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Reprioritizing Government Spending on Health : Pushing an Elephant Up the Stairs?Countries vary widely with respect to
 the share of government spending on health, a metric that
 can serve as a proxy for the extent to which health is
 prioritized by governments. World Health Organization (WHO)
 data estimate that, in 2011, health's share of
 aggregate government expenditure in the 170 countries for
 which data were available averaged 12 percent. However,
 country differences were striking: ranging from a low of 1
 percent in Myanmar to a high of 28 percent in Costa Rica.
 Some of the observed differences in health's share of
 government spending across countries are unsurprisingly
 related to differences in national income. However,
 significant variations exist in health's share of
 government spending even after controlling for national
 income. This paper provides a global overview of
 health's share of government spending and summarizes
 key theoretical and empirical perspectives on allocation of
 public resources to health vis-a-vis other sectors from the
 perspective of reprioritization, one of the modalities for
 realizing fiscal space for health. Theory and cross-country
 empirical analyses do not provide clear, cut explanations
 for the observed variations in government prioritization of
 health. Standard economic theory arguments that are often
 used to justify public financing for health are equally
 applicable to many other sectors including defense,
 education, and infrastructure. To date, empirical work on
 prioritization has been sparse: available cross-country
 econometric analyses suggests that factors such as
 democratization, lower levels of corruption, ethnolinguistic
 homogeneity, and more women in public office are correlated
 with higher shares of public spending on health; however,
 these findings are not robust and are sensitive to model
 specification. Evidence from case studies suggests that
 country-specific political economy considerations are key,
 and that results-focused reform efforts, in particular
 efforts to explicitly expand the breadth and depth of health
 coverage as opposed to efforts focused only on government
 budgetary targets, are more likely to result in sustained
 and politically-feasible prioritization of health from a
 fiscal space perspective.
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Assessing Fiscal Space for Health in NepalNepal has seen impressive improvements
 in health outcomes and has done well both in its rate of
 progress and relative to its income level. Infant mortality
 has been declining over the past five decades to 38.6 per
 1,000 live births in 2009. Similarly, maternal mortality has
 decreased to 380 per 100,000 live births in 2008. Life
 expectancy has been steadily increasing to 67 years in 2009.
 The rate of progress is better than those witnessed by
 neighboring countries. But challenges remain in addressing
 inequality, high and increasing out of pocket payments.
 Geographic and income-related inequalities in population
 health outcomes remain large and are increasing. For
 example, not only is the decline in infant mortality not
 uniform, some regions have seen an increase. The policy
 response to these challenges has been to expand free care
 services and pilot protection mechanism against the
 financial risk of ill health. There is growing demand to
 expand the package as well as the coverage of existing free
 essential health care to all Nepalese; to introduce new
 programs such as health insurance, and other similar
 initiatives This note identifies efficiency gains as the
 main potential source of additional fiscal space. The
 analysis presented herein indicates that improvement in
 health system efficiency i.e., getting more value for money
 is by far the most plausible option for realizing additional
 fiscal space for health in Nepal. As the note demonstrates,
 the prospects for additional resources for health from all
 other possible sources from conducive macroeconomic
 conditions, re-prioritization of health, external resources,
 and other health-sector specific sources is limited in
 Nepal. On the other hand, there are many indications of
 systemic inefficiencies in the health system of the country
 and the challenge would be to focus on identifying and
 implementing appropriate interventions to improve the
 situation and reduce waste. The note highlights some
 specific areas, such as those related to provider payments,
 drug procurement mechanisms, and hospital and district grant
 allocations whereby significant improvements in obtaining
 better value for money can be realized.
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A Public Expenditure Review for Paraguay : The Quest for Optimal Tax and Expenditure Policies for Shared ProsperityParaguay has achieved significant
 progress in terms of fiscal policy over the past decade.
 Despite this progress on fiscal reform, three major
 challenges remain: 1) a volatile macroeconomic environment;
 2) still insufficient fiscal resources; and 3) high levels
 of poverty and inequality. In light of these three
 challenges, the objective of this report is to examine the
 extent to which fiscal policy in Paraguay has contributed to
 the social progress of the past decade, and can serve the
 purpose of further reducing poverty and enhancing shared
 prosperity in the years to come. Overall, fiscal policy can
 contribute to containing poverty and inequality by buffering
 the negative impact of financial and economic crises on
 vulnerable parts of the population. Moreover, tax and
 expenditure policies that redistribute from high- to
 low-income households in a well-targeted manner can also
 contribute to these goals. The current structure of the tax
 system appears suboptimal in light of the identified
 challenges. Even though the reliance on indirect taxes
 insulates public revenues from economic volatility to a
 certain extent, it imposes high costs associated with
 sufficiency and equity of the system. Adequate taxation of
 the agricultural sector is needed to level the playing field
 for business development in all sectors and to address the
 insufficiency of taxes. While fiscal policy contributes less
 to poverty reduction and shared prosperity in Paraguay than
 in the other countries analyzed for this study, direct
 transfers are well targeted. Overall, Paraguay's fiscal
 system is less progressive than in other Latin American
 countries analyzed. Paraguay's reliance on indirect
 taxes makes its overall tax system regressive. The
 sufficiency and efficiency of social expenditures have to be
 considered within the context of fiscal prudence, which is a
 continuous task. This is especially important in light of
 the recent expansionary fiscal stance. Only if the
 Government is able to sustain fiscal prudence in the future,
 will it be able to maintain macroeconomic stability and performance.