Testing the contextual Interaction theory in a UHC pilot district in South Africa.

BACKGROUND: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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.

Measuring progress towards Sustainable Development Goal 3.8 on universal health coverage in Kenya.

BACKGROUND: The inclusion of universal health coverage (UHC) as a health-related Sustainable Development Goal has cemented its position as a key global health priority. We aimed to develop a summary measure of UHC for Kenya and track the country's progress between 2003 and 2013. METHODS: We developed a summary index for UHC by computing the geometrical mean of indicators for the two dimensions of UHC, service coverage (SC) and financial risk protection (FRP). The SC indicator was computed as the geometrical mean of preventive and treatment indicators, while the financial protection indicator was computed as a geometrical mean of an indicator for the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments. We analysed data from three waves of two nationally representative household surveys. FINDINGS: The weighted summary indicator for SC increased from 27.65% (27.13%-28.14%) in 2003 to 41.73% (41.34%-42.12%) in 2013, while the summary indicator for FRP reduced from 69.82% (69.11%-70.51%) in 2003 to 63.78% (63.55%-63.82%) in 2013. Inequities were observed in both these indicators. The weighted summary measure of UHC increased from 43.94% (95% CI 43.48% to 44.38%) in 2003 to 51.55% (95% CI 51.29% to 51.82%) in 2013. CONCLUSION: Significant gaps exist in Kenya's quest to achieve UHC. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both, rather than on only either, of the dimensions of UHC.

The incidence of health financing in South Africa: findings from a recent data set.

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.

Assessing the impoverishment effects of out-of-pocket healthcare payments prior to the uptake of the national health insurance scheme in Ghana.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Fiscal space for domestic funding of health and other social services.

To progress toward universal health coverage and promote inclusive social and economic development, it will be necessary to strengthen domestic resource mobilization for health. In this paper, we examine options for increasing domestic government revenue in low- and middle-income countries. We analyze the relationship between level of economic development and levels of government revenue and expenditure, and show that a country's level of economic development does not predetermine its spending levels. Government revenue can be increased through improved tax compliance and efficiency in revenue collection, maximizing revenue from mineral and other natural resources, and increasing tax rates where appropriate. The emphasis should be on increasing revenue through the most progressive means possible; the purpose of raising government spending on health would be defeated if that spending were funded by increasing the relative tax burden of those who are meant to benefit. Increasing government revenue through taxation or other sources is first and foremost a fiscal policy choice or political decision and should be supported through concerted global action.

What level of domestic government health expenditure should we aspire to for universal health coverage?

Global discussions on universal health coverage (UHC) have focussed attention on the need for increased government funding for health care in many low- and middle-income countries. The objective of this paper is to explore potential targets for government spending on health to progress towards UHC. An explicit target for government expenditure on health care relative to gross domestic product (GDP) is a potentially powerful tool for holding governments to account in progressing to UHC, particularly in the context of UHC's inclusion in the Sustainable Development Goals. It is likely to be more influential than the Abuja target, which requires decreases in budget allocations to other sectors and is opposed by finance ministries for undermining their autonomy in making sectoral budget allocation decisions. International Monetary Fund and World Health Organisation data sets were used to analyse the relationship between government health expenditure and proxy indicators for the UHC goals of financial protection and access to quality health care, and triangulated with available country case studies estimating the resource requirements for a universal health system. Our analyses point towards a target of government spending on health of at least 5% of GDP for progressing towards UHC. This can be supplemented by a per capita target of $86 to promote universal access to primary care services in low-income countries.

Towards a coherent global framework for health financing: recommendations and recent developments.

The articles in this special issue have demonstrated how unprecedented transitions have come with both challenges and opportunities for health financing. Against the background of these challenges and opportunities, the Working Group on Health Financing at the Chatham House Centre on Global Health Security laid out, in 2014, a set of policy responses encapsulated in 20 recommendations for how to make progress towards a coherent global framework for health financing. These recommendations pertain to domestic financing of national health systems, global public goods for health, external financing for national health systems and the cross-cutting issues of accountability and agreement on a new global framework. Since the Working Group concluded its work, multiple events have reinforced the group's recommendations. Among these are the agreement on the Addis Ababa Action Agenda, the adoption of the Sustainable Development Goals, the outbreak of Ebola in West Africa and the release of the Panama Papers. These events also represent new stepping stones towards a new global framework.

