[Show abstract][Hide abstract] ABSTRACT: Households have been impoverished and faced catastrophic health expenditure as a result of paying out-of-pocket (OOP) health expenses. Using data collected over ten years, changes in utilization and in catastrophic health expenditures in light of the abolition of user fees in 2001 is examined in this article. In the long term, increase in utilization of health services among the poor remained above the national average but cost as a reason for not seeking care was lower among the poor compared with the national average. Use of private providers remained significant. The incidence of catastrophic health expenditure increased following user fee abolition, and although it has decreased in the long term it still remains high. Ensuring financial risk protection calls for health system improvements and exploring ways of harnessing the high OOPs into prepayment. The private sector is a significant player, and its effective regulation will need to be addressed. There is also need for wider government intervention to reduce poverty and control population growth.
[Show abstract][Hide abstract] ABSTRACT: Background:
The objectives of this study were to assess the patterns of treatment seeking behaviour for children under five with malaria; and to examine the statistical relationship between out-of-pocket expenditure (OOP) on malaria treatment for under-fives and source of treatment, place of residence, education and wealth characteristics of Uganda households. OOP expenditure on health care is now a development concern due to its negative effect on households' ability to finance consumption of other basic needs.
The 2009 Uganda Malaria Indicator Survey was the source of data on treatment seeking behaviour for under-five children with malaria, and patterns and levels of OOP expenditure for malaria treatment. Binomial logit and Log-lin regression models were estimated. In logit model the dependent variable was a dummy (1=incurred some OOP, 0=none incurred) and independent variables were wealth quintiles, rural versus urban, place of treatment, education level, sub-region, and normal duty disruption. The dependent variable in Log-lin model was natural logarithm of OOP and the independent variables were the same as mentioned above.
Five key descriptive analysis findings emerge. First, malaria is quite prevalent at 44.7% among children below the age of five. Second, a significant proportion seeks treatment (81.8%). Third, private providers are the preferred option for the under-fives for the treatment of malaria. Fourth, the majority pay about 70.9% for either consultation, medicines, transport or hospitalization but the biggest percent of those who pay, do so for medicines (54.0%). Fifth, hospitalization is the most expensive at an average expenditure of US$7.6 per child, even though only 2.9% of those that seek treatment are hospitalized.The binomial logit model slope coefficients for the variables richest wealth quintile, Private facility as first source of treatment, and sub-regions Central 2, East central, Mid-eastern, Mid-western, and Normal duties disrupted were positive and statistically significant at 99% level of confidence. On the other hand, the Log-lin model slope coefficients for Traditional healer, Sought treatment from one source, Primary educational level, North East, Mid Northern and West Nile variables had a negative sign and were statistically significant at 95% level of confidence.
The fact that OOP expenditure is still prevalent and private provider is the preferred choice, increasing public provision may not be the sole answer. Plans to improve malaria treatment should explicitly incorporate efforts to protect households from high OOP expenditures. This calls for provision of subsidies to enable the private sector to reduce prices, regulation of prices of malaria medicines, and reduction/removal of import duties on such medicines.
[Show abstract][Hide abstract] ABSTRACT: Background
Accelerating progress towards universal coverage in African countries calls for concrete actions that reinforce social health protection through establishment of sustainable health financing mechanisms. In order to explore possible pathways for moving past the existing obstacles, panel discussions were organized on health financing bringing together Ministers of health and Ministers of finance with the objective of creating a discussion space where the different perspectives on key issues and needed actions could meet. This article presents a synthesis of panel discussions focusing on the identified challenges and the possible solutions. The overview of this paper is based on the objectives and proceedings of the panel discussions and relies on the observation and study of the interaction between the panelists and on the discourse used.
The discussion highlighted that a large proportion of the African population has no access to needed health services with significant reliance on direct out of pocket payments. There are multiple obstacles in making prepayment and pooling mechanisms operational. The relatively strong political commitment to health has not always translated into more public spending for health. Donor investment in health in low income countries still falls below commitments. There is need to explore innovative domestic revenue collection mechanisms. Although inadequate funding for health is a fundamental problem, inefficient use of resources is of great concern. There is need to generate robust evidence focusing on issues of importance to ministry of finance. The current unsatisfactory state of health financing was mainly attributed to lack of clear vision; evidence based plans and costed strategies.
