Action to address the household economic burden of non-communicable diseases.

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy.

BACKGROUND: Universal health coverage (UHC) is important in terms of improving access to quality health care while protecting households from the risk of catastrophic health spending and impoverishment. However, progress to UHC has been hampered by the measures to increase mandatory prepaid funds especially in low- and middle-income countries where there are large populations in the informal sector. Important considerations in expanding coverage to the informal sector should include an exploration of the type of prepayment system that is acceptable to the informal sector and the features of such a design that would encourage prepayment for health care among this population group. The objective of the study was to document the views of informal sector workers regarding different prepayment mechanisms, and critically analyze key design features of a future health system and the policy implications of financing UHC in Kenya. METHODS: This was part of larger study which involved a mixed-methods approach. The following tools were used to collect data from informal sector workers: focus group discussions [N = 16 (rural = 7; urban = 9)], individual in-depth interviews [N = 26 (rural = 14; urban = 12)] and a questionnaire survey [N = 455(rural = 129; urban = 326)]. Thematic approach was used to analyze qualitative data while Stata v.11 involving mainly descriptive analysis was used in quantitative data. The tools mentioned were used to collect data to meet various objectives of a larger study and what is presented here constitutes a small section of the data generated by these tools. RESULTS: The findings show that informal sector workers in rural and urban areas prefer different prepayment systems for financing UHC. Preference for a non-contributory system of financing UHC was particularly strong in the urban study site (58%). Over 70% in the rural area preferred a contributory mechanism in financing UHC. The main concern for informal sector workers regardless of the overall design of the financing approach to UHC included a poor governance culture especially one that does not punish corruption. Other reasons especially with regard to the contributory financing approach included high premium costs and inability to enforce contributions from informal sector. CONCLUSION: On average 47% of all study participants, the largest single majority, are in favor of a non-contributory financing mechanism. Strong evidence from existing literature indicates difficulties in implementing social contributions as the primary financing mechanism for UHC in contexts with large informal sector populations. Non-contributory financing should be strongly recommended to policymakers to be the primary financing mechanism and supplemented by social contributions.

An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS).

Brazil, Russia, India, China, and South Africa (BRICS) represent almost half the world's population, and all five national governments recently committed to work nationally, regionally, and globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by China's rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.

Progress towards universal health coverage in BRICS: translating economic growth into better health.

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--represent some of the world's fastest growing large economies and nearly 40% of the world's population. Over the last two decades, BRICS have undertaken health-system reforms to make progress towards universal health coverage. This paper discusses three key aspects of these reforms: the role of government in financing health; the underlying motivation behind the reforms; and the value of the lessons learnt for non-BRICS countries. Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. There is a reliance on direct expenditures in China and India and a substantial presence of private insurance in Brazil and South Africa. The Brazilian health reforms resulted from a political movement that made health a constitutional right, whereas those in China, India, the Russian Federation and South Africa were an attempt to improve the performance of the public system and reduce inequities in access. The move towards universal health coverage has been slow. In China and India, the reforms have not adequately addressed the issue of out-of-pocket payments. Negotiations between national and subnational entities have often been challenging but Brazil has been able to achieve good coordination between federal and state entities via a constitutional delineation of responsibility. In the Russian Federation, poor coordination has led to the fragmented pooling and inefficient use of resources. In mixed health systems it is essential to harness both public and private sector resources.

Le Brésil, la Fédération de Russie, l'Inde, la Chine et l'Afrique du Sud ­ les pays connus sous le nom de BRICS ­ représentent quelques-unes des grandes économies ayant connu la croissance la plus rapide dans le monde et près de 40% de la population mondiale. Au cours des 2 dernières décennies, le groupe BRICS a engagé des réformes de son système de santé pour atteindre la couverture de santé universelle. Cet article aborde les 3 aspects clés de ces réformes: le rôle du gouvernement dans le financement de la santé; la motivation profonde derrière ces réformes; et la valeur des leçons tirées pour les pays non-BRICS. Bien que les gouvernements nationaux jouent un rôle majeur dans ces réformes, le financement privé constitue une part importante des dépenses de santé dans le groupe BRICS. Il existe une dépendance à l'égard des dépenses directes en Chine et en Inde et à l'égard d'une présence importante des assurances privées au Brésil et en Afrique du Sud. Les réformes de la santé du Brésil ont fait suite à un mouvement politique qui a fait de la santé un droit constitutionnel, alors que les réformes en Chine, en Inde, en Fédération de Russie et en Afrique du Sud ont représenté des tentatives visant à améliorer la performance du système public et à réduire les inégalités de l'accès aux soins. Les progrès vers la couverture de santé universelle ont été lents. En Chine et en Inde, les réformes n'ont pas abordé suffisamment le problème des paiements restants à charge. Les négociations entre les entités nationales et infranationales ont souvent été difficiles, mais le Brésil a pu parvenir à une coordination adéquate entre les entités fédérales et étatiques grâce à une délimitation constitutionnelle des responsabilités. Dans la Fédération de Russie, le manque de coordination a entraîné un regroupement fragmenté et une utilisation inefficace des ressources. Dans les systèmes de santé à financement mixte, il est essentiel de maîtriser à la fois les ressources des 2 secteurs: public et privé.

