The purpose of this study is to examine the vertical and horizontal equity of the premium collection of the Ghanaian National Health Insurance Scheme (NHIS), which was introduced to help ensure universal coverage. Horizontal inequity was measured through the effect of the premium on redistribution of ability to pay of members. The extent to which the premium could cause catastrophic expenditure was also examined. The results showed that revenue collection was both vertically and horizontally inequitable. The horizontal inequity had a greater effect on redistribution of ability to pay than vertical inequity. The computation of catastrophic expenditure showed that a small minority of the poor were likely to incur catastrophic expenditure from paying the premium a situation that could impede the achievement of universal coverage. The author provides recommendations to improve the inequitable system of premium payment to help achieve universal coverage.
Resource allocation and health financing
Drawing on a study conducted in five African countries, the authors of this paper explore different stakeholder perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and health and how different stakeholders perceive this. The countries were Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi. Key background documents were analysed and 258 semi-structured interviews and 45 focus group discussions were held. Although the researchers found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS.
For the past ten years, the South African government has not adjusted the means test for patients using public hospitals, leaving more and more poor people without medical aid to foot their own bills, according to this article. In addition, treatment and hospital fees have risen by up to 75% since the means test was first set in 2002. As a result, many families that have had to contend with serious illness face debts that can take years to pay off. Between four and six million South Africans have no medical aid insurance and do not qualify for discounted fees at public hospitals, putting them at risk of huge medical bills. The Uniform Patient Fee Schedule policy says patients who cannot afford the fees levied according to their classification "may be reclassified" as exempt from fees "by the person in charge of the health facility", enabling hospitals to write off part or all of a patient’s debt. But many patients have neither the energy or skills to navigate the bureaucracy, and staff do not always verify patient claims, leaving the process open to corruption. In the long run, the state’s plans to introduce National Health Insurance (NHI), which would be free at the point of service, should do away with the financial burden facing public sector patients, the author argues. But in the short term, the NHI plan could inadvertently make things worse. This is because the NHI pilot project includes funding to improve hospitals’ revenue collection. If that aspect of the project is not carefully managed, more patients could find themselves in severe financial straits.
The landscape of foreign aid is changing, according to this book. New development actors are on the rise, from the 'emerging' economies to numerous private foundations and philanthropists. At the same time the nature of the global poverty 'problem' has also changed: most of the world's poor people no longer live in the poorest countries. Sumner and Mallet review of research on foreign aid to outline a series of policy proposals for global development cooperation in the twenty-first century.
To comprehensively assess the existing evidence on the costs that tuberculosis (TB) patients incur in Sub-Saharan Africa, researchers undertook a systematic review of the existing literature for articles containing a quantitative measure of direct or indirect patient costs, finally including 30 articles that met all of the inclusion criteria. Depending on type of costs, costs varied from less than US$1 to almost $600 or from a small fraction of mean monthly income for average annual income earners to over 10 times the annual income that the average person in the income-poorest 20% of the population earns. Out of the eleven types of TB patient costs identified in this review, the costs for hospitalisation, medication, transportation, and care in the private sector were largest. The authors argue that it is likely that for many households, TB treatment and care-related costs were catastrophic because costs commonly amounted to 10% or more of per-capita income. These results suggest that policies to decrease direct and indirect TB patient costs are urgently needed to prevent poverty due to TB treatment and care for those affected by the disease.
On 15 November 2012 Eurodad and Oxfam International organised the public seminar ‘The future of aid and development effectiveness’ to debate the role of aid in the post-Busan agenda. At the seminar, presenters highlighted how the ineffective practices of external funders and recipient countries continue to constrain the full potential of aid to deliver development outcomes. Participants agreed that it is essential to monitor progress towards commitments on a rolling basis, but called for caution when using results-based approaches to aid, arguing that increasing pressure on aid budgets and calls for greater accountability should not be translated into modalities that undermine aid effectiveness principles. In order to prevent this from happening, the aid effectiveness agenda should serve as a reference framework to ensure that new aid modalities are an improvement over existing ones. While some considered a results-based approach as a way to ensure that aid is effective, others regarded it as quick win and a funder-driven agenda for times of crisis that could reverse the progress made so far in developing more equitable aid programmes.
Targeting to identify the poorest or those most in need of exemptions has proven a major challenge under exemption schemes in terms of protecting the poor from financial risk. In this presentation given at the Second Global Symposium on Health Systems Research in November 2012, the author discusses her research into Madagascar’s Equity Fund, which is intended to exempt the poorest in Madagascar from costs such as user fees at health facilities. She assessed the accuracy of the Fund’s targeting process to determine who receives benefits by examining whether the socio-economic status of equity fund beneficiaries was lower than that of non-beneficiaries, as well as identify factors influencing the targeting outcomes. Results suggested that beneficiaries were reasonably well targeted; however, both leakage and under-coverage occurred. Coverage remains very low, with conflicts of interest between health administrators and village level agents. The local health administration could not monitor or influence village level agents’ behaviour during beneficiary identification. Monitoring, decision-making and managerial mechanisms were re-shaped to allow health administrators to influence the number of indigents registered on the list. In addition, a re-orientation of the policy objectives changed the emphasis of equity fund operations to favour financial performance.
In this study, researchers conducted a whole-system analysis - integrating both public and private sectors - of the equity of health-system financing and service use in Ghana, South Africa and Tanzania. They used primary and secondary data to calculate the progressivity of each health-care financing mechanism, catastrophic spending on health care, and the distribution of health-care benefits. Overall, health-care financing was found to be progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries. These findings raise questions over the appropriate financing mechanism for the health care of people outside the formal sector. Physical and financial barriers to service access must be addressed if universal coverage is to become a reality.
South Africa is in the process of implementing a National Health Insurance (NHI) scheme to address drastic inequalities in the health sector and transform the health system. In particular, NHI is expected to have a significant positive impact on females, who are disadvantaged under the current system, with higher rates of poor health and lower rates of medical scheme membership. Despite NHI’s transformative potential, however, the public discourse on NHI as portrayed in the media suggests that it is an unpopular policy. The authors of this paper assessed the general public’s opinion on NHI and explored gender differences in perceptions, using data from a 2010 survey of the South African population that looked at social attitudes. They found that there is broad public acceptance of NHI, with an overwhelming majority of South Africans preferring an NHI system to the current two-tiered system. More females than males said they supported NHI, reflecting the potential of the NHI system to have a positive impact on gender equality and the health of women and girls. It appears that support for NHI has increased since similar studies in 2005 and 2008, with the simultaneous growth of public discourse on the policy.
In this report, the authors assess the potential of results-based approaches to deliver long-term and sustainable results by measuring the performance of different initiatives against widely agreed aid effectiveness principles. They found that, in general, results-based approaches are not particularly good at supporting aid effectiveness principles but broader approaches do appear to be better aligned with the principles. Ownership tends to be higher when the responsibility for designing programmes falls on recipient governments. This does not mean that funder-led approaches cannot achieve significant degrees of ownership, but results are likely to be less consistent, have higher costs and impose a significant burden on host governments and civil society. Results-based approaches tend to reinforce accountability to external funders and in doing so, undermine mutual accountability. In general, the problem is less acute with country-wide initiatives and it is most pressing when working through third party service providers. In addition, the level of harmonisation of results-based approaches is low because of their widespread use of parallel structures. Eligibility and public financial management criteria demanded by funders can further influence and limit the type of country systems that recipient countries can implement.