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Challenges in Financing Universal Health Coverage in Sub-Saharan Africa
Abstract and Figures
and Keywords Within the context of the Sustainable Development Goals, it is important to critically review research on healthcare financing in sub-Saharan Africa (SSA) from the perspective of the universal health coverage (UHC) goals of financial protection and access to quality health services for all. There is a concerning reliance on direct out-of-pocket payments in many SSA countries, accounting for an average of 36% of current health expenditure compared to only 22% in the rest of the world. Contributions to health insurance schemes, whether voluntary or mandatory, contribute a small share of current health expenditure. While domestic mandatory prepayment mechanisms (tax and mandatory insurance) is the next largest category of healthcare financing in SSA (35%), a relatively large share of funding in SSA (14% compared to <1% in the rest of the world) is attributable to, sometimes unstable, external funding sources. There is a growing recognition of the need to reduce out-of-pocket payments and increase domestic mandatory prepayment financing to move towards UHC. Many SSA countries have declared a preference for achieving this through contributory health insurance schemes, particularly for formal sector workers, with service entitlements tied to contributions. Policy debates about whether a contributory approach is the most efficient, equitable and sustainable means of financing progress to UHC are emotive and infused with "conventional wisdom." A range of research questions must be addressed to provide a more comprehensive empirical evidence base for these debates and to support progress to UHC.
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... However, the NHIS has faced enormous pressure to achieve this and as a result, has threatened its sustainability. Like any Low Middle-Income Country (LMIC), poor healthcare financing is characterised by underdeveloped health insurance schemes, the barest minimum resources allocated to its health sector, and inadequate government spending (McIntyre et al., 2018). This has resulted in high OOP payments spent by households regardless of their socio-economic status which has drawn millions of people in Africa into poverty. ...
Despite global improvements made in access to healthcare, out-of-pocket payments (OOPs) continue to be one of the drawbacks in improving universal access to health. Although one of the Ghanaian National Health Insurance Scheme (NHIS) objectives is to financially protect households from making OOPs, many households continue to face challenges in accessing health services, even after twenty years of the NHIS being implemented. This study investigates the impact of the determinants of NHIS on OOP payments among NHIS beneficiaries. Using a cross-sectional household survey, through stratified random sampling, primary data was collected from 559 households in Ghana. Analysis was conducted using Partial Least Square Structural Equation Modelling (PLS-SEM), to estimate the effect of the determinants of NHIS utilisation on OOP payments. The results from our study show that both financial affordability, benefit package, distance to health facilities and perceived quality of service are statistically significant in explaining out-of-pocket payments incurred by NHIS beneficiaries at a 1% level. However, gender, household size and income range were found to be statistically insignificant. The difficulty in accessing health services due to the OOP payments encountered by NHIS beneficiaries, have potential to derail the country's efforts towards achieving universal health coverage goals. Our results suggest that significant policy reforms are needed in the areas of premiums, benefit package, and the quality of service delivered.
... However, the NHIS has faced enormous pressure to achieve this and as a result, has threatened its sustainability. Like any Low Middle-Income Country (LMIC), poor healthcare financing is characterised by underdeveloped health insurance schemes, the barest minimum resources allocated to its health sector, and inadequate government spending (McIntyre et al., 2018). This has resulted in high OOP payments spent by households regardless of their socio-economic status which has drawn millions of people in Africa into poverty. ...
Despite global improvements made in access to healthcare, out-of-pocket payments (OOPs) continue to be one of the drawbacks in improving universal access to health. Although one of the Ghanaian National Health Insurance Scheme (NHIS) objectives is to financially protect households from making OOPs, many households continue to face challenges in accessing health services, even after twenty years of the NHIS being implemented. This study investigates the impact of the determinants of NHIS on OOP payments among NHIS beneficiaries. Using a cross-sectional household survey, through stratified random sampling, primary data was collected from 559 households in Ghana. Analysis was conducted using Partial Least Square Structural Equation Modelling (PLS-SEM), to estimate the effect of the determinants of NHIS utilisation on OOP payments. The results from our study show that both financial affordability, benefit package, distance to health facilities and perceived quality of service are statistically significant in explaining out-of-pocket payments incurred by NHIS beneficiaries at a 1% level. However, gender, household size and income range were found to be statistically insignificant. The difficulty in accessing health services due to the OOP payments encountered by NHIS beneficiaries, have potential to derail the country's efforts towards achieving universal health coverage goals. Our results suggest that significant policy reforms are needed in the areas of premiums, benefit package, and the quality of service delivered.
