RESUMO
South Africa's effort to eliminate malaria is significantly challenged by a large number of imported malaria cases, especially from neighbouring Mozambique. The country has a funding gap to achieve its malaria elimination goals (prior to 2019) and is ineligible to receive a national allocation from the Global Fund. The findings of an IC were utilised to successfully mobilise resources for malaria elimination in South Africa in 2018. A five-step resource mobilisation strategy was implemented to highlight financing challenges and leverage the economic evidence from an IC for malaria elimination in South Africa. South Africa's malaria programme implements control and elimination activities in three malaria-endemic provinces (KwaZulu Natal, Limpopo, and Mpumalanga). Driven by the IC findings, the South African government took an unprecedented step and increased total domestic malaria financing by approximately 36%, from the 2018/19 to the 2019/20 financial years through the creation of a new conditional grant for malaria. The IC findings predicted that malaria control in southern Mozambique is a prerequisite to eliminate malaria in South Africa. Based on this, the South African government also allocated funding towards a co-financing mechanism to support malaria control efforts in southern Mozambique. The IC findings assisted the South African National Department of Health to make a convincing case to key government decision-makers to invest in national malaria elimination and maximise economic returns in the long run. The South African government is the first in Southern Africa to mobilise a significant increase in domestic malaria financing to address the financial sustainability of both national and regional malaria elimination efforts. Continued surveillance activities will be required to prevent the re-establishment of malaria transmission even after malaria elimination is achieved in South Africa. Information sharing and close collaboration with provincial and national government officials were key to the successful outcome.
Assuntos
Malária , Humanos , África do Sul/epidemiologia , Malária/epidemiologia , Malária/prevenção & controle , África Austral , Moçambique/epidemiologia , Organização do FinanciamentoRESUMO
While South Africa has some experience in various forms of health technology assessment (HTA), it is currently fragmented across numerous players. Additionally, there is a lack of systematic and consistently applied HTA processes that inform priority-setting and budget allocations. To address this, the country is journeying toward more institutionalized use of HTA. This will begin with the establishment of a Ministerial Advisory Committee on HTA for National Health Insurance (NHI) and will gradually embed HTA processes in decision-making. The goal is to create an independent HTA agency. Although these reforms will be intrinsically linked to the wider health financing reforms envisaged under NHI, such as formulating the benefits package, they will also assist in strengthening South Africa's health system. As a country facing a highly constrained fiscal environment, with limited space for additional funding for the health sector, evidence-based priority-setting will be critical to ensure that value for money is achieved in the government's investments in health care services in NHI.
Assuntos
Programas Nacionais de Saúde , Avaliação da Tecnologia Biomédica , África do Sul , Avaliação da Tecnologia Biomédica/métodos , Humanos , Reforma dos Serviços de Saúde/métodos , Reforma dos Serviços de Saúde/tendências , Comitês Consultivos , Prioridades em Saúde/tendênciasRESUMO
South Africa has embarked on major health policy reform to deliver universal health coverage through the establishment of National Health Insurance (NHI). The aim is to improve access, remove financial barriers to care, and enhance care quality. Health technology assessment (HTA) is explicitly identified in the proposed NHI legislation and will have a prominent role in informing decisions about adoption and access to health interventions and technologies. The specific arrangements and approach to HTA in support of this legislation are yet to be determined. Although there is currently no formal national HTA institution in South Africa, there are several processes in both the public and private healthcare sectors that use elements of HTA to varying extents to inform access and resource allocation decisions. Institutions performing HTAs or related activities in South Africa include the National and Provincial Departments of Health, National Treasury, National Health Laboratory Service, Council for Medical Schemes, medical scheme administrators, managed care organizations, academic or research institutions, clinical societies and associations, pharmaceutical and devices companies, private consultancies, and private sector hospital groups. Existing fragmented HTA processes should coordinate and conform to a standardized, fit-for-purpose process and structure that can usefully inform priority setting under NHI and for other decision makers. This transformation will require comprehensive and inclusive planning with dedicated funding and regulation, and provision of strong oversight mechanisms and leadership.
