Ghana’s National Health Insurance Scheme (NHIS) was established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing. This study analyses NHIS members’ perceptions of service provision at the national level using data from the 2008 Ghana Demographic Health Survey. Results demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, the study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. The authors conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate.
Resource allocation and health financing
This paper is focused on the question: why do the governments of low income countries not raise more tax revenues? Two different but complementary approaches are used to answer it. The first approach is comparisons: among countries today, and within countries over time. This approach tends to generate relatively conservative answers to the central question. It leads to an emphasis on the ‘sticky’ nature of the taxation. For any individual country in ‘normal times’ – i.e. excluding situations of war, major internal conflict, the collapse or rapid reconstruction of state power - revenue collections, measured as a proportion of GDP, do not change much from year to year. This is partly because effective taxation systems require a great deal of coordination and cooperation between revenue agencies and other organisations, both inside and outside the public sector. It is hard quickly to improve the effectiveness of a complex organisational network. The ‘stickiness’ of tax collections also reflects the fact that the overall tax take – i.e. the proportion of GDP raised as public revenue – is to a significant degree determined by the structure of national economies. For logistical reasons, it is much easier to raise revenue from economies (a) that are high income, urban and non-agricultural and (b) where the ratio of international trade to GDP is high. The government of the average low income country raises less than 20 per cent of GDP in revenue. The author argues that this weakens the ability of such governments to aim to match OECD tax takes of 30-45 per cent of GDP.
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.
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.
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 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.
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.
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.
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.
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.