Resource allocation and health financing

Efficiency and effectiveness of strategies for promoting access for the poor and vulnerable groups within user fee system: Mwanza and Misungwi districts, Tanzania
Kumallja GJ: MPH Thesis University of Dar es Salaam, September 2013

The implementation of user fees while fostering equity in access of quality health services for the poor is still a problem in health facilities in Tanzania. A cross sectional exploratory descriptive study was conducted in Mwanza at Sekou- Toure (public) and Bukumbi (Voluntary) hospitals in June 2002 to investigate the strategies for promoting access for the poor and vulnerable groups within their user fee systems, through exit interviews, documentary reviews and observations. Of 150 respondents from each hospital, only 36% of the public and 26% of the voluntary hospitals respondents were aware of the existence of the exemption mechanism in those hospitals. The findings from the study showed that the strategies implemented by the public and voluntary hospitals are not enough to effectively and efficiently identify the poor in their user fee system. The implementation of user fees while fostering equity in access of quality health services for the poor is still a problem in health facilities in Tanzania.

Human Rights, Social Inclusion and Health Equity in International Donors' Policies
Eide AH, Amin M, MacLachlan M, Mannan H, Schneider M: Disability, CBR and Inclusive Development Journal, 23, 4, 144, 2012

Health policies have the potential to be important instruments in achieving equity in health. A framework – EquiFrame - for assessing the extent to which health policies promote equity was used to perform an equity audit of the health policies of three international aid organizations, to assess the extent to which social inclusion and human rights feature in the health policies of DFID (UK), Irish Aid, and NORAD (Norway). EquiFrame was used as a tool for analysing equity and quality of health policies with regards to social inclusion and human rights. Each health policy was analyzed with regards to the frequency and content of a predefined set of Vulnerable Groups and Core Concepts. The three policies varied but were all relatively weak with regards to social inclusion and human rights issues as defined in EquiFrame. The needs and rights of vulnerable groups for adequate health services were largely not addressed. In order to enhance a social inclusion and human rights perspective that will promote equity in health through more equitable health policies, it is suggested that EquiFrame can be used to guide the revision and development of the health policies of international organizations, aid agencies and bilateral donors in the future.

Does Abolishing User Fees Lead to Improved Health Status? Evidence from Post-Apartheid South Africa
Tanaka S: Social Science and Research Network, July 2013

In this paper, the author examines the impact of removing user fees from healthcare on the health status of poor children in South Africa. By comparing health development across similar children, the author found that free healthcare improved the health status of all children, but to a greater extent for boys than for girls. These results present several important policy implications for other developing countries contemplating the abolition of user fees. First, removing user fees is effective in improving child health status through increased access to and utilisation of health services in an environment where poor households face significant budget constraints. Second, increased access to health services is an important determinant of better health outcomes. Third, free health services are often challenged by a potential trade off between quantity and quality of services. The study supports the assertion that the quality of health services appears to have deteriorated, due to poor financial management, leading to lower health status among older children in the high treatment region. However, the net benefits were still positive and significant for children who received free healthcare.

Global health actors no longer in favour of user fees: a documentary study
Robert E and Ridde V: Globalization and Health 9(29), 26 July 2013

This study identified and analysed the stance of global health actors (GHAs) in the debate on user fees. The authors reviewed public documents published by and officially attributed to GHAs from 2005 to 2011. They identified 56 GHAs, and analysed 140 documents. Among them, 55% were in favour of the abolition of user fees or in favour of free care at the point of delivery. None of the GHAs stated that they were in favour of user fees, although 30% did not take a stand. The World Bank declared support for both user fees and free care at point of service. GHAs generally circumscribe their stance to specific populations (pregnant women, children under 5 years, etc.) or to specific health services (primary, basic, essential). Three types of arguments are used by GHAs to justify their stance: economic, ethical and pragmatic. While the principle of “user pays” certainly seems to have fallen out of favour, the authors suggest that the next step is yet to be taken, ie for GHAs to provide technical and financial support to those countries that have chosen to implement user fee exemption policies.

Health financing for universal coverage and health system performance: concepts and implications for policy
Kutzin J: Bulletin of the World Health Organisation 91(8): 602-611, August 2013

All countries that are seeking to improve equity in the use of health services, service quality and financial protection for their populations must pursue universal health care (UHC), according to the author of this paper. He argues that health financing policy is an integral part of efforts to move towards UHC. To be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Adding schemes for specific social groups is incompatible with a universal coverage approach and may even undermine UHC, as scheme members protect their own benefits to the cost of wider equity.

