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.
Resource allocation and health financing
In March 2009, the Task Force for Innovative International Financing for Health Systems recommended a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others, and the Health Systems Funding Platform was soon launched. Despite its potential significance, there has been little comment in peer-reviewed literature, though some disquiet in the international development community around the scope of the Platform and the capacity of the partners, which appears disproportionate to the available information. This case study uses documentary analysis, participant observation and 24 in-depth interviews to examine the processes of development and key issues raised by the Platform. The findings show a fluid and volatile process, with debate over whether ongoing engagement in health system strengthening by the Global Fund and GAVI represents a dilution of organisational focus, risking ongoing support, or a paradigm shift that facilitates the achievement of targeted objectives, builds systems capacity, and will attract additional resources. The tensions, however, appear to have been resolved through a focus on national planning, applying International Health Partnership principles, though the global financial crisis and key personnel changes may yet alter outcomes. Despite its dynamic evolution, the Platform may offer an incremental path towards increasing integration around health systems that has not been previously possible, the authors conclude.
The objective of this study was to measure the direct cost burdens (health care expenditure as a percentage of total household expenditure) for households in rural South Africa, and examine the expenditure and use patterns driving those burdens in a setting with free public primary health care and hospital exemptions for the poor. Data was drawn from a cross-sectional survey of 280 households. The low overall mean cost burden of 4.5% suggests that free primary care and hospital exemptions provided financial protection. However, transport costs, the difficulty of obtaining hospital exemptions, use of private providers, and complex treatment patterns undermined this. The significant non-use of care shows the need for other measures such as more outreach services and more exemptions in rural areas. Fee removal anywhere must be accompanied by wider measures to ensure improved access.
With recent threats by the United states (US) Congress for extensive cuts to the federal government's budget for global health programmes, the author of ths paper argues that there could not be a worse time to pull back from long-standing American commitments to the health of people around the world. The cuts are argued to be particularly brutal at a time when medical science and field research shows the potential to achieve huge advances in the quality and scope of actions in global health. Major progress has been made in terms of providing care to malaria- and HIV-infected individuals. Rather than slashing global health funding, which represents less than 1% of the federal budget, the author argues that the US should be ensuring funding of successful international health initiatives and exploring new ways of generating predictable revenue for vital lifesaving programmes.
This study assessed the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa, using a synthesis model. In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision. However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to women having transactional sex was the most cost-effective. To maximize population health within a fixed budget, the authors argue that CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality.
This paper synthesises the evidence on cash transfers (CTs) impacts on social determinants of health and health inequalities in sub-Saharan Africa, and to identify the barriers and facilitators of effective CTs. Twenty-one electronic databases and the websites of 14 key organizations were searched in addition to grey literature and hand searching of selected journals for quantitative and qualitative studies on CTs’ impacts on social determinants of health and health outcomes. Out of 182 full texts screened for eligibility, 79 reports that reported findings from 53 studies were included in the final review. The review found that CTs can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration. CTs modify intermediate determinants such as nutrition, dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage. In conjunction with their influence on social determinants of health, there is moderate evidence from the review that CTs impact on health and quality of life outcomes. Many factors relating to intervention design features, macro-economic stability, household dynamics and community acceptance of programs influence the effectiveness of CTs.
The objective of this study was to evaluate the impact of health insurance on resource mobilisation, financial protection, service utilisation, quality of care, social inclusion and community empowerment in low- and lower-middle-income countries in Africa and Asia. A literature review was undertaken and 159 studies were included – 68 in Africa and 91 in Asia. Most African studies reported on community-based health insurance (CBHI) and were of relatively high quality, whereas social health insurance (SHI) studies were mostly Asian and of medium quality. Only one Asian study dealt with private health insurance (PHI). Most studies were observational, while four had randomised controls and 20 had a quasi-experimental design. In these studies, financial protection, utilisation and social inclusion were far more common subjects than resource mobilisation, quality of care or community empowerment. Strong evidence shows that CBHI and SHI improve service utilisation and protect members financially by reducing their out-of-pocket expenditure, and that CBHI improves resource mobilisation too. Weak evidence pointed to a positive effect of both SHI and CBHI on quality of care and social inclusion. The effect of SHI and CBHI on community empowerment was inconclusive and findings for PHI were also inconclusive because of a lack of studies. The authors conclude that health insurance offers some protection against the detrimental effects of user fees and a promising avenue towards universal health-care coverage.
How does health insurance affect health? After reviewing the evidence on this question, we reach three conclusions. First, many of the studies claiming to show a causal effect of health insurance on health do not do so convincingly because the observed correlation between insurance and good health may be driven by other, unobservable factors. Second, convincing evidence demonstrates that health insurance can improve health measures of some population subgroups, some of which, although not all, are the same subgroups that would be the likely targets of coverage expansion policies. Third, for policy purposes we need to know whether the results of these studies generalize. Solid answers to the multitude of important questions about how specific health insurance policy options may affect health seem likely to be forthcoming only with investment of substantial resources in social experiments.
This study assessed the impact of introducing user fees on 28 601 births at Haydom Lutheran Hospital, Tanzania, comparing the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. The monthly number of births fell by 17.3% after fees were introduced. After the introduction of ambulance and delivery fees, the study found an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight. The authors suggest that this might indicate that women delayed seeking skilled birth attendance or did not seek help at all, possibly due to financial reasons, and argue that free delivery care should be a high priority.
This study exploits the opportunities created by a pilot study of micro health insurance with capitation in Rwanda to address this issue. Using cross-sectional data collected in 52 health centres, the paper employs an econometric cost function with payer-specific outputs to assess the cost impact of two provider payment mechanisms: (1) user fees for care paid by the uninsured, and (2) capitation payment paid by informal insurance schemes for the insured. Findings point to significant differences in cost between the two payment forms. For both payment types there are important short-run economies of scale, which could be exploited through more intensive use of idle resources in health centres.