Methods to promote equity in health resource allocation in low- and middle-income countries: an overview.

Unfair differences in healthcare access, utilisation, quality or health outcomes exist between and within countries around the world. Improving health equity is a stated objective for many governments and international organizations. We provide an overview of the major tools that have been developed to measure, evaluate and promote health equity, along with the data required to operationalise them.Methods are organised into four key policy questions facing decision-makers: (i) what is the current level of inequity in health; (ii) does government health expenditure benefit the worst-off; (iii) can government health expenditure more effectively promote equity; and (iv) which interventions provide the best value for money in reducing inequity.Benefit incidence analysis can be used to estimate the distribution of current public health sector expenditure, with geographical resource allocation formulae and health system reform being the main government policy levers for improving equity. Techniques from the economic evaluation literature, such as extended and distributional cost-effectiveness analysis can be used to identify 'best buy' interventions from a health equity perspective. A range of inequality metrics, from gap measures and slope indices to concentration indices and regression analysis, can be applied to these approaches to evaluate changes in equity.Methods from the economics literature can provide policymakers with a toolkit for addressing multiple aspects of health equity, from outcomes to financial protection, and can be adapted to accommodate data commonly available in low- and middle-income settings.

Household coverage of Swaziland's national community health worker programme: a cross-sectional population-based study.

OBJECTIVES: To ascertain household coverage achieved by Swaziland's national community health worker (CHW) programme and differences in household coverage across clients' sociodemographic characteristics. METHODS: Household survey from June to September 2015 in two of Swaziland's four administrative regions using two-stage cluster random sampling. Interviewers administered a questionnaire to all household members in 1542 households across 85 census enumeration areas. RESULTS: While the CHW programme aims to cover all households in the country, only 44.5% (95% confidence interval: 38.0% to 51.1%) reported that they had ever been visited by a CHW. In both uni- and multivariable regressions, coverage was negatively associated with household wealth (OR for most vs. least wealthy quartile: 0.30 [0.16 to 0.58], P < 0.001) and education (OR for >secondary schooling vs. no schooling: 0.65 [0.47 to 0.90], P = 0.009), and positively associated with residing in a rural area (OR: 2.95 [1.77 to 4.91], P < 0.001). Coverage varied widely between census enumeration areas. CONCLUSIONS: Swaziland's national CHW programme is falling far short of its coverage goal. To improve coverage, the programme would likely need to recruit additional CHWs and/or assign more households to each CHW. Alternatively, changing the programme's ambitious coverage goal to visiting only certain types of households would likely reduce existing arbitrary differences in coverage between households and communities. This study highlights the need to evaluate and reform large long-standing CHW programmes in sub-Saharan Africa.

Distrusting community health workers with confidential health information: a convergent mixed-methods study in Swaziland.

BACKGROUND: Patients are unlikely to share the personal information that is critical for effective healthcare, if they do not trust that this information will remain confidential. Trust in confidentiality may be particularly low in interactions with community health workers (CHW) because CHW deliver healthcare outside the clinic setting. This study aims to determine the proportion of Swaziland's population that does not trust the national CHW cadre with confidential medical information, and to identify reasons for distrust. METHODS: Using two-stage cluster random sampling, we carried out a household survey covering 2000 households across 100 census enumeration areas in two of Swaziland's four regions. To confirm and explain the quantitative survey results, we used qualitative data from 19 semi-structured focus group discussions in the same population. RESULTS: 49% of household survey participants stated that they distrust the national CHW cadre with confidential health information. Having ever been visited by a CHW was positively associated with trust (aOR: 2.11; P < 0.001), while higher levels of schooling of the respondent were negatively associated (aOR for more than secondary schooling versus no schooling: 0.21; P < 0.001). The following three primary reasons for distrusting CHW with confidential health information emerged in the qualitative analyses: (1) CHW are members of the same community as their clients and may thus share information with people who know the client, (2) CHW are mostly women and several focus group participants assumed that women are more likely than men to share information with other community members, and (3) CHW are not sufficiently trained in confidentiality issues. CONCLUSION: Our findings suggest that confidentiality concerns could be a significant obstacle to the successful rollout of CHW services for stigmatized conditions in Swaziland. Increasing coverage of the CHW program, raising the population's confidence in CHWs' training, assigning CHW to work in communities other than the ones in which they live, changing the CHW gender composition, and addressing gender biases may all increase trust with regards to confidentiality.

Is universal coverage via social health insurance financially feasible in Swaziland?

OBJECTIVE: 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. METHODS: 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. RESULTS AND CONCLUSION: 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.