Summary Background Universal coverage of health care is now receiving substantial worldwide and national attention, but debate continues on the best mix of financing mechanisms, especially to protect ...people outside the formal employment sector. Crucial issues are the equity implications of different financing mechanisms, and patterns of service use. We report a whole-system analysis—integrating both public and private sectors—of the equity of health-system financing and service use in Ghana, South Africa, and Tanzania. Methods We used primary and secondary data to calculate the progressivity of each health-care financing mechanism, catastrophic spending on health care, and the distribution of health-care benefits. We collected qualitative data to inform interpretation. Findings Overall health-care financing was progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries. Interpretation Analyses of the equity of financing and service use provide guidance on which financing mechanisms to expand, and especially raise questions over the appropriate financing mechanism for the health care of people outside the formal sector. Physical and financial barriers to service access must be addressed if universal coverage is to become a reality. Funding European Union and International Development Research Centre.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Inequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social ...services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. However, these studies are based on selected disease conditions and only consider a single point in time. Trend analyses have yet to be produced. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s.
Several rounds (2002, 2004, 2006, and 2008) of the South African General Household Surveys (GHS) data were used, with standardized and normalized self-reported illness and disability concentration indices to assess the distribution of illness and disability across socio-economic groups. Composite indices of socio-economic status were created using a set of common assets and household characteristics.
This study demonstrates the existence of socio-economic gradients in self-reported ill-health in South Africa. The burden of the major categories of ill-health and disability is greater among lower than higher socio-economic groups. Even non-communicable diseases, which are frequently seen as diseases of affluence, are increasingly being reported by lower socio-economic groups. For instance, the concentration index of flu (and diabetes) declined from about 0.17 (0.10) in 2002 to 0.05 (0.01) in 2008. These results have also been confirmed internationally.
The current burden and distribution of ill-health indicates how critical it is for the South African health system to strive for access to and use of health services that is in line with need for such care. Concerted government efforts, within both the health sector and other social and economic sectors are therefore needed to address the significant health inequalities in South Africa.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Increasing attention has been paid in recent years to efforts to strengthen the impact of research on policy in low- and middle-income countries. However, the processes by which such research might ...have policy impact remain a subject of debate. This paper presents an analysis of the research/policy interface, drawing on the experiences of two South African health policy and systems research (HPSR) units and one specific study which traced the development and implementation of three areas of health care financing policy change and debate between 1994 and 1999. The analysis is based primarily on the authors' own experiences and has been developed through a deliberate process of reflection. It suggests, first, that it is important to acknowledge the conceptual and symbolic uses and impacts of research – perhaps, particularly in relation to the system-oriented work of HPSR groups. These uses may not be verifiable by specific changes in policy and practice but are important contributions to the policy environment and do filter into policy-makers' understandings and actions. Second, achieving any form of impact on policy is linked to the attention researchers pay to the context in which the research is undertaken, the nature and credibility of the research; and the importance of nesting any single project in a broader programme of engagement with the policy environment that builds trust in the researchers.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. John E. Ataguba and colleagues illustrate progress towards UHC and its monitoring and evaluation in ...South Africa.
Please see later in the article for the Editors' Summary
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Action on the social determinants of health (SDH) is relevant for reducing health inequalities. This is particularly the case for South Africa (SA) with its very high level of income inequality and ...inequalities in health and health outcomes. This paper provides evidence on the key SDH for reducing health inequalities in the country using a framework initially developed by the World Health Organization.
This paper assesses health inequalities in SA and explains the factors (i.e. SDH and other individual level factors) that account for large disparities in health. The relative contribution of different SDH to health inequality is also assessed.
A cross-sectional design is used. Data come from the third wave of the nationally representative National Income Dynamics Study. A subsample of adults (18 years and older) is used. The main variable of interest is dichotomised good versus bad self-assessed health (SAH). Income-related health inequality is assessed using the standard concentration index (CI). A positive CI means that the rich report better health than the poor. A negative value signifies the opposite. The paper also decomposes the CI to assess its contributing factors.
