The objective of this study was to evaluate the impact of health insurance on resource mobilisation, financial protection, service utilisation, quality of care, social inclusion and community empowerment in low- and lower-middle-income countries in Africa and Asia. A literature review was undertaken and 159 studies were included – 68 in Africa and 91 in Asia. Most African studies reported on community-based health insurance (CBHI) and were of relatively high quality, whereas social health insurance (SHI) studies were mostly Asian and of medium quality. Only one Asian study dealt with private health insurance (PHI). Most studies were observational, while four had randomised controls and 20 had a quasi-experimental design. In these studies, financial protection, utilisation and social inclusion were far more common subjects than resource mobilisation, quality of care or community empowerment. Strong evidence shows that CBHI and SHI improve service utilisation and protect members financially by reducing their out-of-pocket expenditure, and that CBHI improves resource mobilisation too. Weak evidence pointed to a positive effect of both SHI and CBHI on quality of care and social inclusion. The effect of SHI and CBHI on community empowerment was inconclusive and findings for PHI were also inconclusive because of a lack of studies. The authors conclude that health insurance offers some protection against the detrimental effects of user fees and a promising avenue towards universal health-care coverage.
Resource allocation and health financing
In this study, the authors argue that a better understanding of the impact of aid on both state capacity for, and elite commitment to, sustainable development has the potential to improve practices in the field of international development. This requires better empirical insight into how external funders interact with formal and informal institutions in the countries where they work, particularly in aid-dependent countries. Furthermore, it is critical to see aid as part of a spectrum of international exchange, rather than in isolation. This implies a significant research agenda, combining quantitative and in-depth qualitative analysis, as there are barriers for more informed political analysis to inform practice. Little analysis exists of how external funders, even where they do start adopting a political perspective, do influence local institutions and the people they work with. The authors review large research programmes on politics of international development, consider the role and impact of external funders’ political economy approaches, scan the literature on aid modalities, and discuss the practices of emerging external funders, particularly China.
The authors of this paper argue that at the sub-national level - where most health services are delivered - critical knowledge and capacity gaps exist, which prevent evidence from making a direct contribution to health plans and budgets. To remedy this problem, they propose an Investment Case Framework, which pairs locally led problem-solving analysis with quantitative techniques to inform local planning and decision-making. The framework allows for the development of locally appropriate strategies to overcome identified health system constraints and it estimates cost and impact should such strategies be implemented. The varied success of this initiative in terms of influencing annual plans and budgets reflects the political nature of resource allocation and the need to embed such approaches in the local policy process. To sustain evidence-based planning, the authors recommend a collaborative arrangement that allows researchers to address specific evidence gaps and health managers to focus on their core business of delivering universal health coverage.
The aim of this study was to model the cost-effectiveness in Uganda of combination antiretroviral therapy (ART) to prevent mother-to-child transmission of HIV. The cost-effectiveness of ART was evaluated on the assumption that it reduces the risk of an HIV-positive pregnant woman transmitting HIV to her baby from 40% (when the woman is left untreated) to between 3.8% and 25.8%. Compared with single-dose nevirapine, dual therapy and no therapy, 18 months of ART averted between 3.22 and 8.58 disability-adjusted life years (DALYs), at a cost of between US$34 and $99 per DALY averted. The corresponding figures for lifetime ART range from 11.87 to 31.6 DALYs averted, at a cost of between $172 and $354 per DALY averted. According to these findings, it appears ART is highly cost-effective for the prevention of mother-to-child HIV transmission, even if continued over the patients’ lifetimes. Given the additional public health benefits of ART, efforts to ensure that all HIV-positive pregnant women have access to lifelong ART should be intensified, the authors conclude.
The primary objective of this study was to identify decision criteria reported in the literature on healthcare decision-making. An extensive literature search was performed and, out of 356 articles assessed for eligibility, 39 were included in the study. Large variations in terminology used to define decision criteria were observed and 338 different terms were identified. The most frequently mentioned decision criteria were: equity/fairness (33 times), efficacy/effectiveness (28), healthcare stakeholder interests and pressures (28), cost-effectiveness (24), strength of evidence (20), safety (19), mission and mandate of health system (18), need (16), organisational requirements and capacity (18) and patient-reported outcomes (16). This study highlights the importance of considering both normative and feasibility criteria for fair allocation of resources and optimised decision-making. It may be used to develop a questionnaire for an international survey of health decision-makers on criteria, with the ultimate objective of developing sound multicriteria approaches.