The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms.

BACKGROUND: The need to provide quality and equitable health services and protect populations from impoverishing health care costs has pushed universal health coverage (UHC) to the top of global health policy agenda. In many developing countries where the majority of the population works in the informal sector, there are critical debates over the best financing mechanisms to progress towards UHC. In Kenya, government health policy has prioritized contributory financing strategy (social health insurance) as the main financing mechanism for UHC. However, there are currently no studies that have assessed the cost of either social health insurance (SHI) as the contributory approach or an alternative financing mechanism involving non-contributory (general tax funding) approaches to UHC in Kenya. The aim of this study was to critically assess the financial requirements of both contributory and non-contributory mechanisms to financing UHC in Kenya in the context of large informal sector populations. METHODS: SimIns Basic® model, Version 2.1, 2008 (WHO/GTZ), was used to assess the feasibility of UHC in Kenya and provide estimates of financial resource needs for UHC over a 17-year period (2013-2030). Data sources included review of national and international literature on inflation, demography, macro-economy, health insurance, health services unit costs and utilization rates. The data were triangulated across geographic regions for accuracy and integrity of the simulation. SimIns models for 10 years only so data from the final year of the model was used to project for another 7 years. The 17-year period was necessary because the Government of Kenya aims to achieve UHC by 2030. RESULTS AND CONCLUSIONS: The results show that SHI is financially sustainable (Sustainability in this study is used to mean that expenditure does not outstrip revenue.) (revenues and expenditure match) within the first five years of implementation, but it becomes less sustainable with time. Modelling for a non-contributory scenario, on the other hand, showed greater sustainability both in the short- and long-term. The financial resource requirements for universal access to health care through general government revenue are compared with a contributory health insurance scheme approach. Although both funding options would require considerable government subsidies, given the magnitude of the informal sector in Kenya and their limited financial capacity, a tax-funded system would be less costly and more sustainable in the long-term than an insurance scheme approach. However, more innovative financing for health care as well as giving the health sector higher priority in government expenditure will be required to make the non-contributory financing mechanism more sustainable.

Explaining the role of the social determinants of health on health inequality in South Africa.

BACKGROUND: 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. OBJECTIVE: 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. DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.

Synthesizing qualitative and quantitative evidence on non-financial access barriers: implications for assessment at the district level.

INTRODUCTION: A key element of the global drive to universal health coverage is ensuring access to needed health services for everyone, and to pursue this goal in an equitable way. This requires concerted efforts to reduce disparities in access through understanding and acting on barriers facing communities with the lowest utilisation levels. Financial barriers dominate the empirical literature on health service access. Unless the full range of access barriers are investigated, efforts to promote equitable access to health care are unlikely to succeed. This paper therefore focuses on exploring the nature and extent of non-financial access barriers. METHODS: We draw upon two structured literature reviews on barriers to access and utilization of maternal, newborn and child health services in Ghana, Bangladesh, Vietnam and Rwanda. One review analyses access barriers identified in published literature using qualitative research methods; the other in published literature using quantitative analysis of household survey data. We then synthesised the key qualitative and quantitative findings through a conjoint iterative analysis. RESULTS: Five dominant themes on non-financial access barriers were identified: ethnicity; religion; physical accessibility; decision-making, gender and autonomy; and knowledge, information and education. The analysis highlighted that non-financial factors pose considerable barriers to access, many of which relate to the acceptability dimension of access and are challenging to address. Another key finding is that quantitative research methods, while yielding important findings, are inadequate for understanding non-financial access barriers in sufficient detail to develop effective responses. Qualitative research is critical in filling this gap. The analysis also indicates that the nature of non-financial access barriers vary considerably, not only between countries but also between different communities within individual countries. CONCLUSIONS: To adequately understand access barriers as a basis for developing effective strategies to address them, mixed-methods approaches are required. From an equity perspective, communities with the lowest utilisation levels should be prioritised and the access barriers specific to that community identified. It is, therefore, critical to develop approaches that can be used at the district level to diagnose and act upon access barriers if we are to pursue an equitable path to universal health coverage.

