Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa

Abstract

In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-of-pocket payments and health insurance for the informal sector are regressive. The distribution of health care benefits is generally pro-rich. This paper explores the factors influencing these distributions in the three countries. Qualitative data were collected through focus group discussions and in-depth interviews with insurance scheme members, the uninsured, health care providers and managers. Household surveys were also conducted in all countries. Flat-rate contributions contributed to the regressivity of informal sector voluntary schemes, either by design (in Tanzania) or due to difficulties in identifying household income levels (in Ghana). In all three countries, the regressivity of out-of-pocket payments is due to the incomplete enforcement of exemption and waiver policies, partial or no insurance cover among poorer segments of the population and limited understanding of entitlements among these groups. Generally, the pro-rich distribution of benefits is due to limited access to higher level facilities among poor and rural populations, who rely on public primary care facilities and private pharmacies. Barriers to accessing health care include medical and transport costs, exacerbated by the lack of comprehensive insurance coverage among poorer groups. Service availability problems, including frequent drug stock-outs, limited or no diagnostic equipment, unpredictable opening hours and insufficient skilled staff also limit service access. Poor staff attitudes and lack of confidence in the skills of health workers were found to be important barriers to access. Financing reforms should therefore not only consider how to generate funds for health care, but also explicitly address the full range of affordability, availability and acceptability barriers to access in order to achieve equitable financing and benefit incidence patterns.

Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index

“…The findings suggest that, in the more vulnerable areas, this ‘choice’ was limited. The findings on the concentration of hospitals, especially private hospitals in less vulnerable and more urbanized areas, is corroborated by studies in India and other LMICs [8,17,19,21]. …”

“…The location of health services and hospitals is very important for access, especially for the poor, and, although the services may be available outside the district, either within the state or in adjoining states, cost and distance act as barriers to access [8,15,19,21]. Therefore, ‘claims made by hospitals in the district’ was used in calculating the outcome indicators, instead of ‘claims of people living in the district’ that would have also included claims made outside the district.…”

“…However, evidence from India and other LMICs shows that there is a skewed distribution of health facilities and resources, with the formal private sector mostly concentrated in urban and richer areas and employing the majority of the medical specialists [8,16–21]. Studies have also found that insurance coverage is not a sufficient condition to ensure equity in healthcare utilization [22,23] and that non-financial factors, such as the nature, distribution and performance of health systems, are equally important for improved access [19,23–29]. Moreover, inequitable utilization tends to be clustered geographically [19,26,29].…”

“…Studies have also found that insurance coverage is not a sufficient condition to ensure equity in healthcare utilization [22,23] and that non-financial factors, such as the nature, distribution and performance of health systems, are equally important for improved access [19,23–29]. Moreover, inequitable utilization tends to be clustered geographically [19,26,29]. This study seeks to further examine the phenomenon of geographical equity in availability of facilities under publicly-funded health insurance schemes, including the distribution of private and public hospitals.…”

Social Capital and Willingness to Pay for Community Based Health Insurance: Empirical Evidence from Rural Tanzania

“…Those who trust CHF management were 19.2 per cent points more willing to pay for a health insurance than those who do not trust the CHF management (p<0.05). Evidence from other studies in Tanzania also shows that trust in the CHF management is among the key factors determining enrollment in CHF (Macha et al, 2012). This further suggests that CHFs could increase their membership if the avenues for trust building or building a positive image of the schemes are created and nurtured.…”