Resource allocation and health financing

Who benefits from health care in Tanzania?
Health Economics Unit, University of Cape Town: 2010

According to this fact sheet, health care services overall in Tanzania benefit the rich more than the poor. In particular, the poorest 20% receive less benefit than they need. Benefits from outpatient and inpatient care in public hospitals, and private facilities are pro-rich, while benefits from faith-based facilities are generally evenly distributed with benefits being shared equally among people of all socio-economic groups, especially for inpatient care. Distance to referral facilities and cost are two factors that limit access to inpatient care for poorer groups, especially in rural areas. Poor quality of care in public facilities leads to a preference for private facilities among those who have the ability to pay. The greater availability of faith-based providers in rural areas and their flexible pricing policies leads to a more even share of benefits between rich and poor.

Who benefits from increased service utilisation? Examining the distributional effects of payment for performance in Tanzania
Binyaruka P; Robberstad B; Torsvik G; et al: International Journal for Equity in Health 17(14), doi: https://doi.org/10.1186/s12939-018-0728-x, 2018

The authors examined pay for performance (P4P) effects on service utilisation across different population subgroups in Tanzania. About 3000 households were surveyed of women who delivered in the last 12 months prior to the interview from seven intervention and four comparison districts in January 2012 and a similar number of households in 13 months later. The household data were used to generate the population subgroups and to measure the incentivised service utilisation outcomes, with a focus on the institutional delivery rate and the uptake of antimalarials for pregnant women. P4P led to a significant increase in the rate of institutional deliveries among women in poorest and in middle wealth status households, but not among women in least poor households. The differential effect was marginally greater among women in the middle wealth households compared to women in the least poor households. The effect of P4P on institutional deliveries was also significantly higher among women in rural districts compared to women in urban districts, and among uninsured women than insured women. The effect of P4P on the uptake of antimalarials was equally distributed across population subgroups. The authors suggest that P4P can enhance equitable healthcare access and use especially when the demand-side barriers to access care such as user fees associated with drug purchase due to stock-outs have been reduced.

WHO estimates cost of reaching global health targets by 2030
World Health Organisation: WHO, Geneva, 2017

The SDG Health Price Tag estimates the costs and benefits of progressively expanding health services in order to reach 16 Sustainable Development Goal (SDG) health targets in 67 low- and middle-income countries that account for 75% of the world’s population. The analysis shows that investments to expand services towards universal health coverage and the other SDG health targets could prevent 97 million premature deaths globally between now and 2030, and add as much as 8.4 years of life expectancy in some countries. While most countries can afford the investments needed, the poorest nations will need assistance to reach the targets. The SDG Health Price Tag models two scenarios: an “ambitious” scenario in which investments are sufficient for countries to attain the health targets in the SDGs by 2030, and a “progress” scenario in which countries get two thirds or more of the way to the targets. These investments would boost health spending as a proportion of gross domestic product across all 67 countries from an average of 5.6% to 7.5%. The global average for health spending as a proportion of GDP is 9.9%. Although higher spending does not necessarily translate to improved health, making the right investments at the right time can. The SDG Health Price Tag does not prescribe what countries should spend on health, but is intended as a tool to inform further research. It also highlights that achieving universal health coverage and the other health targets requires not only funding but political will and respect for human rights. WHO plans to update the estimates every five years and will include other health-related targets and diseases as more evidence becomes available.

WHO faces funding shortfall in 2011
Saez C and New W: Intellectual Property Watch, 17 January 2011

At the opening of the World Health Organization’s (WHO) Executive Board meeting, held from 17–25 January 2011, there were calls for reform amid concerns about WHO’s finances for the year ahead. WHO Director-General, Margaret Chan, said that the United Nations agency is stretched thin due to a high level of demand impacting its efficiency in some areas, and that far-reaching reform is needed. She also warned against big corporations’ influence on policies, in her response to dissension over a pharmaceutical industry representative named by the WHO secretariat to join a new research and development funding working group. In her opening remarks, Chan underlined the financial shortfall of the WHO, which some later said could range between US$200 and $600 million dollars in the biennium.

WHO funders: Setting the agenda for global public health?
Knowledge Ecology International: 15 May 2010

This article supplies basic information on external funding for the World Health Organization's (WHO) activities. The total amount of 'specified' voluntary contributions for the period of 2008 to 2009 is around US$2.3 billion dollars. The Total General Fund for WHO, including specified voluntary contributions, 'core' voluntary contributions and contributions to WHO's Framework Convention on Tobacco Control and the Stop TB Partnership Global Drug Facility, stands at $2,744,594,186 dollars. Unofficial sources within WHO have confirmed that these voluntary contributions form around 80% of WHO’s operating budget. The main external funders have been identified as (in descending order): the United States of America, the Bill and Melinda Gates Foundation, the United Kingdom of Great Britain and Northern Ireland, Rotary International, Norway, Canada, the European Commission, the Global Alliance for Vaccine Immunization (GAVI) and Hoffmann-La Roche. WHO confirmed that Roche's $84 million figure relates to in-kind contributions following the H1N1 pandemic response.

