Resource allocation and health financing

Hundreds march in Cape Town for National Health Insurance
Gonstana M-A: GroundUp, April 2019

Hundreds of people marched through Cape Town to Parliament in April to demand that government implement the National Health Insurance (NHI) system, including members of Sonke Gender Justice; Movement for Change and Social Justice (MCSJ) and the People’s Health Movement South Africa. They sang and danced holding banners and placards. MCSJ founder Mandla Majola, described the NHI as the “first step to better our public healthcare system”. He said the NHI was a fund that would ensure the implementation of proper healthcare for all and would bridge the gap between private and public sectors. Before the march, the MCSJ identified ten private hospitals and sent a small group of people to each hospital to picket outside to try and get help for one member in each group who was struggling to get help at a public clinic. In a memorandum, addressed to Minister of Health Aaron Motsoaledi, the MCSJ highlights structural problems in public clinics and hospitals, such as overcrowding and bed shortages; understaffing and maladministration, such as the disappearance of patient folders and staff shortages; the rural and urban divide, such as the long commutes to and from facilities; and the disparities between private and public sectors, such as drug shortages and long queues. The marchers demanded that NHI be implemented rapidly and adequately; that national government widen the awareness of NHI through initiatives like road shows and campaigns and that there be transparency in the NHI process.

The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis
Cambiano V; Johnson C; Hatzold K; Terris-Prestholt F; et al: Journal of the International AIDS Society 22(51), doi: https://doi.org/10.1002/jia2.25243, 2019

This study assessed the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa, using a synthesis model. In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision. However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to women having transactional sex was the most cost-effective. To maximize population health within a fixed budget, the authors argue that CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality.

Large-scale health insurance for the informal sector in Sub-Saharan Africa: Six years field experience on creating a large scale health insurance in rural Senegal
Docrat S; Lund C; Chisholm D: International Journal of Mental Health Systems 13(4) https://doi.org/10.1186/s13033-019-0260-4, 2019

From 2012 to 2017, the Belgian governmental cooperation and the Senegalese authorities implemented a project aimed at organising health insurance for rural poor people (‘PAODES’) to fund basic health care services at local and district level. It aimed to develop a health insurance model that had been tested long enough on a large enough scale to scale it up. PAODES intervened in four health districts with 480 000 people. The report found that health insurance coverage after two years was at 64% (more than 300,000 people). The health insurance scheme was reported to be financially viable at 30% coverage. Utilisation of primary care was up from 0.6 to 1.2 consultations per person per year for insured people. The authors report that large-scale health insurance for the informal sector can be efficient if it is operated by professional teams, if it is significantly subsidised by government so as to allow poor people to adhere, and if it is embedded in a nation-wide institution with a public purpose. The authors report that the credibility of a health system depends on the quality and packages of care offered. It is argued that large-scale health insurance cannot exist and function without the government addressing at least technical and procedural matters with regard to governance, such as a uniform and government-regulated fee-paying system and a digitalised accounting system for all health facilities and districts.

Public Spending on Health: A Closer Look at Global Trends
Xu K; Soucat A; Kutzin J; Brindley C; et al: World Health Organisation, Geneva, 2018

The 2018 global health financing report presents health spending data for all WHO Member States between 2000 and 2016 based on the SHA 2011 methodology. It shows a transformation trajectory for the global spending on health, with increasing domestic public funding and declining external financing. This report presents, for the first time, spending on primary health care and specific diseases and looks closely at the relationship between spending and service coverage. The key messages include that global trends in health spending confirm the transformation of the world’s funding of health services. Domestic spending on health is central to universal health coverage, but there is no clear trend of increased government priority for health. The report further shows that primary health care is a priority for expenditure tracking. Further, allocations across disease and interventions differ between external and government sources. The report indicates that performance of government spending on health can improve.

Distribution of out of pocket health expenditures in a sub-Saharan Africa country: evidence from the national survey of household standard of living, Côte d’Ivoire
Attia-Konan A; Oga A; Touré A: BMC Research Notes 12(25), doi: https://doi.org/10.1186/s13104-019-4048-z, 2019

This research aimed to identify the determinants of out of pocket (OOP) health expenditures in the Ivory Coast population in Abidjan, a rural and an urban area. The authors used data from the 2015 standard households living survey conducted by the National Institute of Statistics. About 13.3% of the participants experienced OOP expenditures on health with a mean expenditure of US$29. There were significant differences in the self-reported OOP between the three areas. People in Abidjan spent an average of 1.6 and 1.5 times more than those in the rural and urban areas respectively. Hospitalisation is the highest expenditure item in terms of money spent, while medicines are the most common item of expenditure in terms of frequency, regardless of the place of residence. Female gender, high social economic status and large household size increase OOP health expenditure significantly in all areas of residence while having insurance reduces it.

Sustainable financing options for mental health care in South Africa: findings from a situation analysis and key informant interviews
Docrat S; Lund C; Chisholm D: International Journal of Mental Health Systems 13(4) https://doi.org/10.1186/s13033-019-0260-4, 2019

South Africa faces a need to understand how existing reforms may be leveraged to incorporate the objectives of the National Mental Health Policy Framework and Strategic Plan (MHPF) and financed in a context of fiscal constraint. The authors conducted a situational analysis followed by in depth interviews with a range of expert national stakeholders. Although the MHPF is said to be consistent with ongoing efforts toward the implementation of National Health Insurance (NHI), there is clear evidence of discordance between the MHPF and the NHI. The most promising strategies for sustainable mental health financing call for increased decentralization of resources to primary and community mental health services and active integration of mental health into ongoing NHI implementation in district hospitals. The authors suggest several ways in which existing reforms may be leveraged to incorporate the objectives of the MHPF and achieve better mental health outcomes for South Africans, but this needs a costed investment case, projecting potential resource requirements and returns on investment of a strong service platform. In the longer-term, they argue that the NHI benefit package must be expanded to include comprehensive mental health services at all levels, with measures to incentivise quality of care.