... UHC means that everyone should have access to quality healthcare services without facing financial hardship. Achieving UHC requires significant progress toward efficient, accessible, quality, and equitable health services while ensuring financial risk protection for households burdened with significant healthcare expenses (2). However, many low-and middle-income countries (LMICs) face significant budgeting and financial constraints, making it difficult to implement their plans toward UHC (2;3). ...
Ethiopia’s commitment to achieving universal health coverage (UHC) requires an efficient and equitable health priority-setting practice. The Ministry of Health aims to institutionalize health technology assessment (HTA) to support evidence-based decision making. This commentary highlights key considerations for successful formulation, adoption, and implementation of HTA policies and practices in Ethiopia, based on a review of international evidence and published normative principles and guidelines. Stakeholder engagement, transparent policymaking, sustainable financing, workforce education, and political economy analysis and power dynamics are critical factors that need to be considered when developing a national HTA roadmap and implementation strategy. To ensure ownership and sustainability of HTA, effective stakeholder engagement and transparency are crucial. Regulatory embedding and sustainable financing ensure legitimacy and continuity of HTA production, and workforce education and training are essential for conducting and interpreting HTA. Political economy analysis helps identify opportunities and constraints for effective HTA implementation. By addressing these considerations, Ethiopia can establish a well-designed HTA system to inform evidence-based and equitable resource allocation toward achieving UHC and improving health outcomes.
... 49 In some settings where user fees have been formally abolished, they continue to be informally imposed to the users of PHC services . 50 Neoliberal policies also created dualised and fragmented health systems, where the elite minority have access to sophisticated healthcare in the private sector while the majority of the population relies on heavily under-resourced public sector 28 . This further reinforces the negative image that the public health sector is an inferior alternative for the poor. ...
The COVID-19 pandemic has revealed major weaknesses in primary health care (PHC), and how such weaknesses pose a catastrophic threat to humanity. As a result, strengthening PHC has re-emerged as a global health priority and will take centre stage at the 2023 United Nations High Level Meeting (UNHLM) on Universal Health Coverage (UHC). In this analysis, we examine why, despite its fundamental importance and incredible promise, the momentum for PHC has been lost over the years. The portrayal of PHC itself (policy image) and the dominance of global interests has undermined the attractiveness of intended PHC reforms, leading to legacy historical policy choices (critical junctures) that have become extremely difficult to dismantle, even when it is clear that such choices were a mistake. PHC has been a subject of several political declarations, but post-declarative action has been weak. The COVID-19 provides a momentous opportunity under which the image of PHC has been reconstructed in the context of health security, breaking away from the dominant social justice paradigms. However, we posit that effective PHC investments are those that are done under calm conditions, particularly through political choices that prioritise the needs of the poor who continue to face a crisis even in non-pandemic situations. In the aftermath of the 2023 UNHLM on UHC, country commitment should be evaluated based on the technical and financial resources allocated to PHC and tangible deliverables as opposed to the formulation of documents or convening of a gathering that simply (re) endorses the concept.
... One 17 Note: The 14-to 17-year olds should be in secondary school. drawback was that access to these services were unequal with the poor being disadvantaged (Barasa et al., 2019;McIntyre et al., 2018). Antenatal visit remained low between 2003 and 2013 a factor linked to the relatively high maternal and perinatal mortality. ...
Appropriately guided and implemented government interventions help in achieving the desired outcome. They complement the household budget in meeting their basic needs, allowing them to move to a higher satisfaction level. The study looks at the nexus between household poverty and government strategies to stem it. The analysis uses various approaches including the binary and polychotomous logit models to see who is likely to benefit from the interventions, the Tobit model to measure the intensity in closing poverty gap and simulations to capture the impact and cost implications of interventions. While several interventions were introduced, results reveal implementation gaps where the deserving households are not comprehensively covered; the extremely poor have lower probability of uptake of the interventions. Thus, more targeted coverage is necessary in closing the poverty gap.
... Furthermore, over two-thirds suffer from chronic poverty and related problems [6,7]. While health expenditure per capita in sub-Saharan Africa (SSA) has increased by an annualized 3.2% over the last two decades (1995-2014) [8], approximately 36% of healthcare spending in the region continues to be made through direct out of pocket payments, compared to only 22% for the rest of the world [9]. Moreover, existing evidence indicates that catastrophic health expenditures within SSA vary widely -ranging from 1% in Botswana to 25% in Nigeria [10,11]. ...
