Resource allocation and health financing

The complexity of resource allocation for health
Dieleman J, Haakenstad A: The Lancet 3(1), 2015

This research emphasises that many governments are not meeting spending goals, and in many countries the financing gaps are so great that, even if they met the spending goals, expenditure would still fall short of what is needed. Expenditure would cover only 64% of estimated future funding requirements, leaving a gap of around a third of the total US$7.9 billion needed.

Financing and access to health care in West Africa: empirical data, cartoons and received ideas
Queuille L, Ridde V, University of Montreal, School of Public Health: January 2015

The project Access to healthcare for vulnerable groups in West Africa with the Help NGO produces publications in order to make research results and knowledge more accessible. The authors have worked for 10 years on producing and applying scientific knowledge about healthcare access and financing in Africa and aim to share their observations by experimenting with using satirical cartoons as a knowledge sharing tool. Made by the designer Glez, this series of cartoon focuses on preconceived ideas that people can have about the implementation of free health care and health insurance coverage in Sub-Saharan Africa.

Overcoming challenges to sustainable immunisation financing: early experiences from GAVI graduating countries
Saxenian H, Hecht R, Kaddar M, Schmitt S, Ryckman T, Cornejo S: Health Policy and Planning 30(2) 197-205

Over the 5-year period ending in 2018, 16 countries with a combined birth cohort of over 6 million infants requiring life-saving immunizations are scheduled to transition from outside financial and technical support for a number of their essential vaccines. This support has been provided over the past decade by the GAVI Alliance. Will these 16 countries be able to continue to sustain these vaccination efforts? To address this issue, GAVI and its partners are supporting transition planning, entailing country assessments of readiness to graduate and intensive dialogue with national officials to ensure a smooth transition process. The report presents learning form a pilot and observes that the experience of countries that have already transitioned should contribute to thinking about how such transition away from external funding can be achieved in low and middle income countries.

The health system cost of post-abortion care in Rwanda
Vlassoff M, Musange SF, Kalisa IR, Ngabo F, Sayinzoga F, Singh S, Bankole A: Health Policy and Planning 30(2) 223-233

Based on research conducted in 2012, the authors estimated the cost to the Rwandan health-care system of providing post-abortion care (PAC) due to unsafe abortions, a subject of policy importance not studied before at the national level. Thirty-nine public and private health facilities representing three levels of health care were randomly selected for data collection from key care providers and administrators for all five regions. Using an ingredients approach to costing, data were gathered on drugs, supplies, material, personnel time and hospitalisation. Additionally, direct non-medical costs such as overhead and capital costs were also measured. We found that the average annual PAC cost per client, across five types of abortion complications, was $93. The total cost of PAC nationally was estimated to be $1.7 million per year, 49% of which was expended on direct non-medical costs. Satisfying all demands for PAC would raise the national cost to $2.5 million per year. PAC comprises a significant share of total expenditure in reproductive health in Rwanda. Investing more resources in provision of contraceptive services to prevent unwanted or mistimed pregnancies would likely reduce health systems costs.

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.

Costs of Eliminating Malaria and the Impact of the Global Fund in 34 Countries
Zelman B, Kiszewski A, Cotter C, Liu J: PLoS ONE 9(12), December 2014

This study aims to 1) assess past total and Global Fund funding to the 34 current malaria-eliminating countries, and 2) estimate their future funding needs to achieve malaria elimination and prevent reintroduction through 2030. Historical funding is assessed against trends in country-level malaria annual parasite incidences (APIs) and income per capita. Following Kizewski et al. (2007), program costs to eliminate malaria and prevent reintroduction through 2030 are estimated using a deterministic model. The cost parameters are tailored to a package of interventions aimed at malaria elimination and prevention of reintroduction.The majority of Global Fund-supported countries experiencing increases in total funding from 2005 to 2010 coincided with reductions in malaria APIs and also overall GNI per capita average annual growth. The total amount of projected funding needed for the current malaria-eliminating countries to achieve elimination and prevent reintroduction through 2030 is approximately US$8.5 billion, or about $1.84 per person at risk per year (PPY). Although external funding, particularly from the Global Fund, has been key for many malaria-eliminating countries, sustained and sufficient financing is argued to be critical for furthering global malaria elimination.

