5 mortality rate with about 14 deaths per 1,000 live births. For countries that channel at least 75 percent of health expenditures through the government system, this rate increases to 17 deaths per 1,000 child births. Results are robust to using an alternative dependent variable, adding year fixed effects, a sensitivity test where the health financing threshold is varied, a falsification test that verifies whether findings are driven by unobserved governance aspects, a sample restriction, and the inclusion of different controls. Furthermore, the paper provides a comparative analysis for Latin America and Caribbean (LAC), a region that remains mostly overlooked in the literature. The findings for LAC are broadly consistent with the global sample, though less pronounced and without a differential effect for countries across the financing threshold. Overall, the evidence indicates that the pursuit of universal health coverage and the progress toward related SDGs will be costlier if enabling systems are not in place.

This project, based on the Public Expenditure and Financial Accountability (PEFA) data set, researched how PEFA can be used to shape policy development in public financial management (PFM) and other major relevant policy areas such as anticorruption, revenue mobilization, political economy analysis, and fragile states. The report explores what shapes the PFM system in low- and middle-income countries by examining the relationship between political institutions and the quality of the PFM system. Although the report finds some evidence that multiple political parties in control of the legislature is associated with better PFM performance, the report finds the need to further refine and test the theories on the relationship between political institutions and PFM. The report addresses the question of the outcomes of PFM systems, distinguishing between fragile and nonfragile states. It finds that better PFM performance is associated with more reliable budgets in terms of expenditure composition in fragile states, but not aggregate budget credibility. Moreover, in contrast to existing studies, it finds no evidence that PFM quality matters for deficit and debt ratios, irrespective of whether a country is fragile or not. The report also explores the relationship between perceptions of corruption and PFM performance. It finds strong evidence of a relationship between better PFM performance and improvements in perceptions of corruption. It also finds that PFM reforms associated with better controls have a stronger relationship with improvements in perceptions of corruption compared to PFM reforms associated with more transparency. The last chapter looks at the relationship between PEFA indicators for revenue administration and domestic resource mobilization. It focuses on the credible use of penalties for noncompliance as a proxy for the type of political commitment required to improve tax performance. The analysis shows that countries that credibly enforce penalties for noncompliance collect more taxes on average.