Background
Out of pocket payment for healthcare remains a barrier to accessing health care services in sub-Saharan Africa (SSA). Women’s decision-making autonomy may be a strategy for healthcare access and utilization in the region. There is a dearth of evidence on the link between women’s decision-making autonomy and health insurance enrollment. We, therefore, investigated the association between married women’s household decision making autonomy and health insurance enrollment in SSA.
Methods
Demographic and Health Survey data of 29 countries in SSA conducted between 2010 and 2020 were analyzed. Both bivariate and multilevel logistic regression analyses were carried out to investigate the relationship between women’s household decision-making autonomy and health insurance enrollment among married women. The results were presented as an adjusted odds ratio (AOR) and the 95% confidence interval (CI).
Results
The overall coverage of health insurance among married women was 21.3% (95% CI; 19.9-22.7%), with the highest and lowest coverage in Ghana (66.7%) and Burkina Faso (0.5%), respectively. The odds of health insurance enrollment was higher among women who had household decision-making autonomy (AOR = 1.33, 95% CI; 1.03–1.72) compared to women who had no household decision-making autonomy. Other covariates such as women’s age, women’s educational level, husband’s educational level, wealth status, employment status, media exposure, and community socioeconomic status were found to be significantly associated with health insurance enrollment among married women.
Conclusion
Health insurance coverage is commonly low among married women in SSA. Women’s household decision-making autonomy was found to be significantly associated with health insurance enrollment. Health-related policies to improve health insurance coverage should emphasize socioeconomic empowerment of married women in SSA.
Countries that are reforming their health systems to progress towards Universal Health Coverage (UHC) need to consider total resource requirements over the long term to plan for the implementation and sustainable financing of UHC. However, there is a lack of detailed conceptualization as to how the current health financing mechanisms interplay across health system elements. Thus, we aimed to generate evidence on how to utilize resources from different sources of funds in Africa. We conducted a scoping review of empirical research following the six-stage methodological framework for Scoping Review by Arksey & O’Malley and Levac, Colquhoun & O’Brien. We searched for published and grey literature in Medline, Cochrane Library, PubMed, WHO database, World bank and Google Scholar search engines databases and summarized data using a narrative approach, involving thematic syntheses and descriptive statistics. We included 156 studies out of 1,168 studies among which 13% were conceptual studies while 87% were empirical studies. These selected studies focused on the financing of the 13 health system elements. About 45% focused on service delivery, 13% on human resources, 5% on medical products, and 3% on infrastructure and governance. Studies reporting multiple health system elements were 8%, while health financing assessment frameworks was 23%. The publication years ranged from 1975 to 2021. While public sources were the most dominant form of financing, global documentation of health expenditure does not track funding on all the health system dimensions that informed the conceptual framework of this scoping review. There is a need to advocate for expenditure tracking for health systems, including intangibles. Further analysis would inform the development of a framework for assessing financing sources for health system elements based on efficiency, feasibility, sustainability, equity, and displacement.
Background Fragile, Conflict-Affected and Vulnerable Settings (FCV) are under-resourced and rely on public-private engagement (PPE) initiatives for the provision of basic social services, including health, to the general population. Despite the need in FCV, termination of PPE initiatives is inevitable, but often reported to be fraught in effect on the recipient. Understanding this withdrawal process better and learning how public health facilities cope with the withdrawal of partner support, provides lessons on how to sustain gains from PPE initiatives, especially in FCVs. Zimbabwe has been in a protracted state of fragility for the past three decades, and provides a suitable context for this exploration.
Methods: A multiple case study focusing on the withdrawal process of international non-governmental organisations (INGOs) from Tsholotsho District Hospital (TDH), a rural hospital in Zimbabwe, was conducted in three sequential phases, between 2018-2021. Initially, stakeholder consultations with key health system actors were conducted, together with a scoping review to identify evidence gaps. Three cases of PPE initiatives terminated between 2009 and 2019 were purposively selected. A desk-based approach was supplemented with an additional primary research component (including expert interviews with key local stakeholders n=11), which proved to be an important checking and verification process. We describe the withdrawal processes and TDH’s coping strategies following the exit of Médecins Sans Frontières, Ark Zimbabwe and Plan International.