Aspectos econômicos da equidade em saúde / Economic aspects of health equity

As contribuições para este livro fazem um exame crítico de alguns desafios a enfrentarmos nos campos da equidade em saúde e nos sistemas de saúde. Ao mesmo tempo em que fornece uma visão resumida dos problemas da desigualdade em saúde em uma perspectiva global, reflete sobre a importância de examinar a comunidade e a cultura, particularmente a cultura nativa, na busca pela equidade. Também compara e contrasta abordagens neoliberais e igualitárias e o que elas significam para os sistemas de saúde. Explora as diferentes dimensões do acesso aos serviços de saúde e, no tocante à prestação desses serviços, analisa a disponibilidade de recursos humanos e a necessidade de redistribuí-los no nível global. Discute, ainda, desafios e alternativas do financiamento à saúde, sobretudo no contexto dos substanciais setores privados que existem em muitos países. Um dos capítulos aborda a equidade na assistência à saúde brasileira, explicando por que - e como - ela pode melhorar ainda mais. "Todos os autores oferecem sugestões de como a equidade em saúde poderá testemunhar um futuro mais positivo. Há esperança", destacam os organizadores.

Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress.

Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC.

Catastrophic payment for assisted reproduction techniques with conventional ovarian stimulation in the public health sector of South Africa: frequency and coping strategies.

STUDY QUESTION: How often does out-of-pocket payment (OPP) for assisted reproduction techniques (ART) with conventional ovarian stimulation result in catastrophic expenditure for households? SUMMARY ANSWER: Catastrophic cost was a frequent event affecting 51% of the poorest study participants and one in five couples in total. WHAT IS KNOWN ALREADY: There is increasing concern about catastrophic spending on health by households in low resource settings, but to date no study has evaluated OPP for ART. STUDY DESIGN, SIZE, DURATION: We conducted a prospective observational study comprising 135 couples undergoing ART between March 2009 and June 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study was set at an urban, level 3 referral hospital in the public and academic health sector of South Africa. At this institution ART is subsidized but requires co-payment by patients. Couples undergoing ART with conventional ovarian stimulation using GnRH analogs were recruited. A questionnaire capturing information on socioeconomic status, monthly household expenditure, OPP for the index ART cycle and financial coping strategies was administered. Households were categorized into tertiles according to socio-economic status. In addition to descriptive statistics, annualized OPP for ART services as a percentage of annual non-food household expenditure was calculated to estimate catastrophic health care expenditure. The Pearson χ(2) test and a logistic regression were used to identify factors related to incurring catastrophic spending. MAIN RESULTS AND THE ROLE OF CHANCE: In total, one in five couples (22%) incurred catastrophic expenditure (P < 0.01), defined as an OPP of ≥ 40% of annual non-food expenditure. Households used a range of coping strategies including reduced expenditure on items such as clothing and food, use of savings, borrowing money and taking on extra work. Differences were observed between the socio-economic tertiles: in the poorest tertile, 51% of households faced catastrophic costs compared with only 2% of the richest tertile (P < 0.01). Participants in the poorest tertile were more likely to be black (P < 0.01), and less likely to have health insurance (P < 0.01) or female full-time employment (P < 0.01). Longer duration of infertility was an additional risk factor for catastrophic payment (P < 0.05). LIMITATIONS, REASONS FOR CAUTION: No attempt was made to obtain proof of any payment or expenditure, and all information collected relied on participants' verbal account. WIDER IMPLICATIONS OF THE FINDINGS: This is the first study to document the frequency of catastrophic expenditure for ART using conventional ovarian stimulation in a low resource setting. Our results show that not all couples unable to afford treatment forfeit infertility care; instead poor couples are willing to suffer catastrophic financial hardship in order to pay. ART counselling therefore needs to include financial risk counselling in the short term. Long-term interventions comprise cost-reducing strategies as well as health systems strategies that reduce or eliminate the need for OPP for ART wherever possible. Robust evidence on mild versus conventional stimulation for ART in low resource settings is also required in the form of local RCTs which address the many clinical and health economic variables and exclude bias. Our data cannot be extrapolated to patients undergoing ART elsewhere or to patients undergoing ART with mild ovarian stimulation. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the Medical Research Council of South Africa and the University of Cape Town (University Research Committee and Faculty of Health Sciences Research Committee). The authors had no competing interests. TRIAL REGISTRATION NUMBER: not applicable.