Resource allocation and health financing

Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya
Mulupi S, Kirigia D and Chuma J: BMC Health Services Research 13: 474, 12 November 2013

Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. This study contributes to this process by exploring communities' understanding and perceptions of health insurance and their preferred designs features. Data collection methods included a cross-sectional household survey and focus group discussions. About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance but limited knowledge of how it functions or of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority.

Does investment in the health sector promote or inhibit economic growth?
Reeves A, Basu S, McKee M, Meissner C, Stuckler D: Globalization and Health 2013, 9:43

In this study, the authors evaluate the economic effects of alternative types of government spending by estimating “fiscal multipliers” (the return on investment for each $1 dollar of government spending). While the study is implemented using data from Europe the findings may have wider relevance: they indicate that government spending on health may have short-term effects that make recovery more likely.

Health technology assessments as a mechanism for increased value for money: Recommendations to the Global Fund
Teerawattananon Y, McQueston K, Glassman A, Yothasamut J and Myint CY: Globalization and Health 9(35), 21 August 2013

The Global Fund is experiencing increased pressure to optimise results and improve its impact per dollar spent, according to this study. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. The authors assess the efficacy of current Global Fund investment and examine how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidised by the Global Fund. In addition, they identify areas where the application of HTAs can exert the greatest impact and propose ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, they address the challenges facing the Global Fund in realising the full potential of HTAs.

The 2013 DATA Report: Financing the Fight for Africa’s Transformation
One.org: Berlin, 2013

The world has officially entered the final leg of its 15-year journey to halve extreme poverty and reduce child mortality by two-thirds, reverse the tide against HIV/AIDS and malaria, and ensure that more people have access to basic services, such as primary education and safe drinking water. Despite a challenging global economic environment, many low and middle-income countries are making dramatic progress towards the highly ambitious MDG targets. ONE’s 2013 DATA Report examines the recent progress of individual countries against eight MDG targets, focusing particular attention on sub-Saharan Africa, and compares that progress against African government and donor spending in three key poverty-reducing sectors: health, education, and agriculture.

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.

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