Who is covered by health insurance schemes and which services are used in Tanzania?
Health Economics Unit, University of Cape Town: SHIELD Policy Brief, March 2011

According to this brief, health insurance cover is gradually increasing among the Tanzanian population since its introduction over a decade ago. However, wealthier groups working in the formal sector are more likely to benefit from this development than poorer groups. The diversity of schemes, in terms of contribution rates and benefits offered, means that the effectiveness of insurance is inconsistent, both in terms of the amount and nature of services received by members. What is clear is that insurance is generally increasing the intensity of outpatient care use and also influencing where people go for such care, diverting people from informal drug shops to formal care. Members with insurance are more likely to use public primary care than their non‐insured rural counterparts, consistent with their benefit package. Despite equal contributions, health insurance members in urban areas use a much wider range of outpatient care than those in rural areas.

Who is covered by health insurance schemes and which services are used in Tanzania?
SHIELD, Health Economics Unit, University of Cape Town: July 2011

Health insurance cover is gradually increasing among the Tanzanian population since its introduction over a decade ago, according to this policy brief. However, wealthier groups working in the formal sector are more likely to benefit from this development than poorer groups. The diversity of schemes, in terms of contribution rates and benefits offered, means that the effect of insurance is inconsistent, both in terms of the amount and nature of services received by members. What is clear is that insurance is generally increasing the intensity of outpatient care use and also influencing where people go for such care, diverting people from informal drug shops to formal care. CHF members are more likely to use public primary care, than their non‐insured rural counterparts, consistent with their benefit package. Despite equal contributions, NHIF members in urban areas use a much wider range of outpatient care than those in rural areas. SHIELD makes three recommendations for health policy: addressing the lack of publicly available data on use of health services, increasing the availability of affordable insurance options for poorer groups and ensuring greater consistency in benefits offered, and taking into account the inequity in service availability between urban and rural areas when setting premiums for schemes.

Who pays and who benefits from health care? An assessment of equity in health care financing and benefit distribution in Tanzania
Mtei G, Makawia S, Ally M, Kuwawenaruwa A, Meheus F and Borghi J: Health Policy and Planning 27(suppl 1), March 2012

The Tanzanian health care financing system is marginally progressive while benefits are fairly evenly distributed across socio-economic groups, the authors of this study found. However, out-of-pocket payments and voluntary contributions to community health insurance are regressive. The poorest segment of the population receives a lower share of health care benefits relative to their share of need, whereas other population segments receive a greater share of benefits relative to their share of need. The authors conclude that health financing reforms can improve equity, so long as integration of health insurance schemes is promoted along with cross-subsidisation and greater reliance on general taxation to finance health care for the poorest.

Who pays for and who benefits from health care services in Uganda?
Kwesiga B, Ataguba JE, Abewe C, Kizza P, Zikusooka CM: BMC Health Services Research 15:44 February 2015

Equity in health care entails payment for health services according to the capacity to pay and the receipt of benefits according to need. In Uganda, as in many African countries, although equity is extolled in government policy documents, not much is known about who pays for, and who benefits from, health services. This paper assesses both equity in the financing and distribution of health care benefits in Uganda. Data are drawn from the most recent nationally representative Uganda National Household Survey 2009/10. Equity in health financing is assessed considering the main domestic health financing sources (i.e., taxes and direct out-of-pocket payments). This is achieved using bar charts and standard concentration and Kakwani indices. Benefit incidence analysis is used to assess the distribution of health services for both public and non-public providers across socio-economic groups and the need for care. Need is assessed using limitations in functional ability while socioeconomic groups are created using per adult equivalent consumption expenditure. Overall, health financing in Uganda is marginally progressive; the rich pay more as a proportion of their income than the poor. The various taxes are more progressive than out-of-pocket payments. However, taxes are a much smaller proportion of total health sector financing compared with out-of-pocket payments. The distribution of total health sector services benefits is pro-rich. The richest quintile receives 19.2% of total benefits compared to the 17.9% received by the poorest quintile. The rich also receive a much higher share of benefits relative to their need. Benefits from public health units are pro-poor while hospital based care, in both public and non-public sectors are pro-rich.

Who pays for health care in Ghana?
Akazili J, Gyapong J and McIntyre D: International Journal for Equity in Health 10(26), 27 June 2011

This paper presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana. Secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used, triangulated with data from the Ministry of Finance and other relevant sources, and further complemented with primary household data collected in six districts. Results showed that Ghana's health care financing system is generally progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes, which account for close to 50% of health care funding. The national health insurance (NHI) levy (part of VAT) is mildly progressive and formal sector NHI payroll deductions are also progressive. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are regressive form of health payment to households. For Ghana to attain adequate financial risk protection and ultimately achieve universal coverage, it needs to extend pre-payment cover to all in the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the National Health Insurance. Furthermore, the pre-payment funding pool for health care needs to grow so budgetary allocation to the health sector can be enhanced.

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