Brasil, la Federación de Rusia, India, China y Sudáfrica, los países conocidos como BRICS, son algunas de las grandes economías que más rápidamente están creciendo y representan casi el 40% de la población mundial. A lo largo de las últimas dos décadas, los BRICS han emprendido reformas en los sistemas sanitarios para avanzar hacia una cobertura universal de salud. Este artículo analiza tres aspectos clave de estas reformas: el papel del gobierno a la hora de financiar la salud, los motivos subyacentes de las reformas y el valor de las lecciones aprendidas de otros países distintos a los BRICS. Aunque los gobiernos nacionales tienen un papel destacado en las reformas, la financiación privada constituye una parte importante de los gastos sanitarios en estos países. Hay una dependencia de los gastos directos en China e India y una presencia significativa de seguros privados en Brasil y Sudáfrica. Las reformas sanitarias brasileñas tuvieron como resultado un movimiento político que hizo de la salud un derecho constitucional, mientras que las de China, India, la Federación de Rusia y Sudáfrica fueron un intento de mejorar el rendimiento del sistema público y reducir las desigualdades del acceso a este. El avance hacia la cobertura universal de la salud ha sido lento. En China e India, las reformas no han abordado adecuadamente el problema de los pagos directos. A menudo, las negociaciones entre las entidades nacionales y subnacionales han sido difíciles, pero Brasil ha sido capaz de lograr una buena coordinación entre las entidades federales y estatales a través de una descripción constitucional de la responsabilidad. En la Federación de Rusia, una mala coordinación ha tenido como resultado una mancomunación fragmentada y el uso ineficaz de los recursos. En los sistemas sanitarios mixtos, es fundamental emplear recursos tanto del sector público como del privado.

Economic evaluation of task-shifting approaches to the dispensing of anti-retroviral therapy.

BACKGROUND: A scarcity of human resources for health has been identified as one of the primary constraints to the scale-up of the provision of Anti-Retroviral Treatment (ART). In South Africa there is a particularly severe lack of pharmacists. The study aims to compare two task-shifting approaches to the dispensing of ART: Indirectly Supervised Pharmacist's Assistants (ISPA) and Nurse-based pharmaceutical care models against the standard of care which involves a pharmacist dispensing ART. METHODS: A cross-sectional mixed methods study design was used. Patient exit interviews, time and motion studies, expert interviews and staff costs were used to conduct a costing from the societal perspective. Six facilities were sampled in the Western Cape province of South Africa, and 230 patient interviews conducted. RESULTS: The ISPA model was found to be the least costly task-shifting pharmaceutical model. However, patients preferred receiving medication from the nurse. This related to a fear of stigma and being identified by virtue of receiving ART at the pharmacy. CONCLUSIONS: While these models are not mutually exclusive, and a variety of pharmaceutical care models will be necessary for scale up, it is useful to consider the impact of implementing these models on the provider, patient access to treatment and difficulties in implementation.

Exploring inequalities in access to and use of maternal health services in South Africa.

BACKGROUND: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country's Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, "patient-oriented" barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. METHODS: A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. RESULTS: Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. CONCLUSIONS: To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these "patient-oriented" barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.

Who pays for health care in Ghana?

