Commercialisation of health care has contributed to widening inequities between the rich and the poor, especially in settings with suboptimal regulatory frameworks of the health sector. Poorly regulated fee-for-service payment systems generate inequity and initiate a vicious circle in which access to quality health care gradually deteriorates. Although the abolition of user fees is high on the international health policy agenda, the sudden removal of user fees may have disrupting effects on the health system and may not be affordable or sustainable in resource-constrained countries, such as the Democratic Republic of Congo. Between 2008 and 2011, the Belgian development aid agency (BTC) launched a set of reforms in the Kisantu district, in the province of Bas Congo, through an action-research process deemed appropriate for the implementation of change within open complex systems such as the Kisantu local health system. Moreover, the entire process contributed to strengthen the stewardship capacity of the Kisantu district management team. The reforms mainly comprised the rationalisation of resources and the regulation of health services financing. Flat fees per episode of disease were introduced as an alternative to fee-for-service payments by patients. A financial subsidy from BTC allowed to reduce the height of the flat fees. The provision of the subsidy was made conditional upon a range of measures to rationalise the use of resources. The results in terms of enhancing people access to quality health care were immediate and substantial. The Kisantu experience demonstrates that a systems approach is essential in addressing complex problems. It provides useful lessons for other districts in the country.
Resource allocation and health financing
To meet African countries’ massive health burdens, national budget resources are often supplemented by mechanisms that cut across sectors, such as debt-relief proceeds and budgetary support. This requires the Ministry of Health (MoH) to participate in prioritisation debates and compete for resources with other ministries. The authors analysed the MoHs and MoFs of Ghana, Senegal and Uganda. Their findings pointed to the importance of the Ministries working together to build consensus during budget planning and policymaking. The MoH representatives faced capacity and skills constraints for this, such as in cash-flow management and budget preparation. In relation to the MoF, the budget process was still perceived as rigid and predetermined. The authors recommend that the Ministries should each designate an officer to serve as a liaison for informal information sharing, increased accountability, and collaborative budget planning. Governments should institutionalise a forum for promoting dialogue between the Ministries to increase mutual understanding and align goals. They also proposed that MoHs need to strengthen their evidence for increased budget support by linking specific health indicators to budget line items and improving their monitoring and evaluation of programmes.
KEMRI-Wellcome Trust has conducted research to understand how county hospitals in Coastal Kenya set priorities and allocate resources between services. Data was collected in 2012 and 2013. This brief presents the key findings from the research, showing how hospital managers set priorities and the reasons behind their decisions. Even though the study was conducted pre-devolution, findings remain relevant post-devolution, especially in counties where hospitals still enjoy financial autonomy and as they plan ways to structure hospital financing and priority setting. The brief provides recommendations for county departments of health to improve hospital financing and budgeting, and for hospital managers to improve priority setting and ensure a fair allocation of resources between services. Key messages from the report included that hospitals lack explicit processes for setting healthcare priorities; this provides room for the use of inappropriate priority setting criteria such as lobbying and favouritism. Evidence is not used in decision- making. Hospitals are severely under-resourced and depend on user fee revenues. This has turned hospitals into revenue-maximisers whereby managers prioritise services that generate revenue through user-fees and overlook services with limited moneymaking potential, including those for young children and disabled people. Many key stakeholders including middle level managers, clinicians and community members, are not included in priority setting processes. It is important for hospital managers to institute clearly defined procedures and ensure that priority setting is inclusive. Hospital managers are often clinicians with limited training and skills in management and leadership. Many did not choose to become leaders. Educational institutions and county departments of health both have a role to play in strengthening management and leadership capacity, as well as incentivising hospital managers.
The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 11th of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. Objectives We reviewed the literature on incorporating considerations of cost-effectiveness, affordability and resource implications in guidelines and recommendations.
This case study describes the Government of Kenya’s initiative to expand the supply of health care and strengthen primary health care through implementation of the Health Sector Services Fund (HSSF), which provides direct cash transfers to primary health facilities. This initiative has so far been expanded to nearly 3,000 primary health facilities in the public sector. The administrative data of ministries of health suggest increased utilisation of the primary health facilities (from 25.8 million in 2010/11 to 27 million in 2011/12). The health facilities were able to improve their overall upkeep with the local contractual staff and were able to buy consumables to improve quality of care. A pilot undertaken in applying the principles of performance-based financing suggests that such an approach can help further strengthen the monitoring and evaluation systems and contribute to improvements in quality. There are, however, some operational challenges that were faced during the first two years of implementation, like issuing timely authorisations for incurring expenditures, the need for more hands-on support for accounting, and further simplification of accounting at the facility level. These issues are being addressed by the government, which intends to implement ongoing improvements by gathering data through the Public Expenditure Tracking Survey Plus.
Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers’ job satisfaction, motivation, and attrition in Zambia. It uses a randomised intervention/control design to evaluate before–after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. Mixed methods were employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion sought to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centres were staffed with qualified personnel and the personnel had role clarity. In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.
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.
This report summaries the methods for analyzing 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 are organized into four key policy questions facing decision-makers: What is the current level of inequity in health? Does government health expenditure benefit the worst-off? Can government health expenditure more effectively promote equity? and 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.
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.
Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.03–7.5 % in Kenya, with a statistically significant difference in the proportion of spending on SRH services across income quintiles. The poorest households in Kenya spent ten times more on seeking care than the least poor households. The most common coping mechanisms were receiving [money] from partner or household members and using own savings or regular income. Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings.