This paper aimed to measure the impact of user fee reforms on the probability of giving birth in an institution or receiving a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population. The authors analysed data from consecutive surveys in five countries: two case countries that experienced reforms (Ghana and Burkina Faso) in contrast to three that did not experience reforms (Zambia, Cameroon, Nigeria). User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest) and non-educated women and those in rural areas benefited the most from the reforms. Findings show a clear positive impact on access when user fees are removed but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform.
Resource allocation and health financing
The Davis Tax Committee was established in 2013 by the Minister of Finance to inquire into the role of the tax system in promoting inclusive economic growth, employment creation, development and fiscal sustainability. This report concentrates on identifying long term financing principles – the specific operationalisation which will be informed by more detailed implementation and costing plans in order to manage the transition from the status quo to the financing regime envisaged in the National Health Insurance (NHI) in South Africa. This report examines the definition, rationale and design of the proposed NHI. It explores international experience in financing universal health coverage, with a focus on middle income developing countries and existing sources of health financing in South Africa are analysed. Cost estimates and potential macroeconomic impacts are discussed and the report concludes with an evaluation of options for NHI financing. The authors identify a number of factors in the design of NHI, as well as its implementation, all of which have an impact on its financing trajectory. These include parameters on risk pooling, on health care purchasing and on provision. Risk pooling decisions include whether there would be a single or multiple purchaser, the level of consolidation of risk pools and their coverage and composition as well as the nature of the resources allocation formula (evidence and needs based, risk equalisation etc.). The structure of purchasing encompasses, inter alia, the scope and pricing of the benefit package (which had not yet been defined in the White Paper), contractual arrangements with health care providers such as GPs and hospitals, quality management systems, payment and information systems.
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.
Overall, this paper found that health care in South Africa is very ‘pro-rich’, with the richest 20% of the population receiving 36% of total benefits (despite having a ‘health need share’ of less than 10%) while the poorest 20% receive only 12.5% of the benefits (despite having a ‘health need share’ of more than 25%). The findings indicate that there is a lack of cross-subsidies in the overall health system in South Africa. Although health care financing is ‘progressive’, this is largely due to the richest groups bearing the burden of medical scheme funding. However, the richest groups are the exclusive beneficiaries of these funds. The study shows that benefit incidence in South Africa is inequitable and notes that, in terms of a solution, the only component of the current South African health system that could contribute to overall income and risk cross-subsidies is tax funding. However, the strongly progressive component of personal income tax is to some extent offset by the regressivity of excise taxes and fuel levies and the proportional impact of VAT. In the context of the degree of income inequalities that exist in South Africa, the paper calls for a move to a health system where South Africans contribute according to ability-to-pay and benefit according to need for health care.
This paper considers the minimum resources that would be required to achieve South Africa’s proposed National Health Insurance (NHI) system and contrasts these with the costs of scaled up access to antiretroviral treatment (ART) between 2010 and 2020. The costs of ART and universal coverage (UC) were assessed through multiplying unit costs, utilisation and estimates of the population in need during each year of the planning cycle. Costs are from the provider’s perspective reflected in real 2007 prices. The study found that the annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real gross domestic product (GDP) growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget.
This report offers a comprehensive view of trends in public and private financing of development assistance for health (DAH), with preliminary estimates of how the economic downturn is affecting health financing in 2010. The Institute for Health Metrics and Evaluation (IHME) notes that the global economic recession appears to be contributing to a slowing of the rate of growth in DAH. Estimates show continued growth through 2010 to a total of $26.87 billion by year’s end, but the rate of growth was cut by more than half from an annual average of 13% between 2004 and 2008 to 6% annually between 2008 and 2010. Spending on HIV and AIDS programmes continued to rise at a strong rate, making HIV and AIDS the most funded of all health focus areas. Maternal, newborn and child health received about half as much funding as HIV and AIDS in 2008. Tuberculosis funding grew steadily from 1990 through 2008. Malaria funding rose more dramatically than any other health focus area between 2007 and 2008. Despite much discussion about the need for general health sector support, funding for that area has grown slowly since 2006, according to the report. Non-communicable diseases receive the least amount of funding compared with other health focus areas. Uncertainty about the future of DAH underscores the importance of tracking global health spending to ensure resources are directed as efficiently as possible to the world’s most pressing health needs.
This report offers a comprehensive view of trends in public and private financing of development assistance for health (DAH), with preliminary estimates of how the economic downturn is affecting health financing in 2010. The Institute for Health Metrics and Evaluation (IHME) notes that the global economic recession appears to be contributing to a slowing of the rate of growth in DAH. Estimates show continued growth through 2010 to a total of $26.87 billion by year’s end, but the rate of growth was cut by more than half from an annual average of 13% between 2004 and 2008 to 6% annually between 2008 and 2010. Spending on HIV and AIDS programmes continued to rise at a strong rate, making HIV and AIDS the most funded of all health focus areas. Maternal, newborn and child health received about half as much funding as HIV and AIDS in 2008. Tuberculosis funding grew steadily from 1990 through 2008. Malaria funding rose more dramatically than any other health focus area between 2007 and 2008. Despite much discussion about the need for general health sector support, funding for that area has grown slowly since 2006, according to the report. Non-communicable diseases receive the least amount of funding compared with other health focus areas. Uncertainty about the future of DAH underscores the importance of tracking global health spending to ensure resources are directed as efficiently as possible to the world’s most pressing health needs.
In this year’s report, IHME has built on its past data collection and analysis efforts to monitor the resources made available through development assistance for health (DAH) and government health expenditure (GHE). It confirms what many in the global health community expected: After reaching a historic high in 2010, overall DAH declined slightly in 2011 and reached a plateau, with some organisations and governments spending more and others spending less. The research suggests that, despite global macroeconomic stress, the international community continues to respond to the need for health and health system support across the developing world. Over the past two years in particular, DAH has been sustained at levels of spending that would have been inconceivable a decade ago. The recent plateau in DAH, however, raises a number of considerations for decision-makers and other global health stakeholders. Major changes in the global health landscape have transpired during the past few years. The shifts in growth and spending emphasise the continued importance of tracking these funding flows, which ensures that decision makers can make choices about resource allocation with full information.
The gravity of the HIV/AIDS situation in Botswana, Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe calls for prioritisation, protection and targeting of HIV/AIDS spending, says a comparative study by the Human Sciences Research Council (HSRC), South Africa that assesses the readiness and ability of six African countries to respond to the HIV/AIDS epidemic. The study says revenue neutral efforts have not been very successful and that it will be important for all these countries to share lessons and experiences before and after they embark on the Global Fund process. Furthermore, the ability to absorb the vastly increased resources will be a critical determinant of whether these resources are translated into increased outputs and ultimately increased outcomes.
In the past two years, the political commitment to respond to the HIV/AIDS pandemic has increased substantially. In this policy environment, the importance of information on resources allocated to HIV/AIDS prevention and care has increased. In order to avoid resource misallocation, policy makers need information on the level and flow of current resource allocations to HIV/AIDS. They need to know where money for HIV/AIDS prevention and care is coming from, the services and commodities that are purchased with these funds, and the population coverage of the implemented interventions. At the same time, to identify needs and plan strategically, policy-makers require information on the scale of resources required to prevent the further spread of HIV and to provide adequate care for those people living with HIV/AIDS.