BACKGROUND: Financial protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". An important element of financial risk protection is to distribute health care financing fairly in relation to ability to pay. The distribution of health care financing burden across socio-economic groups has been estimated for European countries, the USA and Asia. Until recently there was no such analysis in Africa and this paper seeks to contribute to filling this gap. It presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana. METHODS: Secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used. This was triangulated with data from the Ministry of Finance and other relevant sources, and further complemented with primary household data collected in six districts. We implored standard methodologies (including Kakwani index and test for dominance) for assessing progressivity in health care financing in this paper. RESULTS: Ghana's health care financing system is generally progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes, which account for close to 50% of health care funding. The national health insurance (NHI) levy (part of VAT) is mildly progressive and formal sector NHI payroll deductions are also progressive. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are regressive form of health payment to households. CONCLUSION: For Ghana to attain adequate financial risk protection and ultimately achieve universal coverage, it needs to extend pre-payment cover to all in the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the National Health Insurance. Furthermore, the pre-payment funding pool for health care needs to grow so budgetary allocation to the health sector can be enhanced.

In Appreciation of Adam: Reflections from Friends and Colleagues.

Some of Adam Wagstsaff's colleagues and research collaborators submitted short reflections about the different ways Adam made a difference through his amazing research output to health equity and health systems as well as a leader and mentor. The Guest Editors of this Special Issue selected a set of six essays related to dimensions of Adam's contributions.The first contribution highlights his role early on in his career, prior to joining the World Bank, in defining and expanding an important field of research on equity in health ("Adam and Equity," by Eddy van Doorslaer and Owen O'Donnell). The second contribution focuses on Adam's early work on equity and health within the World Bank and his leadership on important initiatives that have had impact far beyond the World Bank ("Adam and Health Equity at the World Bank," by Davidson Gwatkin and Abdo Yazbeck). The next contribution focuses on Adam's deep dive into providing support, through research, for country-specific programs and reforms, with a special focus on some countries in East Asia ("Adam and Country Health System Research," by Magnus Lindelow, Caryn Bredenkamp, Winnie Yip, and Sarah Bales). The next contribution highlights Adam's many ways of contributing to the International Health Economics Association, from the impressive technical contributions to leadership and organizational reform ("Adam and iHEA," by Diane McIntyre). The next to last contribution focuses on Adam's long-term leadership in the research group at the World Bank and the long-lasting influence on integrating the research produced into World Bank operations and creating an environment that rewarded producing evidence for action ("Adam the Research Manager," by Deon Filmer and Damien de Walque). The last contribution pulls on the thread found in many of the earlier ones, mentorship with honesty, directness, caring, commitment, and equity ("Adam the Mentor," by Agnes Couffinhal, Caryn Bredenkamp, and Reem Hafez).

The health and health system of South Africa: historical roots of current public health challenges.

The roots of a dysfunctional health system and the collision of the epidemics of communicable and non-communicable diseases in South Africa can be found in policies from periods of the country's history, from colonial subjugation, apartheid dispossession, to the post-apartheid period. Racial and gender discrimination, the migrant labour system, the destruction of family life, vast income inequalities, and extreme violence have all formed part of South Africa's troubled past, and all have inexorably affected health and health services. In 1994, when apartheid ended, the health system faced massive challenges, many of which still persist. Macroeconomic policies, fostering growth rather than redistribution, contributed to the persistence of economic disparities between races despite a large expansion in social grants. The public health system has been transformed into an integrated, comprehensive national service, but failures in leadership and stewardship and weak management have led to inadequate implementation of what are often good policies. Pivotal facets of primary health care are not in place and there is a substantial human resources crisis facing the health sector. The HIV epidemic has contributed to and accelerated these challenges. All of these factors need to be addressed by the new government if health is to be improved and the Millennium Development Goals achieved in South Africa.

Does the Informal Sector in Kenya Have Financial Potential to Sustainably Prepay for Health Care? Implications for Financing Universal Health Coverage in Low-Income Settings.

Kenya currently lacks evidence on whether income in the informal sector is sustainable and predictable and therefore able to support financing of universal health coverage (UHC). This article demonstrates the financial potential of informal sector entities to sustainably finance UHC in Kenya. Data were collected using a standardized questionnaire on the following topics: nature and sustainability of informal sector entities, indicators of financial potential, and socioeconomic status. Both descriptive and multivariate analyses were used. The findings indicate that income in the informal sector is generally low although investors in health/medical, stationery, entertainment, manufacturing and craft as well as transportation tend to have higher and more consistent incomes than most others in both sites. Mean monthly incomes ranged from 16.7 USD (lowest) to 786.5 USD (highest). The urban informal sector recorded higher mean monthly incomes of 195.8 USD compared to 77.9 USD in the rural area (P < 0.001). The most sustainable entities in the urban area included stationery (67%), repair and maintenance (50%), food vending (49%), shopkeeping (48%), and clothing and beauty products (43%). Farming (90%), manufacturing and craft (86%), and health/medical (100%) were the most sustainable in the rural area. Key predictors of sustainable informal sector entities include monthly expenditure patterns, gender, marital status, household structure, number of employees in an entity, and land ownership in the rural area and number of entities owned. Informal sector entities are mostly unsustainable, meaning that the majority of premium contributors will not be consistent in payment and will likely to require subsidies.

Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania.

The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.

Household burden of malaria in South Africa and Mozambique: is there a catastrophic impact?

OBJECTIVES: To evaluate treatment-seeking behaviour, financial impact and time lost due to malaria events, in southern Mozambique and eastern South Africa. METHODS: In-depth household surveys (828 in Mozambique and 827 in South Africa) were analysed. An asset index was calculated using principal component analysis to allow comparison across socio-economic groups. Direct costs of seeking care and the time lost due to malaria were determined. The extent of catastrophic payments was assessed using as thresholds the traditional 10% of household income and 40% of non-food income, as recently recommended by WHO. RESULTS: Poverty was highly prevalent: 70% of the South African and 95% of Mozambican households studied lived on less than $1 per capita per day. Around 97% of those with recent malaria sought healthcare, mainly in public facilities. Out-of-pocket household expenditure per malaria episode averaged $2.30 in South Africa and $6.50 in Mozambique. Analysis at the individual household level found that 32-34% of households in Mozambique, compared with 9-13% of households in South Africa, incurred catastrophic payments for malaria episodes. Results based on mean values underestimated the prevalence of catastrophic payments. Days off work/school were higher in Mozambique. CONCLUSIONS: The high rate of health seeking in public health facilities seems unusual in the African context, which bodes well for high coverage with artemisinin-based combinations, even if only deployed within the public sector. However, despite no or modest charges for public sector primary healthcare, households frequently incur catastrophic expenditure on a single malaria episode.

Should countries implementing an artemisinin-based combination malaria treatment policy also introduce rapid diagnostic tests?

BACKGROUND: Within the context of increasing antimalarial costs and or decreasing malaria transmission, the importance of limiting antimalarial treatment to only those confirmed as having malaria parasites becomes paramount. This motivates for this assessment of the cost-effectiveness of routine use of rapid diagnostic tests (RDTs) as an integral part of deploying artemisinin-based combination therapies (ACTs). METHODS: The costs and cost-effectiveness of using RDTs to limit the use of ACTs to those who actually have Plasmodium falciparum parasitaemia in two districts in southern Mozambique were assessed. To evaluate the potential impact of introducing definitive diagnosis using RDTs (costing $0.95), five scenarios were considered, assuming that the use of definitive diagnosis would find that between 25% and 75% of the clinically diagnosed malaria patients are confirmed to be parasitaemic. The base analysis compared two ACTs, artesunate plus sulfadoxine/pyrimethamine (AS+SP) costing $1.77 per adult treatment and artemether-lumefantrine (AL) costing $2.40 per adult treatment, as well as the option of restricting RDT use to only those older than six years. Sensitivity analyses considered lower cost ACTs and RDTs and different population age distributions. RESULTS: Compared to treating patients on the basis of clinical diagnosis, the use of RDTs in all clinically diagnosed malaria cases results in cost savings only when 29% and 52% or less of all suspected malaria cases test positive for malaria and are treated with AS+SP and AL, respectively. These cut-off points increase to 41.5% (for AS+SP) and to 74% (for AL) when the use of RDTs is restricted to only those older than six years of age. When 25% of clinically diagnosed patients are RDT positive and treated using AL, there are cost savings per malaria positive patient treated of up to $2.12. When more than 29% of clinically diagnosed cases are malaria test positive, the incremental cost per malaria positive patient treated is less than US$1. When relatively less expensive ACTs are introduced (e.g. current WHO preferential price for AL of $1.44 per adult treatment), the RDT price to the healthcare provider should be $0.65 or lower for RDTs to be cost saving in populations with between 30 and 52% of clinically diagnosed malaria cases being malaria test positive. CONCLUSION: While the use of RDTs in all suspected cases has been shown to be cost-saving when parasite prevalence among clinically diagnosed malaria cases is low to moderate, findings show that targeting RDTs at the group older than six years and treating children less than six years on the basis of clinical diagnosis is even more cost-saving. In semi-immune populations, young children carry the highest risk of severe malaria and many healthcare providers would find it harder to deny antimalarials to those who test negative in this age group.

Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa.