The authors of this paper oppose the view put forward by some analysts that economic evaluations of antiretroviral therapy (ART) may be used to evaluate HIV treatment as prevention (TasP) programmes. ART outcomes and costs assessed in currently existing programmes are unlikely to be generalisable to TasP programmes programmes for several fundamental reasons, the authors argue. First, to achieve frequent, widespread HIV testing and high uptake of ART immediately following an HIV diagnosis, TasP programmes will require components that are not present in current ART programmes and whose costs are not included in current estimates. Second, the early initiation of ART under TasP will change not only patients' disease courses and treatment experiences - which can affect behaviours that determine clinical treatment success, such as ART adherence and retention - but also quality of life and economic outcomes for HIV-infected individuals. Third, the preventive effects of TasP are likely to alter the composition of the HIV-infected population over time, changing its biological and behavioural characteristics and leading to different costs and outcomes for ART.
In this study, the authors reviewed the available literature on modelled estimates of the cost of providing antiretroviral therapy (ART) to different populations around the world, and they suggest alternative methods of characterising cost when modelling several decades into the future. In past economic analyses of ART provision, costs were often assumed to vary by disease stage and treatment regimen, but for treatment as prevention, in particular, most analyses assume a uniform cost per patient. This approach disregards variables that can affect unit cost, the authors note, such as differences in factor prices (i.e., the prices of supplies and services) and the scale and scope of operations (i.e., the sizes and types of facilities providing ART). They go on to discuss several of these variables, and then present a worked example of a flexible cost function used to determine the effect of scale on the cost of a proposed scale-up of treatment as prevention in South Africa. Adjusting previously estimated costs of universal testing and treatment in South Africa for diseconomies of small scale, i.e., more patients being treated in smaller facilities, adds 42% to the expected future cost of the intervention.
The cost of a highly accurate, rapid diagnostic test for tuberculosis (TB) has been reduced by 40% under a new agreement between the US government, the Bill and Melinda Gates Foundation, and the health financing mechanism, UNITAID. GeneXpert is recommended by the World Health Organisation and it provides a two-hour diagnosis of TB, the TB/HIV co-infection, and drug-resistant TB. To date, the high unit cost of Xpert MTB/RIF cartridges has proven a barrier to their introduction and widespread use in low- and middle-income countries. According to the WHO Stop TB Partnership, 45 developing countries and those with a high TB burden will benefit from the price cut. Research suggests that increased use of the test in countries with high TB burdens could allow the rapid diagnosis of 700,000 cases of TB, and save health systems in low- and middle-income countries more than $18 million in direct costs. The test can be used outside of conventional laboratories because it is self-contained and does not require specialised training.
The primary aim of this research paper was to analyse interventions for the prevention of mother-to-child-transmission of HIV (PMTCT) included in HIV proposals approved for funding by the Global Fund to fight AIDS, Tuberculosis and Malaria. A total of 345 original HIV proposals approved for funding from Rounds 1 to 9 were reviewed according to the four components of the global PMTCT strategy. The researchers found that performance across the components varied. On one hand, prevention of unintended pregnancies in HIV-infected women (component 2) was the least represented, appearing in 34% of the proposals, while on the other, PMTCT (component 3) was present in approximately 90%. Component 2 was the only component that consistently increased throughout the Rounds, with signs of the greatest increase between Rounds 3 and 7. The authors call on countries to support comprehensive PMTCT interventions that are balanced across the four components. Their study highlights interventions that countries could capitalise on to scale-up PMTCT efforts as well as synergise efforts in linking with other global and national initiatives in maternal, reproductive and child health.
Health and education budgets are cut in times of financial crises despite the fact that the opposite should be happening, according to South African health department Director-General Precious Matsoso. Addressing the plenary at the 3rd People’s Health Assembly Matsoso said that while the country was supposed to be rolling out National Health Insurance (NHI), it had to do so with only R11-million per pilot district from Treasury. She argued that social services should not suffer when there is a crisis, the opposite should happen. Instead, she said, we see that when there is a financial crisis, there is a cut in social spending and health. Prior to this, Professor Di McIntyre, who is also a key NHI advisor to the health minister, reiterated that NHI was about the comprehensive reform of the health system. She said one of her key concerns while establishing NHI was the underfunding of the NHI pilot sites by Treasury and the “enormous pressure to protect the positions of the high income groups and private sector profits”.