‘Soda taxes work’
Green A: Health-E News, February 2019

South Africa’s version of a soda tax, called the Health Promotion Levy, will turn one-year-old in April. It was introduced to fight soaring rates of costly health conditions like obesity and diabetes. According to the Healthy Living Alliance’s (Heala) Sbongile Nkosi, excessive consumption of sugary beverages is “a major cause of obesity” and “also increases the risk of diabetes, liver and kidney damage, heart disease and some cancers”. Nkosi also criticised the beverage industry which, she said, “have specifically targeted poor communities who have the least access to quality health services”. In his budget speech, Finance Minister Tito Mboweni announced that the local tax on sugary drinks would be increased slightly in order to account for inflation. But Heala is pushing for the taxation rate to be doubled to bring the country in line with WHO guidelines.

Incorporating concerns for equity into health resource allocation: A guide for practitioners
Love-Koh J; Griffin S; Kataika E; Revill P: CHE Research Paper 160, 1-25, 2019

This paper summaries the methods for analysing health equity available to policymakers regarding the allocation of health sector resources. The authors provide an overview of the major tools that have been developed to measure, evaluate and promote health equity, along with the data required to operationalise them. These were organised into four key policy questions facing decision-makers: (i) what is the current level of inequity in health; (ii) does government health expenditure benefit the worst-off; (iii) can government health expenditure more effectively promote equity; and (iv) which interventions provide the best value for money in reducing inequity? Benefit incidence analysis is identified as the principal tool for estimating the distribution of current public health sector expenditure, with geographical resource allocation formulae and health system reform being the main government policy levers for improving equity. Techniques from the economic evaluation literature, such as extended and distributional cost-effectiveness analysis can be used to identify ‘best buy’ interventions from a health equity perspective. A range of inequality metrics, from gap measures and slope indices to concentration indices and regression analysis, can be applied to these approaches to evaluate changes in equity. Methods from the economics literature can be used to generate novel evidence on the health equity impacts of resource allocation decisions. They provide policymakers with a toolkit for addressing multiple aspects of health equity, from health outcomes to financial protection, and can be adapted to accommodate data commonly available in either high income or low and middle income settings. However, the quality and reliability of the data are crucial to the validity of all methods.

Sociodemographic patterns of health insurance coverage in Namibia
Allcock S; Young E; Sandhu M: International Journal for Equity in Health 18(16) 1-11, 2019

This paper aimed at assessing the prevalence of health insurance, the relation between health insurance and health service utilisation and to explore the sociodemographic factors associated with health insurance in Namibia. Such findings may help to inform health policy to improve financial access to healthcare in the country. Using data on 14,443 individuals, aged 15 to 64 years, from the 2013 Namibia Demographic and Health Survey, the association between health insurance and health service utilisation was investigated using multivariable mixed effects Poisson regression analyses. Just 17.5% of this population were insured. In fully-adjusted analyses, education was significantly positively associated with health insurance, independent of other sociodemographic factors. Female sex and wealth were also independently associated with insurance. There was a complex interaction between sex, education and wealth in the context of health insurance. With increasing education, women were more likely to be insured and education had a greater impact on the likelihood of health insurance in lower wealth quintiles. In this population, health insurance was associated with health service utilisation but insurance coverage was low, and was independently associated with sex, education and wealth. Education may play a key role in health insurance coverage, especially for women and the less wealthy. The authors suggest that the findings may help to inform the targeting of strategies to improve financial protection from healthcare-associated costs in Namibia.

The Politics of Resource Bargaining, Social Relations and Institutional Development in Zimbabwe Since Independence
Saunders R: United Nations Research Institute for Social Development, Working Paper 1, UNRISD, Geneva, 2019

This paper examines evolving models and experiences of domestic resource mobilisation in Zimbabwe since independence in 1980. Grounded in UNRISD’s Politics of Domestic Resource Mobilization and Social Development project, the study explores key questions around the nature and dynamics of resource bargaining over revenue mobilisation and allocation; the changes in relationships among key actors; and the forms and outcomes of institutional development surrounding resource bargaining processes. It adopts a historical approach to explore the balance of forces among actors and institutional constraints in the formulation of successive resource mobilisation strategies. Three case studies in the paper of divergent resource mobilisation innovations underscore the complexity of challenges faced by governments whose actions are shaped by uneven state capacity and policy autonomy; a weak formal sector in which established business actors wield significant power and influence; and growing contestation over legitimacy and participation by political and social actors. The Zimbabwean experience underscores the critical importance of political undercurrents and contesting interests in resource bargaining. It highlights the uneven nature of social actors’ access to and influence in bargaining processes; and of the state itself in the wake of neoliberal austerity, state capture and intra-elite competition. At the same, the author argues that the evidence from Zimbabwe points to the benefits of more transparent, inclusive and capacitated forms of revenue mobilisation involving a wider array of social actors.

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