Results: All three PPE initiatives ended because of withdrawal of funding. Plan and Ark Zimbabwe ‘abruptly’ withdrew support while Médecins Sans Frontières gradually exited over two years. Loss of resources and services provided by INGOs was an acute shock to the district health system. Termination of support by Médecins Sans Frontières had the greatest magnitude of shock as its program had the greatest investment of resources and was deeply embedded into the system. Withdrawal of partner support from Tsholotsho District Hospital was an intricate process occurring within a changing complex health system. Challenges and unintended consequences included delayed planning; limited depth of involvement of Tsholotsho District Hospital program staff; and scaling down or stopping of program activities. The fragile context; systemic challenges; program design and implementation characteristics; and dynamics within the PPE configuration created challenges and/or amplified the shock of losing partner support. Irrespective of how abrupt or gradual the withdrawal of health system support was implemented, the outcome of the process largely depended on the interaction of the withdrawal process with the health system and contextual factors.
Conclusion: The evolving global development environment combined with the underlying drivers of fragility in FCV undermines the sustainability of PPE initiatives. The success of development initiatives in FCV should be centred on the effective implementation and termination of PPE initiatives while allowing FCV to take ownership of health service delivery. Otherwise, what is intended to be supportive can become an additional stressor on less resilient systems
Background:
The goal of universal health coverage (UHC) requires that families who get needed health care do not suffer financial hardship as a result. This can be measured by instances of impoverishment, when a household's consumption including out-of-pocket spending on health is more than the poverty line but its consumption, excluding out-of-pocket spending, is less than the poverty line. This links UHC directly to the policy goal of reducing poverty.
Methods:
We measure the incidence and depth of impoverishment as the difference in the poverty head count and poverty gap with and without out-of-pocket spending included in household total consumption. We use three poverty lines: the US$1·90 per day and $3·10 per day international poverty lines and a relative poverty line of 50% of median consumption per capita. We estimate impoverishment in 122 countries using 516 surveys between 1984 and 2015. We estimate the global incidence of impoverishment due to out-of-pocket payments by aggregating up from each country, using a survey for the year in question when available, and interpolation and model-based estimates otherwise. We do not derive global estimates to measure the depth of impoverishment but focus on the median depth for the 122 countries in our sample, accounting for 90% of the world's population.
Findings:
We find impoverishment due to out-of-pocket spending even in countries where the entire population is officially covered by a health insurance scheme or by national or subnational health services. Incidence is negatively correlated with the share of total health spending channelled through social security funds and other government agencies. Across countries, the population-weighted median annual rate of change of impoverishment is negative at the $1·90 per day poverty line but positive at the $3·10 per day and relative poverty lines. We estimate that at the $1·90 per day poverty line, the worldwide incidence of impoverishment decreased between 2000 and 2010, from 131 million people (2·1% of the world's population) to 97 million people (1·4%). The population-weighted median of the poverty gap increase attributable to out-of-pocket health expenditures among the 122 countries in our sample are ¢1·22 per capita at the $1·90 per day poverty line and ¢3·74 per capita at the $3·10 per day poverty line. In all countries, out-of-pocket spending can be both catastrophic and impoverishing at all income levels, but this partly depends on the choice of the poverty line.
Interpretation:
Out-of-pocket spending on health can add to the poverty head count and the depth of poverty by diverting household spending from non-health budget items. The scale of such impoverishment varies between countries and depends on the poverty line but might in some low-income countries account for as much as four percentage points of the poverty head count. Increasing the share of total health expenditure that is prepaid, especially through taxes and mandatory contributions, can help reduce impoverishment.
Funding:
Rockefeller Foundation, Ministry of Health of Japan, and UK Department for International Development.
Background:
Achieving universal health coverage, including quality essential service coverage and financial protection for all, is target 3.8 of the Sustainable Development Goals (SDG). As a result, an index of essential health service coverage indicators was selected by the UN as SDG indicator 3.8.1. We have developed an index for measuring SDG 3.8.1, describe methods for compiling the index, and report baseline results for 2015.
Methods:
16 tracer indicators were selected for the index, which included four from within each of the categories of reproductive, maternal, newborn, and child health; infectious disease; non-communicable diseases; and service capacity and access. Indicator data for 183 countries were taken from UN agency estimates or databases, supplemented with submissions from national focal points during a WHO country consultation. The index was computed using geometric means, and a subset of tracer indicators were used to summarise inequalities.
Findings:
On average, countries had primary data since 2010 for 72% of the final set of indicators. The median national value for the service coverage index was 65 out of 100 (range 22-86). The index was highly correlated with other summary measures of health, and after controlling for gross national income and mean years of adult education, was associated with 21 additional years of life expectancy over the observed range of country values. Across 52 countries with sufficient data, coverage was 1% to 66% lower among the poorest quintile as compared with the national population. Sensitivity analyses suggested ranks implied by the index are fairly stable across alternative calculation methods.