BACKGROUND: The global focus on promoting Universal Health Coverage has drawn attention to the need to increase public domestic funding for health care in low- and middle-income countries. OBJECTIVES: This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends. METHODS: Three case studies were conducted by different research teams using a common mixed methods approach. Quantitative data were extracted from official government financial reports and used to describe trends in general tax revenue, total government expenditure and government spending on the health sector and other sectors in the first decade of this century. Twenty-seven key informant interviews with officials in Ministries of Health and Finance were used to explore the contextual factors, actors and processes accounting for the observed trends. A thematic content analysis allowed this qualitative information to be compared and contrasted between territories. FINDINGS: Increased tax revenue led to absolute increases in public health spending in all three territories, but not necessarily in real per capita terms. However, in each of the territories, the percentage of the government budget allocated to health declined for much of the period under review. Factors contributing to this trend include: inter-sectoral competition in priority setting; the extent of fiscal federalism; the Ministry of Finance's perception of the health sector's absorptive capacity; weak investment cases made by the Ministry of Health; and weak parliamentary and civil society involvement. CONCLUSION: Despite dramatic improvements in tax revenue collection, fiscal space for health in the three territories did not improve. Ministries of Health must strengthen their ability to motivate for larger allocations from government revenue through demonstrating improved performance and the relative benefits of health investments.

Exploring the Functioning of Decision Space: A Review of the Available Health Systems Literature.

BACKGROUND: The concept of decision space holds appeal as an approach to disaggregating the elements that may influence decision-making in decentralized systems. This narrative review aims to explore the functioning of decision space and the factors that influence decision space. METHODS: A narrative review of the literature was conducted with searches of online databases and academic journals including PubMed Central, Emerald, Wiley, Science Direct, JSTOR, and Sage. The articles were included in the review based on the criteria that they provided insight into the functioning of decision space either through the explicit application of or reference to decision space, or implicitly through discussion of decision-making related to organizational capacity or accountability mechanisms. RESULTS: The articles included in the review encompass literature related to decentralisation, management and decision space. The majority of the studies utilise qualitative methodologies to assess accountability mechanisms, organisational capacities such as finance, human resources and management, and the extent of decision space. Of the 138 articles retrieved, 76 articles were included in the final review. CONCLUSION: The literature supports Bossert's conceptualization of decision space as being related to organizational capacities and accountability mechanisms. These functions influence the decision space available within decentralized systems. The exact relationship between decision space and financial and human resource capacities needs to be explored in greater detail to determine the potential influence on system functioning.

Assessing the catastrophic effects of out-of-pocket healthcare payments prior to the uptake of a nationwide health insurance scheme in Ghana.

BACKGROUND: Financial risk protection against the cost of unforeseen healthcare has gained global attention in recent years. Although Ghana implemented a nationwide health insurance scheme with a goal of reducing financial barriers to accessing healthcare and addressing impoverishing effects of out-of-pocket (OOP) healthcare payments, there is a paucity of knowledge on the extent of financial catastrophe of such payments in Ghana. Thus, this paper assesses the catastrophic effect of OOP healthcare payments in Ghana. METHODS: Ghana Living Standard Survey (GLSS 5) data collected in 2005/2006 are used in this study. Catastrophic effect of OOP healthcare payments is assessed using various thresholds of total household expenditure and non-food expenditure. Furthermore, four indices, namely the catastrophic payment headcount, catastrophic payment gap, weighted catastrophic payment headcount and weighted catastrophic payment gap, are defined and computed. RESULTS: As at 2005/2006, it was estimated that 11.0% of households in Ghana spent over 5% of their total household expenditure on healthcare OOP. However, after adjusting for the concentration of such spending, it decreased to 10.9%. Also 10.7% of households spent more than 10% of their non-food consumption expenditure on OOP healthcare payments. Furthermore, about 2.6% of households are observed to have spent in excess of 20% of their total household income on healthcare OOP. With the exception of the 5% threshold of household expenditure, because the concentration indices of these expenditures are negative, the burden of such expenditures rests more on the poor. CONCLUSIONS: Significant levels of financial catastrophe existed in Ghana prior to the uptake of the national health insurance scheme. Poorer households were at a higher risk than the relatively well-off households. The results of this study present baseline assessment of the impact of Ghana's health insurance policy on catastrophic healthcare payments. Thus, there is a need for continuous monitoring of financial catastrophe in the system to ensure that households are adequately protected.

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.

Improving the public health sector in South Africa: eliciting public preferences using a discrete choice experiment.

