2017年-世界发展银行全球_Fiscal_Space_for_Health_in_Malawi_and_Revenue_Potential_of_Innovative_Financing_69页_1mb

Summary of Fiscal Space for Health in Malawi and Revenue Potential of Innovative Financing

Core Content

This report analyzes the fiscal space for health in Malawi and explores the revenue potential of innovative financing mechanisms, particularly through the introduction of earmarked taxes. It outlines the current health financing landscape, macroeconomic context, and the feasibility of increasing domestic revenue for the health sector.

Main Goals and Objectives

The main objective of the health reforms is to increase access to quality health services through domestic financing, efficiency, and equity. The reforms are grounded in the principle of solidarity, where citizens pay according to their ability to pay, not need. These reforms include the establishment of a Social Health Insurance (SHI) scheme, creation of a Health Fund, decentralization of health service delivery, and review of institutional arrangements between the Government of Malawi (GoM) and the Christian Health Association of Malawi (CHAM).

Key Findings

1. Country Context

• Population and Demographics: Malawi's population grew from 3.6 million in 1960 to 16.3 million in 2015, with 85% in rural areas. The population is young, with almost half under 15 years, and the total fertility rate (TFR) is high at 4.4 children per woman in 2015.
• Health Service Delivery: Malawi has made progress in maternal and child health services but still faces significant challenges in service coverage and quality. For example, only 53% of the population has access to key maternal and child health services nationally, and there are inequalities between urban and rural areas.
• Macro-Fiscal Situation: Malawi's economy is expected to grow modestly at 3.7% between 2016 and 2018, but it faces a high fiscal deficit (4.3% of GDP in 2016/17) and total public debt (52.1% of GDP in 2016/17), limiting the ability to re-prioritize the budget for health.
• Health Financing: Health expenditure as a share of GDP is relatively high in Malawi compared to peer countries, but government health expenditure per capita is only $11.20 in 2014/15, less than one-third of total health expenditure per capita ($39.20). External financing accounts for a large portion of health funding, averaging $27 per capita annually, with 62% allocated to three diseases (HIV/AIDS, Malaria, Reproductive Health), leaving other health components underfunded.

2. Fiscal Space Analysis

• Conducive Macroeconomic Environment: The macroeconomic environment is weak, limiting the ability to expand fiscal space for health.
• Re-Prioritization for Health: Despite the GoM's commitment, re-prioritization is difficult due to high debt-service ratios, competing sectoral priorities, and increasing public wage bills.
• Generating Additional Resources for Health: Increasing domestic revenues through innovative financing and earmarked taxes is considered a viable strategy.
• Increased Health Sector-Specific Foreign Aid: While external financing is a major source, its declining trend and short-term nature pose challenges for long-term health strategies.
• Improved Efficiency in the Health Sector: The report highlights inefficiencies such as leakages (corruption, fraud), high human resource costs, low hospital service utilization, and sub-optimal intervention mix. Addressing these could significantly improve the efficiency of health spending.

3. Revenue Potential of Earmarked Taxes

• Fuel Levy: Introducing a health levy on fuel could generate significant revenue, but the analysis shows that the potential is limited due to the weak macroeconomic environment and existing storage levy.
• Motor Vehicle Insurance Levy: A health levy on motor vehicle insurance could generate revenue, with projections of up to MK8.4 billion annually over 2016/17–2021/22. The levy could be implemented through a Third Party Motor Compensation Fund (TPMCF).
• Extractives Industry: The potential for a health levy in the extractives industry is explored, with estimates of revenue generation based on production and tax data.
• Alcohol and Tobacco: Health levies on alcohol and tobacco are also proposed, with potential revenue estimates provided in the annexes.

4. Risks and Challenges

• Earmarked taxes reduce the flexibility of public finances and resource allocation.
• There is a risk that health budgets may be reduced if earmarked taxes are introduced.
• The informal sector's large size (89% of the labor force) and low wages make SHI implementation challenging.
• External funding is declining, especially after the 'Cashgate' scandal, reducing predictability and long-term planning.

Key Recommendations

• Broaden Tax System: Efforts to increase government spending in the health sector should be integrated into the broader tax system. Tax revenue as a share of GDP should be increased from 16.1% to 20%.
• Improve Efficiency: Enhancing efficiency in the health sector is the most viable option for increasing fiscal space. A dedicated study should be conducted to examine the sources of inefficiency, ways to address them, and actual potential savings.
• Strengthen Governance: To avert the decline in external financing, the Government of Malawi should regain the confidence of development partners by implementing robust governance and accountability systems.
• Reduce Fragmentation: Development partners should reduce fragmentation and increase predictability and flexibility in resource allocation.

Conclusion

The report concludes that while there is potential for increasing domestic revenue for health through earmarked taxes, the impact is limited due to the weak macroeconomic environment and the risks associated with reduced flexibility. Improving efficiency in the health sector and enhancing the predictability of external financing are critical for expanding fiscal space and achieving the health reform objectives.