Interpretation:
Service coverage within universal health coverage can be measured with an index of tracer indicators. Our universal health coverage service coverage index is simple to compute by use of available country data and can be refined to incorporate relevant indicators as they become available through SDG monitoring.
Funding:
Ministry of Health, Japan, and the Rockefeller Foundation.
Background:
The goal of universal health coverage (UHC) requires inter alia that families who get needed health care do not suffer undue financial hardship as a result. This can be measured by the percentage of people in households whose out-of-pocket health expenditures are large relative to their income or consumption. We aimed to estimate the global incidence of catastrophic health spending, trends between 2000 and 2010, and associations between catastrophic health spending and macroeconomic and health system variables at the country level.
Methods:
We did a retrospective observational study of health spending using data obtained from household surveys. Of 1566 potentially suitable household surveys, 553 passed quality checks, covering 133 countries between 1984 and 2015. We defined health spending as catastrophic when it exceeded 10% or 25% of household consumption. We estimated global incidence by aggregating up from every country, using a survey for the year in question when available, and interpolation and model-based estimates otherwise. We used multiple regression to explore the relation between a country's incidence of catastrophic spending and gross domestic product (GDP) per person, the Gini coefficient for income inequality, and the share of total health expenditure spent by social security funds, other government agencies, private insurance schemes, and non-profit institutions.
Findings:
The global incidence of catastrophic spending at the 10% threshold was estimated as 9·7% in 2000, 11·4% in 2005, and 11·7% in 2010. Globally, 808 million people in 2010 incurred catastrophic health spending. Across 94 countries with two or more survey datapoints, the population-weighted median annual rate of change of catastrophic payment incidence was positive whatever catastrophic payment incidence measure was used. Incidence of catastrophic payments was correlated positively with GDP per person and the share of GDP spent on health, and incidence correlated negatively with the share of total health spending channelled through social security funds and other government agencies.
Interpretation:
The proportion of the population that is supposed to be covered by health insurance schemes or by national or subnational health services is a poor indicator of financial protection. Increasing the share of GDP spent on health is not sufficient to reduce catastrophic payment incidence; rather, what is required is increasing the share of total health expenditure that is prepaid, particularly through taxes and mandatory contributions.
Funding:
Rockefeller Foundation, Ministry of Health of Japan, UK Department for International Development (DFID).
Background: Kenya has made a policy decision to use contributory health insurance as one of its key pre-payment health financing mechanisms. The National Hospital Insurance Fund (NHIF) is the main health insurer in Kenya. While the NHIF has hitherto focused its efforts on providing health insurance coverage to individuals in the formal sector, it has recently broadened its focus to include individuals in the informal sector. This paper provides an analysis of the perceptions, and experiences of informal sector individuals in Kenya with regard to enrolment with the NHIF.
Methods: We collected data through key informant interviews (39) in two purposefully selected counties. Study participants were drawn from healthcare facilities contracted by the NHIF, and current, former, and prospective informal sector members. We analyzed data using a grounded approach.
Results: Participants felt that the NHIF provided inadequate information about the registration and membership processes as well as benefit entitlements. There was variable and inconsistent communication by the NHIF. There was also variance between the official benefit package and the actual benefits received by members. The NHIF registration requirements and processes presented an administrative barrier to obtaining membership. The NHIF premium level and contribution mechanism presents a financial barrier to current and prospective members. Healthcare providers discriminated against NHIF members compared to cash-payers or private insurance holders.
Conclusions: The NHIF could improve enrolment and retention of informal sector individuals by; 1) using communication strategies that are effective at reaching the informal sector, 2) improving the affordability of the premium rates, 3) simplifying the enrolment requirements and process, and 4) strengthening accountability mechanisms between itself and healthcare facilities to ensure that enrolled members receive the benefits that they are entitled to, and that client experience at healthcare facilities are satisfactory.
Background:
Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low- and middle-income countries (LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the National Hospital Insurance Fund (NHIF) as a case study.
Methods:
We applied a principal-agent relationship framework, which identifies three pairs of principal-agent relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through document reviews (statutes, policy and regulatory documents) and in-depth interviews (n=62) with key informants including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers. Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed using a thematic framework approach.
