With 3.1 million people on antiretrovirals (ARV), South Africa has the world’s largest ARV programme. Sustaining it – and the HIV response – is argued to more than double in cost in the next two decades, according to new research. The research reported in this paper modelled the cost of county’s HIV response and what it will take to meet ambitious international development targets adopted by the country in 2014. The research found that South Africa’s HIV programme will cost about R40 billion each year by 2033 – more than double the R21 billion budgeted for the programme in the next financial year. The analysis also revealed the top 18 most cost-effective ways South Africa can tackle its epidemic. Top of the list was increasing condom distribution, medical male circumcision and mass communication campaigns promoting safer sex among teens.
Resource allocation and health financing
In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, the authors consider inequalities in access to the DG for patients on ART and implications of DG access for on-going access to healthcare. Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. Grant recipients were comparatively worse off than non-recipients in terms of employment and wealth. The regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed. Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG. The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.
South Africa's proposed National Health Insurance (NHI) scheme, is many years away, but many of the country’s 10 pilot sites are reported to be making progress. Of the 10 NHI pilot districts Health e-news investigated all – with the exception of OR Tambo in the Eastern Cape – are making reasonable progress in improving public health. The pilot districts, covering 20 percent of the population, were set up almost five years previously after Health Minister Aaron Motsoaledi announced the NHI as government policy. Negative patient experiences in public health facilities led government to concentrate on cleaning its own house before attempting any engagement of the NHI with the private sector.
The Ebola crisis exposed the weaknesses of healthcare systems in low- and middle-income countries created mainly by insufficient funding. Given the global community’s commitment to universal health coverage (UHC), the Ebola outbreak has prompted serious reflection among health policy decision-makers. One of the central features of this debate is financing: how can relatively poor countries find the money to pay for universal health coverage? To date, low- and middle-income countries have been growing toward UHC through social health insurance systems funded through employment. Yet, progress has been slow and uneven leaving people in the informal sector, who are the majority of the population, out was insurance schemes. Rather than seeking innovative solutions to this old problem, this blog outlines how Aaron Reeves argues that what is needed is a renewed commitment to an old solution: tax-based financing. Using data from low- and middle-income countries my colleagues and I examined the association between tax revenues and health spending. We found that tax revenue was a major statistical determinant of progress towards UHC. Each $10 per-capita increase in tax revenue was associated with an additional $1 of public health spending per capita. Whereas each $10 increase in GDP per capita was associated with an increase of $0.10. Crucially, tax revenues sit on the pathway between economic growth and health spending. In short, tax financing is an efficient way of translating economic growth into health spending. Countries with more tax revenues have also made more progress on other indicators of UHC, even after adjusting for economic activity in the country. Among tax poor countries, greater tax revenues are associated with more women being attended by a skilled healthcare worker during pregnancy and greater access to healthcare for all people.
Development assistance for health (DAH) has grown to more than $31.3 billion in 2013. This paper presents evidence on the degree to which countries with high concentrations of conflict, violence, inequality, debt and corruption have received health aid compared to other countries. The authors combined DAH estimates and a multidimensional fragile states index for 2005 to 2011 comparing 'fragile' versus 'stable' states. Comparing low-income countries, fragile countries received $7.22 per person while stable countries received $11.15 per person. Funders preferred funding to low-income fragile countries that have refugees or ongoing external intervention but tended to avoid funding countries perceived to have political gridlock, flawed elections, or economic decline. While external health funding to 'fragile' countries has increased since 2005, it is per person almost half as much as the DAH provided to more stable countries of comparable income levels.
With user fees now seen as a major hindrance to universal health coverage, many countries have introduced fee reduction or elimination policies, but there is growing evidence that adherence to reduced fees is often highly imperfect. In 2004, Kenya adopted a reduced and uniform user fee policy providing fee exemptions to many groups. The authors present data on user fee implementation, revenue and expenditure from a nationally representative survey of 248 Kenyan public health centres and dispensaries in 2010. No facilities adhered fully to the user fee policy across eight tracer conditions, with adherence ranging from 62.2% for an adult with tuberculosis to 4.2% for an adult with malaria. Three quarters of exit interviewees had paid some fees and a quarter of interviewees were required to purchase additional medical supplies at a later stage from a private drug retailer. No consistent pattern of association was identified between facility characteristics and policy adherence. User fee revenues accounted for almost all facility cash income, with average revenue of USD 683 per facility per year. Fee revenue was mainly used to cover support staff, non-drug supplies and travel allowances. Adherence to user fee policy was very low, leading to concerns about the impact on access and the financial burden on households. However, the potential to ensure adherence was constrained by the facilities’ need for revenue to cover basic operating costs, highlighting the need for alternative funding strategies for peripheral health facilities.
This CDI Practice Paper provides a critical assessment of the literature on tax experiments to date. It examines the main conceptual, methodological and data-related challenges, and provides practical reflections on how to move forward in low- and middle-income countries where this type of research is still underdeveloped. It offers a guide for practitioners on the main challenges in quantitative research on tax compliance and on the methods used tackle them, which may be of interest for evaluation research more generally.
Social protection and taxation feature prominently as key policy instruments available to governments in the pursuit of development goals in both the Financing for Development (FFD) Addis Ababa Action Agenda and the Sustainable Development Goals (SDGs). This reflects a growing recognition among policy makers in the international development context of the powerful role fiscal policy plays in shaping development outcomes. It also represents an important opportunity for closer consideration of the ways in which taxation and social protection operate jointly in practice. Taxes and transfers commonly continue to be discussed separately, yet in practice they interact to shape the distribution and redistribution of income and wealth both directly – through the distribution of transfers and the tax burden – and by influencing processes of government accountability and legitimacy, the quality of service provision and people’s willingness to pay taxes. If appropriately designed and implemented, taxes and transfers can make a significant dent in poverty and inequality. In high-income OECD countries, direct taxes and transfers alone contribute to an average 30% reduction in income inequality, reducing the average Gini coefficient from 0.41 to 0.29. In comparison, in developing countries, their impact is more muted. There is thus scope to strengthen these systems, particularly as in July 2015, world leaders in Addis Ababa agreed on a commitment to delivering social protection and essential public services for all through a new social compact to ‘end poverty in all its forms everywhere’.
This paper presents an interview with South Africa's Health Minister, Aaron Motsoaledi. in which he answers six big questions about the National Health Insurance White Paper: Are you intending to stop medical schemes providing the same services as NHI? Are you intending to curb, if not entirely limit, private health care? Was a battle with the Treasury over the enormous amounts of public money it’s going to take to fund NHI a main reason behind the delay in releasing the White Paper? What’s the point in the Healthcare Market Inquiry (HMI)? You’re looking at full implementation of the NHI by 2025. Is that fair? It presents the Minister's answers. He notes that the NHI envisages a society based on values, justice, fairness and social solidarity. Health care is a social investment, therefore it should not be subject to the normal market forces and treated as a normal commodity.
Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. EnrolLing all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.