Assuntos
Programas Nacionais de Saúde , Avaliação da Tecnologia Biomédica , Seguro Saúde , Setor Privado , África do Sul , Cobertura Universal do Seguro de SaúdeRESUMO
BACKGROUND: Many countries have committed to achieving Universal Health Coverage. This paper summarizes selected health financing themes from five middle-income country case studies with incomplete progress towards UHC. METHODS: The paper focuses on key flagship UHC programs in these countries, which exist along other publicly financed health delivery systems, reviewed through the lens of key health financing functions such as revenue raising, pooling and purchasing as well as governance and institutional arrangements. RESULTS: There is variable progress across countries. Indonesia's Jaminan Kesehatan Nasional (JKN) reforms have made substantial progress in health services coverage and health financing indicators though challenges remain in its implementation. In contrast, Ghana has seen reduced funding levels for health and achieved less than 50% in the UHC service coverage index. In India, despite Ayushman Bharat (PM-JAY) reforms having provided important innovations in purchasing and public-private mix, out of pocket spending remains high and the public health financing level low. Kenya still has a challenge to use public financing to enhance coverage for the informal sector, while South Africa has made little progress in strategic purchasing. CONCLUSIONS: Despite variations across countries, therefore, important challenges include inadequate financing, sub-optimal pooling, and unmet expectations in strategic purchasing. While complex federal systems may complicate the path forward for most of these countries, evidence of strong political commitment in some of these countries bodes well for further progress.
Assuntos
Financiamento da Assistência à Saúde , Cobertura Universal do Seguro de Saúde , Financiamento Governamental , Gastos em Saúde , Humanos , Assistência MédicaRESUMO
Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage . This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.
RESUMO
The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.
Assuntos
Atenção à Saúde/organização & administração , Saúde Global , Prioridades em Saúde , Cobertura Universal do Seguro de Saúde , HumanosRESUMO
BACKGROUND: We were tasked by the South African Department of Health to assess the cost implications to the largest ART programme in the world of adopting sets of ART guidelines issued by the World Health Organization between 2010 and 2016. METHODS: Using data from large South African ART clinics (n = 24,244 patients), projections of patients in need of ART, and cost data from bottom-up cost analyses, we constructed a population-level health-state transition model with 6-monthly transitions between health states depending on patients' age, CD4 cell count/ percentage, and, for adult first-line ART, time on treatment. FINDINGS: For each set of guidelines, the modelled increase in patient numbers as a result of prevalence and uptake was substantially more than the increase resulting from additional eligibility. Under each set of guidelines, the number of people on ART was projected to increase by 31-133% over the next seven years, and cost by 84-175%, while increased eligibility led to 1-26% more patients, and 1-17% higher cost. The projected increases in treatment cost due to the 2010 and the 2015 WHO guidelines could be offset in their entirety by the introduction of cost-saving measures such as opening the drug tenders for international competition and task-shifting. Under universal treatment, annual costs of the treatment programme will decrease for the first time from 2024 onwards. CONCLUSIONS: Annual budgetary requirements for ART will continue to increase in South Africa until universal treatment is taken to full scale. Model results were instrumental in changing South African ART guidelines, more than tripling the population on treatment between 2009 and 2017, and reducing the per-patient cost of treatment by 64%.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Adulto , Fármacos Anti-HIV/economia , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , África do Sul , Adulto JovemRESUMO
Five years after the release of its Green Paper on National Health Insurance (NHI),years after the institution of NHI pilot sites and following the recent release of the White Pa 4 per on NHI, South Africa (SA) needs to move beyond the phase 1 plans of policy making and healthening activities to phase 2 - putting into place the legal and institutional frameth system strengworks and systems for implementation of its universal health coverage (UHC) system. In doing so, SA can draw on considerable practical lessons from other countries' reforms in managing UHC with favourable equity outcomes over the past decade. We outline some potentially significant lessons from the Thai health financing system for SA.