Results:
The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting, monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist, they do not always function appropriately and awareness of these channels to the beneficiaries is limited.
Conclusion:
Addressing the gaps in the NHIF's purchasing performance requires a number of approaches. Critically, there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the multiplicity of actors given Kenya's devolved context. Relatively recent decentralisation reforms present an opportunity that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal health coverage (UHC).
Ensuring an equitable health financing system is a major concern particularly in many developing countries. Internationally, there is a strong debate to move away from excessive reliance on direct out-of-pocket (OOP) spending towards a system that incorporates a greater element of risk pooling and thus affords greater protection for the poor. This is a major focus of the move towards universal health coverage (UHC). Currently, Zambia with high levels of poverty and income inequality is implementing health sector reforms for UHC through a social health insurance scheme. However, the way to identify the health financing mechanisms that are best suited to achieving this goal is to conduct empirical analysis and consider international evidence on funding universal health systems. This study assesses, for the first time, the progressivity of health financing and how it impacts on income inequality in Zambia. Three broad health financing mechanisms (general tax, a health levy and OOP spending) were considered. Data come from the 2010 nationally representative Zambian Living Conditions and Monitoring Survey with a sample size of 19,397 households. Applying standard methodologies, the findings show that total health financing in Zambia is progressive. It also leads to a statistically significant reduction in income inequality (i.e. a pro-poor redistributive effect estimated at 0.0110 (p < 0.01)). Similar significant pro-poor redistribution was reported for general taxes (0.0101 (p < 0.01)) and a health levy (0.0002 (p < 0.01)). However, the redistributive effect was not significant for OOP spending (0.0006). These results further imply that health financing redistributes income from the rich to the poor with a greater potential via general taxes. This points to areas where government policy may focus in attempting to reduce the high level of income inequality and to improve equity in health financing towards UHC in Zambia.
There is an international call for countries to ensure universal health coverage. This call has been embraced in South Africa (SA) in the form of a National Health Insurance (NHI). This is expected to be financed through general tax revenue with the possibility of additional earmarked taxes including a surcharge on personal income and/or a payroll tax for employers. Currently, health services are financed in SA through allocations from general tax revenue, direct out-of-pocket payments, and contributions to medical scheme. This paper uses the most recent data set to assess the progressivity of each health financing mechanism and overall financing system in SA. Applying standard and innovative methodologies for assessing progressivity, the study finds that general taxes and medical scheme contributions remain progressive, and direct out-of-pocket payments and indirect taxes are regressive. However, private health insurance contributions, across only the insured, are regressive. The policy implications of these findings are discussed in the context of the NHI.
OBJECTIVE: To quantify the extent of catastrophic household health care expenditure and determine the factors responsible for it in Nouna District, Burkina Faso. METHODS: We used the Nouna Health District Household Survey to collect data on 800 households during 2000-01 for our analysis. The determinants of household catastrophic expenditure were identified by multivariate logistic regression method. FINDINGS: Even at very low levels of health care utilization and modest amount of health expenditure, 6-15% of total households in Nouna District incurred catastrophic health expenditure. The key determinants of catastrophic health expenditure were economic status, household health care utilization especially for modern medical care, illness episodes in an adult household member and presence of a member with chronic illness. CONCLUSION: We conclude that the poorest members of the community incurred catastrophic health expenses. Setting only one threshold/cut-off value to determine catastrophic health expenses may result in inaccurate estimation leading to misinterpretation of important factors. Our findings have important policy implications and can be used to ensure better access to health services and a higher degree of financial protection for low-income groups against the economic impact of illness.
This article examines socioeconomic inequalities in maternal and child health care in Nigeria over an 18-year period. Studies demonstrate that maternal and child mortality is much higher amongst the poor in low-income countries, with access to health care concentrated among the wealthiest. Evidence suggests that in Nigeria inequalities in access to quality services continue to persist. We use data from two rounds of the Nigerian Demographic and Heath Survey (NDHS) conducted in 1990 and 2008 and measure inequalities in maternal and child health care variables across socioeconomic status using concentration curves and indices. Factors contributing to the inequalities are investigated using decomposition analysis. The results show that in 1990, maternal access to skilled assistance during delivery had the highest levels of inequalities. It reveals that child and maternal health inequalities appear to be determined by different factors and while inequalities in child care have declined, inequalities in maternal care have increased. We discuss the findings in relation to the much greater attention paid to child health programmes. The findings of this study call for specific maternal programmes targeting the poor, less educated and rural areas in Nigeria.