In this study, researchers developed a model to assess the impact of possible moves towards universal coverage in Tanzania over a 15-year time frame. The model estimated the costs of delivering public health services and all health services to the population as a proportion of Gross Domestic Product (GDP), and forecast revenue from user fees and insurance premiums. Findings indicated that expanded financial protection in Tanzania will have a significant effect on utilisation levels, especially for public outpatient care. Universal coverage, offering a minimum benefit package to the population through the two largest health insurance schemes, would require the share of government allocation to health to increase to 18% initially (driven largely by the health system strengthening costs required to support additional demand, combined with costs of expanding cover among the informal sector). Reserve funds from the National Health Insurance Fund (NHIF) could be used to finance universal coverage or additional resources could be generated through increases in the rate of value-added tax (VAT) or expanding the income tax base. The authors emphasise the fact that regulation of health care to control costs is paramount to the feasibility of universal coverage, as this affects the overall cost of expanding coverage as well as the extent of the revenue surplus available from the NHIF.
Resource allocation and health financing
In this paper, the authors examined individual preferences for willingness to pre-pay for health care and willingness to cross-subsidise the sick and the poor in Ghana, South Africa and Tanzania. Household surveys in the three countries elicited views on cross-subsidisation within health care financing. In South Africa and Ghana, 62% and 55% of total respondents, respectively, were in favour of a progressive financing system in which richer groups would pay a higher proportion of income than poorer groups, rather than a system where individuals pay the same proportion of income irrespective of their wealth (proportional). In Tanzania, 45% of the total sample were willing to pay for the health care of the poor. However, in all three countries, a progressive system was favoured by a smaller proportion of the most well off than of less well off groups. The three countries had different experiences of health insurance and this may have contributed to the above differences in expressed willingness to pay between countries. Building and ‘living with’ institutions that provide affordable universal coverage is likely to be an essential part of the learning process which supports the development of social solidarity.
In January 2012, The UK’s Department for International Development announced a fivefold increase in its support for programmes to control neglected tropical diseases (NTDs). However, the authors of this paper point to a growing body of research that highlights hazards associated with current modes of implementing NTD control strategies, including undermining already-fragile health care systems, facing serious logistical problems and medical risks, and contributing in administrative failure. They draw on fieldwork in Uganda and Tanzania to shows that the specific political, economic, and social contexts in which mass drug administration (MDA) programmes are rolled out profoundly affects the uptake of drugs for the treatment of some NTDs. Average drug uptake in 2010 was well below 50%, an issue which remains unaddressed. The authors call for governments to deal with NTDs in a sustainable way that will involve a range of factors, including behavioural change, and promote an integrated bio-social approach, with more adequate monitoring and surveillance.
Flows of development financing from the BRICs (Brazil, Russia, India, and China) to low-income countries (LICs) have surged in recent years. The authors of this paper found that, though there are some differences across BRICs, the philosophies of most BRICs for development financing differ from traditional external funders (donors) in three main ways: BRICs, with the exception of Russia, provide financial assistance based on the principle of ‘mutual benefits’ in the spirit of South-South cooperation, while Russia and traditional funders emphasise the role of aid in poverty reduction. Second, BRICs, particularly China, view policy conditionality as interfering with recipients’ sovereignty and tend to provide noncash financing as a means to circumvent corruption, whilst traditional funders view policy conditionality as a means to ensure efficient use of aid. Third, different emphasis is placed on how to ensure debt sustainability, with some BRICs giving a greater weight to microsustainability and growth while traditional funders paying more attention to long-run macrosustainability. This difference is, however, narrowing with BRICs increasingly appreciating the importance of overall debt sustainability and traditional funders the need for investing in physical capital and seeing results.
In this interview with Irene Agyepong, Regional Director of Health for Greater Accra, she attributes Ghana’s success in rolling out universal coverage to genuine political commitment as well as demand from society for change. She identifies three major challenges facing Ghana: poor capacity, loss of health workers who migrate overseas and lack of financing. She gives advice to other countries wishing to implement universal coverage. First, they should build a strong health system as well as technical and administrative capacity and make sure that they retain that capacity to support universal coverage. Second, governments and external funders must realise that leadership has to come from within the country – externally motivated change is unlikely to work. Third, context and history matter. Countries need to tailor their systems to fit their context and history. Overall, stakeholders should bear in mind that universal coverage is a long-term goal.
As the need for anti-retroviral therapy (ART) grows without commensurate increase in the amount of available resources, it is critical to assess the health and economic gains being realised from increasingly large investments in ART. This study estimates total programme costs and compares them with selected economic benefits of ART for an estimated 3.5 million ART patients in low-and middle-income countries whose treatment is co-financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Using 2009 anti-retroviral prices and ART programme costs, the authors estimate that the cost of maintaining these patients is US$14.2 billion for the period 2011–2020. This investment is expected to save 18.5 million life-years and return $12 to $34 billion to the economy through increased labour productivity, averted orphan care and deferred medical treatment for opportunistic infections and end-of-life care. These results suggest that, in addition to the large health gains generated, the economic benefits of treatment will substantially offset, and likely exceed, programme costs within 10 years of investment.
In this study, the authors argue that, in Ghana, Tanzania and South Africa, the regressivity of voluntary health insurance and out-of-pocket payments results from charging flat insurance premiums, ineffective systems to exempt poor groups and insufficient prepayment funding to cover the health care costs of the poor. The cost of health care is not the only barrier to health care access, as the authors found a wide range of affordability, availability and acceptability barriers, which affect poorer groups most severely. Changing the way in which health services are funded, particularly moving away from out-of-pocket payments and towards a greater reliance on prepayment funding mechanisms, will be necessary to address these inequities, they argue. However, explicit measures to address the full range of access barriers are also required.
Encouraged by the growing number of social protection mechanisms in the Africa region delegates from the 1st Pan-African Congress on Universal Health Coverage (15-17 November 2011) have drafted and adopted a declaration to create a “Movement for Universal Coverage for Health in Africa” or MUCH in Africa. The MUCH in Africa delegation consists of representatives from ministries of health, directors general, chief executives of health insurance schemes, chief directors, principal secretaries, academics, policy experts and researchers from twenty-seven (27) African countries and multilateral, bilateral, regional, development partner and civil society organisations. In consultation with countries and development partners, the new organisation will advocate for and catalyse action through constructive engagement and advocacy and push for universal health coverage as a reform agenda in African countries. They made a number of resolutions to improve health financing, health systems and collaborative research in Africa.
Total health care financing in South Africa is progressive, as richer socio-economic groups spend more of their consumption expenditure on health care than poorer groups. In contrast, the overall distribution of both public and private sector health care benefits in South Africa is pro-rich, as poorer socio-economic groups are benefiting less from the use of health services than richer groups. The overall distribution of health care benefits is also not in line with the need for care: poorer groups that indicate poorer self-assessed health status receive fewer health care benefits compared with richer groups with higher self-assessed health status. In their final analysis the authors argue that the South African health system, considering both the delivery and financing of health care, is inequitable.
In this study, researchers developed two practical methods for measuring the affordability of medicines in developing countries. The proposed methods – catastrophic and impoverishment methods – rely on easily accessible aggregated expenditure data and take into account a country’s income distribution and absolute level of income. The catastrophic method quantifies the proportion of the population whose resources would be catastrophically reduced by spending on a given medicine; the impoverishment method estimates the proportion of the population that would be pushed below the poverty line by procuring a given medicine. The authors found that, when accurate aggregate data are available, the proposed methods offer a practical way to obtain informative and accurate estimates of affordability. Their results are very similar to those obtained with household micro-data analysis and are easily compared across countries.