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Financiamento da Assistência à Saúde , Cobertura Universal do Seguro de Saúde/economia , Reforma dos Serviços de Saúde/economia , Humanos , Atenção Primária à Saúde/economia , Mecanismo de Reembolso/economia , África do Sul , TailândiaRESUMO
South Africa provides a useful country case study for financing vaccinations. It has been an early adopter of new vaccinations and has financed these almost exclusively from domestic resources, largely through general taxation. National vaccination policy is determined by the Department of Health, based on advice from a national advisory group on immunisation. Standard health economic criteria of effectiveness, cost-effectiveness, affordability and burden of disease are used to assess whether new vaccinations should be introduced. Global guidelines and the advice of local and international experts are also helpful in making the determination to introduce new vaccines. In terms of recent decisions to introduce new vaccines against pneumococcal disease and rotavirus diarrhoea in children, the evidence has proved unequivocal. Universal rollout has been implemented even though this has led to a fivefold increase in national spending on vaccines. The total cost to government remains below 1-1.5% of public expenditures for health, which is viewed by the South African authorities as affordable and necessary given the number of lives saved and morbidity averted. To manage the rapid increase in domestic spending, efforts have been made to scale up coverage over several years, give greater attention to negotiating price reductions and, in some cases, obtain initial donations or frontloaded deliveries to facilitate earlier universal rollout. There has been strong support from a wide range of stakeholders for the early introduction of new generation vaccines.
Assuntos
Programas de Imunização/economia , Vacinação/economia , Análise Custo-Benefício , Política de Saúde , Humanos , Vacinas Pneumocócicas/administração & dosagem , Vacinas Pneumocócicas/economia , Vacinas contra Rotavirus/administração & dosagem , Vacinas contra Rotavirus/economia , África do SulAssuntos
Intoxicação Alcoólica/economia , Intoxicação Alcoólica/etiologia , Depressores do Sistema Nervoso Central/efeitos adversos , Etanol/efeitos adversos , Ferimentos e Lesões/economia , Ferimentos e Lesões/etiologia , Acidentes de Trânsito/economia , Acidentes de Trânsito/mortalidade , Consumo de Bebidas Alcoólicas/efeitos adversos , Consumo de Bebidas Alcoólicas/epidemiologia , Intoxicação Alcoólica/mortalidade , Causas de Morte , Depressores do Sistema Nervoso Central/sangue , Etanol/sangue , Humanos , África do Sul , Ferimentos e Lesões/mortalidadeRESUMO
OBJECTIVES: To analyse the financial basis for downsizing of a provincial health department and suggest implications for fiscal policy. DESIGN: Analysis of relevant departmental, provincial and national financing and expenditure trends from 1995/96 to 2002/03. SETTING: Western Cape (WC) Department of Health (DOH). RESULTS: Downsizing involving 9,282 health workers (27.9%) and closure of 3,601 hospital beds (24.4%) over 5 years. Total aggregate provincial transfers (all provinces) remained fairly constant in real terms. The WC's share decreased from 11.8% in 1996/97 to 9.8% in 2002/03. This was offset by the DOH's share of the WC budget increasing from 25.6% to 29.6%, mainly because of an increase in national health conditional grants. The net effect of financing changes was that the DOH's allocation in real terms was similar in 2002/03 and 1995/96, which suggests that financing changes are not the major cause of downsizing. Expenditure analysis revealed a 39.7% real rise in the average cost of health personnel. Substantial interprovincial inequities remain. CONCLUSION: The major cause of downsizing was wage growth, particularly following the 1996 wage agreement. Disjointed fiscal and wage policy has affected health services. Simultaneous application of policies of fiscal constraint, redistribution and substantial real wage growth has resulted in substantial downsizing with limited inroads into inequities. Inequities will continue to call for further redistribution, reduction in conditional grants and downsizing, much of which could have been avoided if fiscal and wage policy choices had been optimal.