Based on the analysis of discussion made, there are points of convergence and divergence in the discourse and positions of the two ministries. The current blockage points holding back budget allocations for health can be solved with a more evidence based approach and dialogue based on a clear vision and costed strategic plan articulated by the ministry of health. Improving health in Africa is a driver for long-term economic growth and development and this is the reason why the ministries of health and finance will need to find common ground on how to create policy coherence and how to articulate their respective objectives.
BMC International Health and Human Rights 11/2012; 12(1):30. DOI:10.1186/1472-698X-12-30 · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The implementation of policies remains a huge challenge in many low-income countries. Several factors play a role in this, but improper management of existing knowledge is no doubt a major issue. In this article, we argue that new platforms should be created that gather all stakeholders who hold pieces of relevant knowledge for successful policies. To build our case, we capitalize on our experience in our domain of practice, health care financing in sub-Saharan Africa. We recently adopted a community of practice strategy in the region. More in general, we consider these platforms as the way forward for knowledge management of implementation issues.
L’implémentation des politiques reste un énorme défi dans les pays à faibles revenus. Plusieurs facteurs y jouent un rôle, mais la mauvaise gestion des connaissances existantes est sans aucun doute un enjeu majeur. Dans cet article, nous soutenons que de nouvelles plates-formes devraient être créées afin de réunir toutes les parties prenantes qui détiennent des parts de connaissances pertinentes pour des politiques efficaces. Pour élaborer notre cas, nous capitalisons sur notre expérience dans notre domaine de pratique: le financement des soins de santé en Afrique subsaharienne. Nous avons récemment adopté une stratégie de communauté de pratique dans la région. Plus en général, nous considérons ces plates-formes comme la voie à suivre pour la gestion des connaissances sur les questions d’implémentation.
Tropical Medicine & International Health 05/2011; 16(8):1007-14. DOI:10.1111/j.1365-3156.2011.02794.x · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Government of Swaziland decided to explore the feasibility of social health insurance (SHI) in order to enhance universal access to health services. We assess the financial feasibility of a possible SHI scheme in Swaziland. The SHI scenario presented is one that mobilises resources additional to the maintained Ministry of Health and Social Welfare (MOHSW) budget. It is designed to increase prepayment, enhance overall health financing equity, finance quality improvements in health care, and eventually cover the entire population.
The financial feasibility assessment consists of calculating and projecting revenues and expenditures of the SHI scheme from 2008 to 2018. SimIns, a health insurance simulation software, was used. Quantitative data from government and other sources and qualitative data from discussions with health financing stakeholders were gathered. Policy assumptions were jointly developed with and agreed upon by a MOHSW team.
SHI would take up an increasing proportion of total health expenditure over the simulation period and become the dominant health financing mechanism. In principle, and on the basis of the assumed policy variables, universal coverage could be reached within 6 years through the implementation of an SHI scheme based on a mix of contributory and tax financing. Contribution rates for formal sector employees would amount to 7% of salaries and the Ministry of Health and Social Welfare budget would need to be maintained. Government health expenditure including social health insurance would increase from 6% in 2008 to 11% in 2018.
South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 03/2011; 101(3):179-83. · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rwanda has expanded mutual health insurance considerably in recent years, which has a great potential for making health services more accessible. In this paper, we examine the effect of mutual health insurance (MHI) on utilization of health services and financial risk protection.
We used data from a nationally representative survey from 2005-2006. We analysed this data through summary statistics as well as regression models.
Our statistical modelling shows that MHI coverage is associated with significantly increased utilization of health services. Indeed, individuals in households that had MHI coverage used health services twice as much when they were ill as those in households that had no insurance coverage. Additionally, MHI is also associated with a higher degree of financial risk protection and the incidence of catastrophic health expenditure was almost four times less than in households with no coverage. Nonetheless, the limitations of the MHI coverage also become apparent.
These promising results indicate that MHI has had a strong positive impact on access to health care and can continue to improve health of Rwandans even more if its limitations are addressed further.