Good SAH is significantly concentrated among the rich rather than the poor (CI=0.008; p<0.01). Decomposition of this result shows that social protection and employment (contribution=0.012; p<0.01), knowledge and education (0.005; p<0.01), and housing and infrastructure (−0.003; p<0.01) contribute significantly to the disparities in good SAH in SA. After accounting for these other variables, the contribution of income and poverty is negligible.
Addressing health inequalities inter alia requires an increased government commitment in terms of budgetary allocations to key sectors (i.e. employment, social protection, education, housing, and other appropriate infrastructure). Attention should also be paid to equity in benefits from government expenditure. In addition, the health sector needs to play its role in providing a broad range of health services to reduce the burden of disease.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
World-wide, there is growing universal health coverage (UHC) enthusiasm. The South African government began piloting policies aimed at achieving UHC in 2012. These UHC policies have been and are ...being rolled out in the ten selected pilot districts. Our study explored policy implementation experiences of 71 actors involved in UHC policy implementation, in one South African pilot district using the Contextual Interaction Theory (CIT) lens.
Our study applied a two-actor deductive theory of implementation, Contextual Interaction Theory (CIT) to analyse 71 key informant interviews from one National Health Insurance (NHI) pilot district in South Africa. The theory uses motivation, information, power, resources and the interaction of these to explain implementation experiences and outcomes. The research question centred on the utility of CIT tenets in explaining the observed implementation experiences of actors and outcomes particularly policy- practice gaps.
All CIT central tenets (information, motivation, power, resources and interactions) were alluded to by actors in their policy implementation experiences, a lack or presence of these tenets were explained as either a facilitator or barrier to policy implementation. This theory was found as very useful in explaining policy implementation experiences of both policy makers and facilitators.
A central tenet that was present in this context but not fully captured by CIT was leadership. Leadership interactions were revealed as critical for policy implementation, hence we propose the inclusion of leadership interactions to the current CIT central tenets, to become motivation, information, power, resources, leadership and interactions of all these.
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CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
8.
Hambani kahle Gavin and Del McIntyre, Di
Australian and New Zealand journal of public health,
February 2013, Volume:
37, Issue:
1
Journal Article
Peer reviewed
Open access
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BFBNIB, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
There is a global concern regarding how households could be protected from relatively large healthcare payments which are a major limitation to accessing healthcare. Such payments also endanger the ...welfare of households with the potential of moving households into extreme impoverishment. This paper examines the impoverishing effects of out-of-pocket (OOP) healthcare payments in Ghana prior to the introduction of Ghana's national health insurance scheme.
Data come from the Ghana Living Standard Survey 5 (2005/2006). Two poverty lines ($1.25 and $2.50 per capita per day at the 2005 purchasing power parity) are used in assessing the impoverishing effects of OOP healthcare payments. We computed the poverty headcount, poverty gap, normalized poverty gap and normalized mean poverty gap indices using both poverty lines. We examine these indicators at a national level and disaggregated by urban/rural locations, across the three geographical zones, and across the ten administrative regions in Ghana. Also the Pen's parade of "dwarfs and a few giants" is used to illustrate the decreasing welfare effects of OOP healthcare payments in Ghana.
There was a high incidence and intensity of impoverishment due to OOP healthcare payments in Ghana. These payments contributed to a relative increase in poverty headcount by 9.4 and 3.8% using the $1.25/day and $2.5/day poverty lines, respectively. The relative poverty gap index was estimated at 42.7 and 10.5% respectively for the lower and upper poverty lines. Relative normalized mean poverty gap was estimated at 30.5 and 6.4%, respectively, for the lower and upper poverty lines. The percentage increase in poverty associated with OOP healthcare payments in Ghana is highest among households in the middle zone with an absolute increase estimated at 2.3% compared to the coastal and northern zones.
It is clear from the findings that without financial risk protection, households can be pushed into poverty due to OOP healthcare payments. Even relatively richer households are impoverished by OOP healthcare payments. This paper presents baseline indicators for evaluating the impact of Ghana's national health insurance scheme on impoverishment due to OOP healthcare payments.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
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