How does health insurance affect health? After reviewing the evidence on this question, we reach three conclusions. First, many of the studies claiming to show a causal effect of health insurance on health do not do so convincingly because the observed correlation between insurance and good health may be driven by other, unobservable factors. Second, convincing evidence demonstrates that health insurance can improve health measures of some population subgroups, some of which, although not all, are the same subgroups that would be the likely targets of coverage expansion policies. Third, for policy purposes we need to know whether the results of these studies generalize. Solid answers to the multitude of important questions about how specific health insurance policy options may affect health seem likely to be forthcoming only with investment of substantial resources in social experiments.
Resource allocation and health financing
Informal payments for health services are common in many countries, especially in transitional and developing countries. As part of a larger study focusing on health worker performance in Tanzania, one objective was to investigate the nature of informal payments in the health sector, and to identify mechanisms through which informal payments are affecting the quality of health services. A more profound understanding of these mechanisms is of interest because it may improve knowledge of how quality may be enhanced within a system where informal payments are common practice. The findings reveal a variety of positive and negative mechanisms through which informal payments may impact on the quality of health care. Furthermore, they show that informal payments add to health workers' incomes, thus contributing to the retention of workers in the health sector and to avoiding a further escalation of the current health worker shortage.
In the face of the dual TB/HIV epidemic, the ProTEST Initiative was one of the first to demonstrate the feasibility of providing collaborative TB/HIV care for people living with HIV (PLWH) in poor settings. The ProTEST Initiative facilitated collaboration between service providers. Voluntary counselling and testing (VCT) acted as the entry point for services including TB screening and preventive therapy, clinical treatment for HIV-related disease, and home-based care (HBC), and a hospice. This paper estimates the costs of the ProTEST Initiative in two sites in urban Zambia, prior to the introduction of anti-retroviral therapy. This study shows that coordinating an integrated and comprehensive package of services for PLWH is relatively inexpensive. The lessons learnt in this study are still applicable today in the era of ART, as these services must still be provided as part of the continuum of care for people living with HIV.
Save the Children called on African leaders to fulfil their promises made in Abuja in 2001 to spend at least 15% of their annual budgets on health. In the briefing ‘Not another one, not another day’ they look at how African governments, despite commitments in 2001 and 2005, still aren’t spending enough on health. It also shows that the EU is failing to support the development of health systems in Africa, with most member states still falling short of their commitment to spend 0.7% of their gross national income on aid. It includes a list of recommendations to get the AU and EU back on track to meet the Millennium Development Goals.
Maximising health as the guiding principle for resource allocation in health has been challenged by concerns about the distribution of health outcomes. There are few empirical studies that consider these potentially divergent objectives in settings of extreme resource scarcity. The aim of this study is to help fill this knowledge gap by exploring distributional preferences among health planners in Tanzania. Distribution of health outcomes, in terms of life-years, matters. Specifically, the lower the initial life expectancy of the target group, the more important the programme is considered. Such preferences are compatible, within the sphere of health, with what ethicists call “prioritarianism”.
This article assesses the effectiveness of conditional cash transfers in improving access to and use of health services, as well as improving health outcomes, in low- and middle-income countries. The article provides a description of interventions in Mexico, Nicaragua, Columbia, Honduras, Brazil and Malawi. It finds that overall conditional cash transfer programmes are effective in increasing the use of preventive services. Their effect on health status is less clear as the supply of adequate and effective health services is also an important factor.
The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.
This paper compares the welfare effects of a community based insurance scheme - the Community Health Fund (CHF) - and user fees for public health care in Tanzania. Under the CHF, households pay a predetermined fixed annual premium for free access to public health facilities. The paper summarises the controversies and achievements of user fees in poor countries and Tanzania in particular. The discussion focuses on two issues: whether user fees are better than insurance schemes in public health care financing, and whether it is possible to charge for public health services and at the same time achieve universal access to these services.
This paper re-examines the efficiency-based arguments for optimal health insurance, extending the classic analysis to consider optimal coverage for prevention and treatment separately. The paper considers the tradeoff between individuals’ risk reduction on the one hand, and both ex ante and ex post moral hazard on the other. The authors demonstrate that it is always desirable to offer at least some insurance coverage for preventive care if individual consumers ignore the impact of their preventive care on the health premium. Using a utility-based framework, they reconfirm the conventional tradeoff between risk avoidance (by risk sharing) and moral hazard for insuring treatment goods. Uncompensated losses that reduce effective income provide a new efficiency-based argument for more generous insurance coverage for prevention and treatment of health conditions. The optimal coinsurance rates for prevention and for treatment are not identical.
Save the Children called on African leaders to fulfil their promises made in Abuja in 2001 to spend at least 15% of their annual budgets on health. In the briefing ‘Not another one, not another day’ they look at how African governments, despite commitments in 2001 and 2005, still aren’t spending enough on health. It also shows that the EU is failing to support the development of health systems in Africa, with most member states still falling short of their commitment to spend 0.7% of their gross national income on aid. It includes a list of recommendations to get the AU and EU back on track to meet the Millennium Development Goals.