Health Policy 10/2010; 99(3):203-9. DOI:10.1016/j.healthpol.2010.09.009 · 1.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In many low-income countries, public health systems do not meet the needs and demands of the population. We aimed to assess the extent to which output-based payment could boost staff productivity at health care facilities.
We assessed the performance of 15 health care centres in Kabutare, Rwanda, comparing productivity in 2001, when fixed annual bonuses were paid to staff, with that in 2003, when an output-based payment incentive scheme was implemented.
Changes to the structure of contracts were associated with improvements in health centre performance: specifically, output-based performance contracts induced sharp increases in the productivity of health staff.
Institutional configurations of health care organizations deserve more attention. Those currently in place in the public sector may not the most suitable to meet current challenges in health care. More experiments are needed to confirm these early results from Rwanda and elsewhere, since risks associated with output-based incentive schemes should not be ignored.
Bulletin of the World Health Organisation 03/2007; 85(2):108-15. DOI:10.2471/BLT.06.032110 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In many low-income countries, performance of pyramidal health systems with a public purpose is not meeting the expectations and needs of the populations they serve. A question that has not been studied and tested sufficiently is, ‘What is the right package of institutional mechanisms required for organisations and individuals working in these health systems?’ This paper presents the experience of the Performance Initiative, an innovative contractual approach that has reshaped the incentive structure in place in two rural districts of Rwanda. It describes the general background, the initial analysis, the institutional arrangement and the results after 3 years of operations. At this stage of the experience, it shows that ‘output-based payment + greater autonomy’ is a feasible and effective strategy for improving the performance of public health centres. As part of a more global package of strategies, contracting-in approaches could be an interesting option for governments, donors and non-governmental organisations in their effort to achieve some of the Millennium Development Goals.
Dans de nombreux pays à faibles ressources, la performance des systèmes de santé pyramidaux avec un but public ne répond pas aux attentes et besoins des populations qu'ils servent. Une question qui n'a pas étéétudiée et testée suffisamment est ‘Quel est le bon volet du programme dans les mécanismes institutionnels, nécessaire pour les organisations et les individus travaillant dans ces systèmes de santé?’. Cet article présente les expériences de l'Initiative de Performance, une approche contractuelle innovante, qui a remodelé la structure d'incitation en place dans deux districts ruraux du Rwanda. Il décrit les données de base générales, l'analyse initiale, les arrangements institutionnels et les résultats après trois ans d'opération. A cette étape de l'expérience, il est démontré que le ‘paiement basé sur le rendement + une plus grande autonomie’ est une stratégie faisable et effective pour l'amélioration de la performance des centres de santé publique. Les approches par des contrats, en tant que partie des volets stratégiques, pourraient être une option intéressante pour le gouvernement, les bailleurs de fond et les ONG dans leur effort pour atteindre certains des Objectifs du Développement Millénaire.
En muchos países de baja renta, el desempeño de los sistemas de salud piramidales con fines públicos no está cumpliendo con las expectativas y necesidades de la población a la que sirven. Una pregunta que aún no ha sido tratada e investigada suficientemente es ‘‘¿‘Cual es el paquete adecuado de mecanismos institucionales requerido por organizaciones e individuos trabajando en estos sistemas de salud?’’ Este artículo presenta la experiencia de la Iniciativa de Rendimiento (Performance Initiative), un enfoque contractual innovador que ha reorganizado las estructuras de incentivos existentes en dos distritos rurales de Ruanda. Describe los antecedentes generales, el análisis inicial, los arreglos institucionales y los resultados después de tres años de operaciones. Hasta este momento la experiencia muestra que ‘‘el pago basado en resultados + mayor autonomía’’ es una estrategia factible y efectiva para mejorar el desempeño de los centros de salud públicos. Como parte de un paquete más global de estrategias, este enfoque de contratación podría ser una opción interesante para el gobierno, donantes y ONGs en su esfuerzo por alcanzar algunos de los Objetivos de Desarrollo del Milenio.
