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Gabani J, Mazumdar S, Hadji SB, Amara MM. The redistributive effect of the public health system: the case of Sierra Leone. Health Policy Plan 2024; 39:4-21. [PMID: 37990623 PMCID: PMC10775248 DOI: 10.1093/heapol/czad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 09/24/2023] [Accepted: 10/25/2023] [Indexed: 11/23/2023] Open
Abstract
Universal health coverage (UHC), health equity and reduction of income inequalities are key objectives for the Sierra Leone government. While investing in health systems may drive economic growth, it is less clear whether investing in health systems reduces income inequality. Therefore, a crucial issue is to what extent the Sierra Leone public healthcare system reduces income inequality, and finances and provides healthcare services equitably. We use data from the Sierra Leone Integrated Household Survey 2018 to complete a financing and benefit incidence analysis of the Sierra Leone public healthcare system. We extend these analyses by assessing the redistributive effect of the public healthcare system (i.e. fiscal incidence analysis). We compute the redistributive effect as the change in Gini index induced by the payments for, and provision of, public healthcare services. The financing incidence of the Sierra Leone public healthcare system is marginally progressive (i.e. Kakwani index: 0.011*, P-value <0.1). With regard to public healthcare benefits, while primary healthcare (PHC) benefits are pro-poor, secondary/tertiary benefits are pro-rich. The result is that overall public healthcare benefits are equally distributed (concentration index (CI): 0.008, not statistically different from zero). However, needs are concentrated among the poor, so benefits are pro-rich when needs are considered. We find that the public healthcare system redistributes resources from better-off quintiles to worse-off quintiles (Gini coefficient reduction induced by public healthcare system = 0.5%). PHC receives less financing than secondary/tertiary care but delivers a larger reduction in income inequality. The Sierra Leone public healthcare system redistributes resources and reduces income inequality. However, the redistributive effect occurs largely thanks to PHC services being markedly pro-poor, and the Sierra Leone health system could be more equitable. Policy-makers interested in improving Sierra Leone public health system equity and reducing income inequalities should prioritize PHC investments.
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Affiliation(s)
- Jacopo Gabani
- Centre for Health Economics, University of York, Alcuin Block A, Heslington, York YO10 5DD, UK
- Department of Economics and Related Studies, University of York, Heslington, York, YO10 5DD, UK
| | - Sumit Mazumdar
- Centre for Health Economics, University of York, Alcuin Block A, Heslington, York YO10 5DD, UK
| | - Sylvester Bob Hadji
- Department of Economics, University of Sierra Leone, Fourah Bay College, Mount Aureol, Freetown, Sierra Leone
| | - Michael Matthew Amara
- Ministry of Health and Sanitation, Government of Sierra Leone, 4th & 5th Floor, Youyi Building, Brookfields, Freetown, Sierra Leone
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Haemmerli M, Asante A, Susilo D, Satrya A, Fattah RA, Cheng Q, Kosen S, Novitasari D, Puteri GC, Adawiyah E, Hayen A, Gilson L, Mills A, Tangcharoensathien V, Jan S, Thabrany H, Wiseman V. Using measures of quality of care to assess equity in health care funding for primary care: analysis of Indonesian household data. BMC Health Serv Res 2022; 22:1349. [PMID: 36376946 PMCID: PMC9664775 DOI: 10.1186/s12913-022-08739-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many countries implementing pro-poor reforms to expand subsidized health care, especially for the poor, recognize that high-quality healthcare, and not just access alone, is necessary to meet the Sustainable Development Goals. As the poor are more likely to use low quality health services, measures to improve access to health care need to emphasise quality as the cornerstone to achieving equity goals. Current methods to evaluate health systems financing equity fail to take into account measures of quality. This paper aims to provide a worked example of how to adapt a popular quantitative approach, Benefit Incidence Analysis (BIA), to incorporate a quality weighting into the computation of public subsidies for health care. METHODS We used a dataset consisting of a sample of households surveyed in 10 provinces of Indonesia in early-2018. In parallel, a survey of public health facilities was conducted in the same geographical areas, and information about health facility infrastructure and basic equipment was collected. In each facility, an index of service readiness was computed as a measure of quality. Individuals who reported visiting a primary health care facility in the month before the interview were matched to their chosen facility. Standard BIA and an extended BIA that adjusts for service quality were conducted. RESULTS Quality scores were relatively high across all facilities, with an average of 82%. Scores for basic equipment were highest, with an average score of 99% compared to essential medicines with an average score of 60%. Our findings from the quality-weighted BIA show that the distribution of subsidies for public primary health care facilities became less 'pro-poor' while private clinics became more 'pro-rich' after accounting for quality of care. Overall the distribution of subsidies became significantly pro-rich (CI = 0.037). CONCLUSIONS Routine collection of quality indicators that can be linked to individuals is needed to enable a comprehensive understanding of individuals' pathways of care. From a policy perspective, accounting for quality of care in health financing assessment is crucial in a context where quality of care is a nationwide issue. In such a context, any health financing performance assessment is likely to be biased if quality is not accounted for.
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Affiliation(s)
- Manon Haemmerli
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| | - Augustine Asante
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Dwidjo Susilo
- Faculty of Public Health, University of Indonesia, Jakarta, Indonesia
| | - Aryana Satrya
- Department of Management, Faculty of Economics, University of Indonesia, Depok, Indonesia
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
| | - Rifqi Abdul Fattah
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
| | - Qinglu Cheng
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Danty Novitasari
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
| | - Gemala Chairunnisa Puteri
- Centre for Social Security Studies, University of Indonesia, Jakarta, Indonesia
- Centre for Health Economics and Policy Studies, University of Indonesia, Jakarta, Indonesia
| | - Eviati Adawiyah
- Faculty of Public Health, University of Indonesia, Jakarta, Indonesia
| | - Andrew Hayen
- School of Public Health, University of Technology Sydney, Sydney, Australia
| | - Lucy Gilson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Health Policy and Systems Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Anne Mills
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- Kirby Institute, University of New South Wales, Sydney, Australia
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Selvaraj S, Karan AK, Mao W, Hasan H, Bharali I, Kumar P, Ogbuoji O, Chaudhuri C. Did the poor gain from India's health policy interventions? Evidence from benefit-incidence analysis, 2004-2018. Int J Equity Health 2021; 20:159. [PMID: 34246269 PMCID: PMC8272306 DOI: 10.1186/s12939-021-01489-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01489-0.
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Affiliation(s)
| | - Anup K Karan
- Indian Institute of Public Health, Gurugram, India
| | - Wenhui Mao
- Centre for Policy Impact in Global Health, Duke University, Durham, NC, 27708, USA
| | - Habib Hasan
- Indian Institute of Public Health, Gurugram, India
| | - Ipchita Bharali
- Centre for Policy Impact in Global Health, Duke University, Durham, NC, 27708, USA
| | - Preeti Kumar
- Public Health Foundation of India, Gurugram, India
| | - Osondu Ogbuoji
- Centre for Policy Impact in Global Health, Duke University, Durham, NC, 27708, USA
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Asante A, Wasike WSK, Ataguba JE. Health Financing in Sub-Saharan Africa: From Analytical Frameworks to Empirical Evaluation. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:743-746. [PMID: 33145665 PMCID: PMC7609366 DOI: 10.1007/s40258-020-00618-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Augustine Asante
- School of Population Health, University of New South Wales (UNSW) Sydney, Room 238, Level 2 Samuels Building, Sydney, NSW, 2052, Australia.
| | | | - John E Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
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