Researchers in this study analysed nine low-income and lower-middle-income countries in Africa and Asia that have implemented national health insurance reforms designed to move towards universal health coverage. Using the functions-of-health-systems framework, they first describe these countries' approaches to raising prepaid revenues, pooling risk, and purchasing services. Then, using the coverage-box framework, they assess their progress across three dimensions of coverage: who, what services, and what proportion of health costs are covered. Their findings revealed some patterns in the structure of these countries' reforms, such as use of tax revenues to subsidise target populations, steps towards broader risk pools, and emphasis on purchasing services through demand-side financing mechanisms. However, none of the reforms purely conformed to common health-system archetypes, nor were they identical to each other. Trends in these countries' progress towards universal coverage include increasing enrolment in government health insurance, a movement towards expanded benefits packages, and decreasing out-of-pocket spending accompanied by increasing government share of spending on health. Common, comparable indicators of progress towards universal coverage are needed to enable countries undergoing reforms to assess outcomes and make midcourse corrections in policy and implementation.
Resource allocation and health financing
Mozambique is referred to as being a success story after seventeen years of civil war and economic and social decline. The country is highly dependent on external aid. Long before the Paris Declaration on Aid Effectiveness, the Government of Mozambique (GoM) and a group of donors made efforts to coordinate and harmonise external aid. Therefore, it is interesting to study the evolution of external aid mechanisms to the country. The general objective of the research is to contribute to the agenda, discussion and results of the Ghana High Level Forum on aid effectiveness, reporting on progress and concerns regarding the implementation of the Paris Declaration. In the specific case of Mozambique, the research aims to examine critically the aid system and the mplications of the Paris Declaration, especially concerning ownership and accountability in the external aid system.
The performance of donors and recipient countries for delivery and use of aid undermine its potential to do good. Some conditionalities imposed to aid recipient countries, like Mozambique, reduce the extent to which it can contribute to poverty reduction and achieve the MDGs - by forcing governments to implement policies that lead to unemployment, declining public services and reduced capacity by citizens to access basic services. On the other hand, Mozambique still faces challenges in ensuring good governance, adequate institutional capacity and coordination of activities at different levels. Corruption practices without an appropriate mechanism for imputing responsibilities, lack of coordination across sectors and weak institutions and systems combined with the absence or weak donors’ coordination and harmonisation practices undermine the full potential of aid.
This study reviews primary data from seven country studies on the effects of three GHIs on coordination of HIV and AIDS programmes: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief (PEPFAR), and the World Bank's HIV and AIDS programmes, including the Multi-country AIDS Programme (MAP). In-depth interviews were conducted at national and sub-national levels (179 and 218 respectively) in seven countries in Europe, Asia, Africa and South America, between 2006 and 2008. Studies explored the development and functioning of national and sub-national HIV coordination structures, and the extent to which coordination efforts around HIV and AIDS are aligned with and strengthen country health systems. Positive effects of GHIs included the creation of opportunities for multi-sectoral participation, greater political commitment and increased transparency among most partners. However, the quality of participation was often limited, and some GHIs bypassed coordination mechanisms, especially at the sub-national level, weakening their effectiveness. The paper identifies residual national and sub-national obstacles to effective coordination and optimal use of funds by focal GHIs, which these GHIs, other donors and country partners need to collectively address.
The paper reports on work to collect, compile and evaluate publicly available national health accounts (NHA) reports produced worldwide between 1996 and 2010. The authors compiled data in the four main types used in these reports: (i) financing source; (ii) financing agent; (iii) health function; and (iv) health provider. The authors identified 872 NHA reports from 117 countries containing a total of 2936 matrices for the four data types. Most countries did not provide complete health expenditure data: only 252 of the 872 reports contained data in all four types. Some countries reported substantial year-on-year changes in both the level and composition of health expenditure that were probably produced by data-generation processes. All study data are publicly available at http://vizhub.healthdata.org/nha/. Data from NHA reports on health expenditure are often incomplete and, in some cases, of questionable quality. Better data would help finance ministries allocate resources to health systems, assist health ministries in allocating capital within the health sector and enable researchers to make accurate comparisons between health systems.