Tropical Medicine & International Health 09/2006; 11(8):1303-17. DOI:10.1111/j.1365-3156.2006.01680.x · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: After the war and the 1994 genocide, Rwanda drew up a national health policy with a view to realigning its health system. The reform, which was designed to remedy the deficiencies of the previous system, focused on community involvement in managing and financing health services. Achieving this objective was never going to be easy, but thanks to a growing number of initiatives 37.8 per cent of the Rwandan population now have some degree of sickness insurance cover. However, the system in general, and more particularly the mutual associations organized around the community, needs to be strengthened.
International Social Security Review 04/2006; 59(1). DOI:10.1111/j.1468-246X.2005.00235.x
[Show abstract][Hide abstract] ABSTRACT: The study intended to analyse the financial flows in two provinces within the Rwandan health system through the review of all available documentation and through interviews with key informants, to assess the scope for improved resource allocation. In Rwanda, there exists a large deficit of available financial resources in the health sector in general, and more specifically at health centre level. To improve this situation, it is considered to cover a large proportion of the entire population by mutual health insurance schemes. The schemes are able to pool certain risks, and they definitely improve financial access to health services. Nonetheless, they are inaccessible to the 'very poor', and--due to their limited financial base--they are unable to cover a complementary health care package. It is unlikely that they will mobilize substantial additional resources for health. External long-term commitments are required to cover this gap. A reassurance and readjustment system between the various insurance schemes should be established in order to increase financial protection provided. It might link up with insurance schemes in the formal employment sector. The combination of such a support for health insurance with performance-related incentives for health staff has the potential to increase both equity and quality of health services simultaneously and substantially.
Tropical Medicine & International Health 10/2005; 10(9):872-8. DOI:10.1111/j.1365-3156.2005.01464.x · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The establishment of mutual health insurance systems is one of the priorities of the Rwandan government. Pilot studies have been conducted in three districts of the country. Nonetheless, after 4 years of implementation (1999-2003), the population coverage by these insurance systems remains relatively low. A cross-sectional study of 1042 households in the Kabutare health district allowed for a comparison of socio-economic and demographic variables, and the medical, surgical, gynaecological, and obstetrical history of health insurance scheme members and non-members. The results of the study demonstrate that the distribution of members and non-members is similar in terms of sex, marital status, professional status and medical history. However, larger households (more than five members) and those having a relatively higher income (more than USD 230 per annum) are more likely to be insured than other households. Members of the mutual health insurance use more the health services than non-members, spend less on health care and increasingly maintain membership. The study emphasizes the relevance to further promote mutual health insurance, but also points to the need for mechanisms to ensure financial access for the poor rural population.
Tropical Medicine & International Health 12/2004; 9(11):1222-7. DOI:10.1111/j.1365-3156.2004.01318.x · 2.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Rwanda, the Ministry of Health is rebuilding the health sector destroyed during the genocide while trying to guarantee the financial accessibility of the population to the services through the setting up of a prepayment scheme. Membership remains low in the three pilot districts where the prepayment scheme was introduced four years before (15,6%). In two of these districts, the curative consultation and maternity utilisation has increased appreciably. The members of the prepayment scheme make greater use of the services than the rest of the population. There is a significantly higher prepayment scheme membership among households with a relatively high income and those with a large family (more than 5 family members). Overall, non-members of the prepayment scheme spend more on health services than members do. There are indications that developing the prepayment scheme would be very useful for the people in Rwanda if specific strategies geared to the poor were set up.
[Show abstract][Hide abstract] ABSTRACT: Rwanda has made the setting up of a prepayment scheme a priority in its health sector reform in order to make health services more financially accessible to the population. A pilot study was carried out in three districts. The yearly family subscription charge was fixed at 7.9 US dollars, which covers care delivered at Health Centre level as well as some services at the hospital. The beneficiaries and providers mention difficulties in order to mobilise the subscription charges all at a time, the insufficiency of the offer of services at the hospital and the absence of involvement of the political authorities in the process. The Ministry of Health did initiate the experiment but the choice of the privileged pilot districts prevents results from being extrapolated to the country taken as a whole with a view to a possible extension at a later stage. Given the relatively short time in which it has taken place, the population could neither understand the contingency and solidarity issues implied nor have the opportunity to feel personally involved in the system. As a conclusion, the study advocates the continuation of the experiment with a reinforcement of the coordination which should take the weak points identified into account.