The administrative costs of community-based health insurance: a case study of the community health fund in Tanzania
Borghi J, Makawia S, Kuwawenaruwa A: Health Policy and Planning 30 (1)19-27, December 2014

Community-based health insurance expansion has been proposed as a financing solution for the sizable informal sector in low-income settings. However, there is limited evidence of the administrative costs of such schemes. We assessed annual facility and district-level costs of running the Community Health Fund (CHF), a voluntary health insurance scheme for the informal sector in a rural and an urban district from the same region in Tanzania. Information on resource use, CHF membership and revenue was obtained from district managers and health workers from two facilities in each district. The administrative cost per CHF member household and the cost to revenue ratio were estimated. Revenue collection was the most costly activity at facility level (78% of total costs), followed by stewardship and management (13%) and pooling of funds (10%). Stewardship and management was the main activity at district level. The administration cost per CHF member household ranged from USD 3.33 to USD 12.12 per year. The cost to revenue ratio ranged from 50% to 364%. The cost of administering the CHF was high relative to revenue generated. Similar studies from other settings should be encouraged.

Strategic Purchasing Factsheet
Asia Pacific Observatory on health policy and systems: October 2014

A core function of health care financing is purchasing – the process by which funds are allocated to providers to obtain health services on behalf of the population. If designed and undertaken strategically, purchasing can improve health systems performance by promoting quality, efficiency, equity and responsiveness in health service provision. This brief discusses dimensions of purchasing in ten countries.

Inequities in accessibility to and utilisation of maternal health services in Ghana after user-fee exemption: a descriptive study
Ganle JK, Parker M, Fitzpatrick R, Otupiri E: International Journal for Equity in Health13(89), 1 November 2014

Inequities in accessibility to, and utilisation of maternal healthcare services impede progress towards attainment of the maternal health-related Millennium Development Goals. This study examined the extent to which maternal health services are used in Ghana, and whether inequities in accessibility to and utilization of services have been eliminated following the implementation of a user-fee exemption policy, that aims to reduce financial barriers to access, reduce inequities in access, and improve access to and use of birthing services.. The authors analyzed data from the 2007 Ghana Maternal Health Survey for inequities in access to and utilization of maternal health services. In measuring the inequities, frequency tables and cross-tabulations were used to compare rates of service utilization by region, residence and selected socio-demographic variables. Findings show marginal increases in accessibility to and utilisation of skilled antenatal, delivery and postnatal care services following the policy implementation (2003-2007). However, large gradients of inequities exist between geographic regions, urban and rural areas, and different socio-demographic, religious and ethnic groupings. The findings raise questions about the potential equity and distributional benefits of Ghana’s user-fee exemption policy, and the role of non-financial barriers or considerations. Exempting user-fees for maternal health services is a promising policy option for improving access to maternal health care, but might be insufficient on its own to secure equitable access to maternal health services in Ghana. Ensuring equity in access will require moving beyond user-fee exemption to addressing wider issues of supply and demand factors and the social determinants of health, including redistributing healthcare resources and services, and redressing the positional vulnerability of women in their communities.

The prevalence and determinants of catastrophic health expenditures attributable to non-communicable diseases in low- and middle-income countries: a methodological commentary
Goryakin Y, Suhrcke M: International Journal for Equity in Health 13(107), November 2014

Non-communicable diseases (NCDs) have been spreading fast in low and middle income countries and may also impose a substantial economic cost. One way in which NCDs might impact people’s economic well-being may be via the out-of-pocket expenditures required to cover treatment and other costs associated with suffering from an NCD. In this commentary, the authors identify and discuss the methodological challenges related to cross-country comparison of-out-of-pocket and catastrophic out-of-pocket health care expenditures, attributable to NCDs, focussing on low and middle income countries. There is evidence of substantial cost burden placed by NCDs on patients living in low and middle income countries, with most of it being heavily concentrated among low socioeconomic status groups. However, a large variation in definition of COOPE between studies prevents cross-country comparison. In addition, as most studies tend to be observational, causal inferences are often not possible. This is further complicated by the cross-sectional nature of studies, small sample sizes, and/or limited duration of follow-up of patients.