The author argues that the accusation that those who developed the policy on National Health Insurance (NHI) will be depriving South Africans of choice is very much unfounded. The development of the NHI policy is evidence-based; in a national survey South Africans were asked if they would support a NHI scheme if it limited their choice of doctors or if waiting lists for non-emergency services were introduced and half of the respondents indicated that they would not support it. Those who prepared the policy on NHI took into account the sentiments of the public by recommending that individuals will choose a provider within their district, whether in the public or private health sector and register for service delivery. They also proposed that the benefits must be portable, meaning that patients are covered even when they are away from their usual place of health care. Long waiting lists for non-emergency care are largely due to a shortage of health workers, particularly doctors in some areas. For this reason, the ANC proposal recommends a set of actions to mitigate overcrowding, which will reduce waiting times; these are increase of doctors through retention, increased intake of students into medicine and importation of doctors.
According to the Human Sciences Research Council’s (HSRC) Olive Shisana, ‘The NHI [national health insurance] system presents itself as an ideal mechanism for achieving equitable access to quality health services in South Africa: firstly, because it satisfies the fundamental principles of a unitary health system enshrined in our constitution; secondly, because it promotes redistribution and sharing of health care resources between the public and private sectors thus meeting our transformation agenda; and thirdly, because research evidence suggests that South Africans are generally willing to contribute to a financing system that caters for them and those unable to contribute.’ If NHI can overcome the inefficiencies of the private sector with its failing medical aid funding arrangement, and if it can address the quality-of-service issues of the public sector, it will indeed be a winning formula.
The author of this paper argues that there are a number of critical aspects which must be considered when reflecting on a national health insurance (NHI) scheme in South Africa. The benefit package ideally should cover a comprehensive package of primary and preventative benefits, with the main aim of providing the most benefits for the most people, given the pool of funds available. Experts will have to cost this package, which will be challenging because using public sector data will be difficult because ICD 10 coding (diagnosis codes) are not routinely used and collected, and the tariff schedule used in the public sector is not reflective of the actual costs of providing the benefit as it does not take into account costs such as infrastructure. Another key aspect is revenue collection. Assuming that the costing had been accurately done, and that a reasonably comprehensive benefit package was affordable, the author suggests that an earmarked tax from payroll seems the most logical manner in which to collect these funds. Critical to this process will be buy-in from labour and employers alike.
The purpose of this chapter in the South African Health Review is to describe the proposed national health insurance (NHI) in South Africa. The author explains the objective of the proposed reform, evaluates how South Africa currently fares relative to this objective and explores the implications of lessons from international experience for the South African health system. She argues that the term ‘NHI’ has itself contributed to the confusion about the intended reform and that the focus should instead be placed on its core objective – a universal health system that ensures that everyone is able to use health services when needed and that provides financial protection against the costs of health care for everyone. Another key area of contention has been whether NHI is affordable or not. The author argues that universal health care is affordable and, instead, the debate around affordability should rather be focused on the appropriateness and effectiveness of system design. The author calls for constructive and evidence-informed debate from all stakeholders on how best to achieve improved health for all South Africans through health system reform.
The crowd of health issues jostling for a share of Kenya's inadequate health budget is expanding, with activists calling for an increase in resources for the management of non-communicable diseases (NCDs), which account for more than 50% of hospital deaths and admissions, according to Plus News. At the same time, against a backdrop of two consecutive rejections for funding by the Global Fund to fight AIDS, Tuberculosis and Malaria and flat-lined funding from the United States President's Emergency Plan for AIDS Relief, Kenyan AIDS activists worry that any move to increase funding for NCDs could mean less for HIV and AIDS. Just 440,000 out of 1.5 million HIV-positive Kenyans have access to treatment, and more than 100,000 new HIV infections occur annually. Activists have identified the problem as a combination of scarce resources and a lack of political will by the country’s leadership. They claim that the government pays lip service to the global health issues in vogue – last year it was maternal health, while this year it is NCDs – without any significant improvements in health services. The medical superintendent of Mbagathi District Hospital in Nairobi says government has policies and guidelines in place for the management of NCDs, but there is a lack of strategic focus on operational implementation.