BACKGROUND: The introduction of national health insurance (NHI), aimed at achieving universal coverage, is the most important issue currently on the South African health policy agenda. Improvement in public sector health-care provision is crucial for the successful implementation of NHI as, regardless of whether health-care services become more affordable and available, if the quality of the services provided is not acceptable, people will not use the services. Although there has been criticism of the quality of public sector health services, limited research is available to identify what communities regard as the greatest problems with the services. METHODS: A discrete choice experiment (DCE) was undertaken to elicit public preferences on key dimensions of quality of care when selecting public health facilities in South Africa. Qualitative methods were applied to establish attributes and levels for the DCE. To elicit preferences, interviews with community members were held in two South African provinces: 491 in Western Cape and 499 in Eastern Cape. RESULTS: The availability of necessary medicine at health facilities has the greatest impact on the probability of attending public health facilities. Other clinical quality attributes (i.e. provision of expert advice and provision of a thorough examination) are more valued than non-clinical quality of care attributes (i.e. staff attitude, treatment by doctors or nurses, and waiting time). Treatment by a doctor was less valued than all other attributes. CONCLUSION: Communities are prepared to tolerate public sector health service characteristics such as a long waiting time, poor staff attitudes and lack of direct access to doctors if they receive the medicine they need, a thorough examination and a clear explanation of the diagnosis and prescribed treatment from health professionals. These findings prioritize issues that the South African government must address in order to meet their commitment to improve public sector health-care service provision.

Inequities in under-five child malnutrition in South Africa.

OBJECTIVES: To assess and quantify the magnitude of inequalities in under-five child malnutrition, particularly those ascribable to socio-economic status and to consider the policy implications of these findings. METHODS: Data on 3765 under-five children were derived from the Living Standards and Development Survey. Household income, proxied by per capita household expenditure, was used as the main indicator of socio-economic status. Socio-economic inequality in malnutrition (stunting, underweight and wasting) was measured using the illness concentration index. The concentration index was calculated for the whole sample, as well as for different population groups, areas of residence (rural, urban and metropolitan) and for each province. RESULTS: Stunting was found to be the most prevalent form of malnutrition in South Africa. Consistent with expectation, the rate of stunting is observed to be the highest in the Eastern Cape and the Northern Province - provinces with the highest concentration of poverty. There are considerable pro-rich inequalities in the distribution of stunting and underweight. However, wasting does not manifest gradients related to socio-economic position. Among White children, no inequities are observed in all three forms of malnutrition. The highest pro-rich inequalities in stunting and underweight are found among Coloured children and metropolitan areas. There is a tendency for high pro-rich concentration indices in those provinces with relatively lower rates of stunting and underweight (Gauteng and the Western Cape). CONCLUSION: There are significant differences in under-five child malnutrition (stunting and underweight) that favour the richest of society. These are unnecessary, avoidable and unjust. It is demonstrated that addressing such socio-economic gradients in ill-health, which perpetuate inequalities in the future adult population requires a sound evidence base. Reliance on global averages alone can be misleading. Thus there is a need for evaluating policies not only in terms of improvements in averages, but also improvements in distribution. Furthermore, addressing problems of stunting and underweight, which are found to be responsive to improvements in household income status, requires initiatives that transcend the medical arena.

Equity in self-reported adult illness and use of health service in South Africa: inter-temporal comparison.

The study was carried out to assess the magnitude of, and change in, inequities in self-reported adult illness and use of healthcare and to consider the policy implications of the findings. Datasets from three household surveys carried out in 1993, 1995, and 1998 were used. Inequities were measured using illness and healthcare-use concentration indices. Self-reported adult illness was greater among the rich in 1993, but this was reversed to reflect higher levels of reported illness among the poor in 1995 and 1998. Inequities were observed in self-reported injury and disability/chronic illness that favour the rich. The poor also reported more days of sickness compared to the rich. Overall, there were higher levels of use of doctors and hospital services by the rich, relative to their levels of reported illness. In contrast, there was a greater use of public-sector facilities by the poor. The time taken to reach a health facility also had a bias in favour of the rich. Although there were some favourable changes in the levels of inequities between the three time periods, there still remained considerable inequities that favoured the rich in self-reported adult illness and use of health services that need to be addressed. The consequences of higher concentration of chronic illness/disability and injury among the poor have far-reaching negative consequences on the socioeconomic welfare of the individuals and households. Redressing these inequities needs a holistic strategy that transcends the health sector.