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.
Resource allocation and health financing
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 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.
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.
This research paper is produced as part of the South Centre’s research on expanding fiscal policies for global and national tobacco control. The objective of this research is to identify innovative solutions to fill the funding gaps in the implementation of the WHO Framework Convention on Tobacco Control (FCTC). Ideas and mechanisms for generating additional funding may be spawned from a review of the popular forms of non-traditional financing mechanisms that have been aimed at mobilizing resources for developmental programmes. The General Assessment section for each innovative financing idea in the paper reflects lessons learned and best practices that provide the reader with some framework when evaluating an innovative financing mechanism. Some are more administratively feasible than others but in all cases, political feasibility is a critical element. A deeper understanding of the political concerns would surface and can possibly be addressed only if the ideas are allowed to be debated on, and sufficient space to explore is provided in the appropriate forum.
Many low- and middle-income countries are seeking to reform their health financing systems to move towards universal coverage. This typically means that financing is based on people’s ability to pay while, for service use, bene-fits are based on the need for health care. Financing incidence analysis (FIA) and benefit incidence analysis (BIA) are two popular tools used to assess equity in health systems financing and service use. FIA studies examine who pays for the health sector and how these contributions are distributed according to socioeconomic status (SES). BIA determines who benefits from health care spending, with recipients ranked by their relative SES. In this article, the authors identify 10 resources to assist researchers and policy makers seeking to undertake or interpret findings from financing and benefit incidence analyses in the health sector. The article pays particular attention to the data requirements, computations, methodological challenges and country level experiences with these types of analyses.
African civil society organizations have called for greater accountability and transparency from African leaders regarding the use of public funds for the survival of mothers and babies. This call to action marks the launch of an African-led network demanding better use of existing funds for African women and children’s health as well as a greater share of African national budgets allocated to mothers and babies’ survival. While most African government have already made commitments about improving the health of their population, including through greater spending, it is difficult to check whether they are keeping their promises if the budget is not publicly available or if the information in the budget is not clearly presented. The members of the Africa Health Budget Network have compiled a scorecard[1] showing how open African Governments are about their health spending. Out of the 26 African countries profiled, only one, South Africa, is reported to be sufficiently transparent.
This article examines elements of a successful cash transfer program from Latin America and discusses challenges inherent in scaling-up such programs. The authors attempt a cost simulation of a cash transfer program for HIV prevention in South Africa comparing its cost and relative effectiveness – in number of HIV infections averted – against other prevention interventions. If a cash transfer program were to be taken to scale, the intervention would not have a substantial effect on decreasing the force of the epidemic in middle- and low-income countries. The integration of cash transfer programs into other sectors and linking them to a broader objective such as girls’ educational attainment is argued by the authors as one way of addressing doubts raised by the authors regarding their value for HIV prevention.
Malawi is one of the most aid dependent countries in the world. When one considers the work that is done by international NGOs, however, or by them through local surrogates, it is argued that there is no aspect of life in Malawi that has escaped external funding. With July 6, 2014 a day 50 years to the day when Malawi became an independent state the author argues that it’s important to accentuate the discussion on aid in Malawi and its implications for Malawi. the author argues that a heavy reliance on external funding means that foreigners, not the citizens, are in charge of the country’s governance.
Principal Recipients (PRs) receive money from the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) to manage and implement programs. However, little research has gone into understanding their opinions and experiences. This survey set out to describe these, thereby providing a baseline against which changes in PR opinions and experiences can be assessed as the recently introduced new funding model is rolled out. An internet based questionnaire was administered to 315 PRs. A total of 115 responded from 69 countries in Africa, Asia, Eastern Europe and Latin America. The study was conducted between September and December 2012. Three quarters of PRs thought the progress update and disbursement request (PU/DR) system was a useful method of reporting grant progress. However, most felt that the grant negotiation processes were complicated, and that the grant rating system did not reflect performance. While nearly all PRs were happy with the work being done by sub-Recipients (92%) and Fund Portfolio Managers (86%), fewer were happy with the Office of the Inspector General (OIG). Non-government PRs were generally less happy with the OIG’s work compared to government PRs. Most PRs thought the Global Fund’s Voluntary Pooled Procurement system made procurement easier. However, only 29% said the system should be made compulsory. When asked which aspects of the Global Fund’s operations needed improvement, most PRs said that the Fund should re-define and clarify the roles of different actors, minimize staff turnover at its Secretariat, and shorten the grant application and approval processes. All these are currently being addressed, either directly or indirectly, under a new funding model. Vigorous assessments should nonetheless follow the roll-out of the new model to ensure the areas that are most likely to affect PR performance realize sustained improvement. Opinions and experiences with the Global Fund were varied, with PRs having good communication with Fund Portfolio Managers and sub-Recipients, but being unhappy with the grant negotiation and grant rating systems. Recommendations included simplifying grant processes, finding performance assessment methods that look beyond numbers, and employing Local Fund Agents who understand public health aspects of programs.