Promoting universal financial protection: contracting faith-based health facilities to expand access – lessons learned from Malawi
Chirwa ML, Kazanga I, Faedo G and Thomas S: Health Research Policy and Systems 11(27), 16 August 2013

This study examined the features of Service Level Agreements (SLAs) and their effectiveness in expanding universal coverage in Malawi. Research was conducted in five Christian Health Association of Malawi (CHAM) health facilities: Mulanje Mission, Holy Family, and Mtengowanthenga Hospitals, and Mabiri and Nkope Health Centres. A total of 155 clients from an expected 175 were recruited in the study. The study findings revealed key aspects of how SLAs were operating, the extent to which their objectives were being attained and why. In general, the findings demonstrated that SLAs had the potential to improve health and universal health care coverage, particularly for the vulnerable and underserved populations. However, the findings show that the performance of SLAs in Malawi were affected by various factors including lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate human and material resources, and lack of systems to monitor performance of SLAs, amongst others. The authors provide recommendations to policy makers for the replication and strengthening of SLA implementation in the roll-out of universalisation policy.

The financial burden from non-communicable diseases in low- and middle-income countries: a literature review
Kankeu HT, Saksena P, Xu K, Evans DB: Health Research Policy and Systems 2013, 11:31, 16 August 2013

In this paper, the authors present a literature review on the costs imposed by non-communicable diseases (NCDs) on households in low- and middle-income countries (LMICs). They examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. These financial costs deter many people suffering from NCDs from seeking the care they need. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. The authors identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

Access for the poor and powerless: How changes to health funding have influenced church health service provision in low- and middle-income countries
Ascroft J, Semos I and Macintyre A: University of Melbourne, June 2013

The authors of this study conducted a review of the international literature on funding issues faced by church- and faith-based service providers in Africa and in Papua New Guinea. They found that funding constraints have been overcome in some cases through greater collaboration between government and church health providers, through the restructuring of user fees to minimise the impact on the poor and through more streamlined and transparent financial reporting. However, failure to fully implement agreed government funding to church health services can cause facility closures and reduced treatments, driving up costs for government and increasing the burden on public provision. The authors also report mixed findings as to whether greater engagement by church health services with government has translated into broader participation in policy formulation, as well as of implementation of community-based health insurance schemes and micro-insurance. Funding constraints influenced the retention of skilled staff by church health services, as workers move from church-managed, rural and remote facilities to public facilities in urban centres.

Domestic Revenue Mobilisation in Countries Emerging from Conflict
Holmes K: International Peace Institute, 10 July 2013

On 10 July 2013, the International Peace Institute hosted Kieran Holmes, General Commissioner of the Burundi Revenue Authority, to present lessons and recommendations from countries emerging from conflict, while positing ways the wider international community can support the development of domestic revenue generation and revenue authority. In this video, he argues from the position that imposed decisions and models of the global agencies are often not the in the best interests of recipient countries. A relevant system should be determined by local conditions. International and national partners must radically change the way they engage with states emerging from conflict. African leaders need to find how to move away from the model of partnership according to which priorities, policies, and funding needs are determined in foreign capitals and development partners’ headquarters. Conflict-affected states need to be able to determine their own destinies.

Health insurance in Ghana: evaluation of policy holders' perceptions and factors influencing policy renewal in the Volta region
Boateng D and Awunyor-Vitor D: International Journal for Equity in Health 12(50), 3 July 2013

The purpose of this study was to assess individual attitudes towards health insurance policy and the factors that influence respondents’ decision to renew their health insurance policy when it expires. It was conducted in the Volta region of Ghana. A total of 300 respondents were randomly sampled and interviewed for the study. The researchers also assessed factors that influence respondents’ decision to take up a health insurance policy and renew it. The study results indicate that 61.1% of respondents are currently being enrolled in the national health insurance system (NHIS): 23.9% had not renewed their insurance after enrollment and 15% had never enrolled. Reasons cited for non-renewal of insurance included poor service quality (58%), lack of money (49%) and experience of other sources of care (23%). The gender, marital status, religion and perception of health status of respondents significantly influenced their decision to enroll and remain in NHIS. The authors conclude that NHIS is experiencing good levels of uptake, with clients testifying to its benefits in keeping them strong and healthy. Efforts therefore must be put in by all stakeholders including the community to educate the individuals on the benefits of health insurance to ensure all have optimal access.

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