Progressivity of health care financing and incidence of service benefits in Ghana

The National Health Insurance (NHI) scheme was introduced in Ghana in 2004 as a pro-poor financing strategy aimed at removing financial barriers to health care and protecting all citizens from catastrophic health expenditures, which currently arise due to user fees and other direct payments. A comprehensive assessment of the financing and benefit incidence of health services in Ghana was undertaken. These analyses drew on secondary data from the Ghana Living Standards Survey (2005/2006) and from an additional household survey which collected data in 2008 in six districts covering the three main ecological zones of Ghana. Findings show that Ghana's health care financing system is progressive, driven largely by the progressivity of taxes. The national health insurance levy (which is part of VAT) is mildly progressive while NHI contributions by the informal sector are regressive. The distribution of total benefits from both public and private health services is pro-rich. However, public sector district-level hospital inpatient care is pro-poor and benefits of primary-level health care services are relatively evenly distributed. For Ghana to attain an equitable health system and fully achieve universal coverage, it must ensure that the poor, most of whom are not currently covered by the NHI, are financially protected, and it must address the many access barriers to health care.     

Essential drugs programmes in Africa

The essential drugs concept encompasses national drug policy, selection, quantification, quality assurance, procurement, inventory control and distribution, financing, rational drug use, and training. People from all sectors and levels were involved in developing Tanzania's national drug policy which was approved in 1991. The process developing a policy in Kenya continues. The policy will allow Kenya's Ministry of Health to implement various operational changes (e.g., improvements in hospital drug management). 40 sub-Saharan African (SSA) countries have a national essential drug list (EDL). A synergistic effect results when EDLs are merged with standard treatment guidelines (STGs) (e.g., in Tanzania and Zimbabwe) or constructed with STGs and a national formulary. The Federal Ministry of Health in Nigeria designated 209 drugs as essential drugs, while Nigerian states determined their own EDLs based on these 209 drugs. Spreadsheet models use morbidity patterns, past consumption, and population to help countries quantify drug needs which are then used to determine drug procurement. Various problems with quality assurance in regional and national quality control laboratories in SSA include staff turnover, limited equipment maintenance, and lack of reagents and laboratory standard solutions. A database, structured, flexible drug registration system allows countries (e.g., Zimbabwe) to monitor drug suppliers and agents. Drug procurement has improved in countries with established procurement systems. Computers help control and manage drug inventories. Kenya, Mozambique, Tanzania, and Uganda distribute ration kits of prepackaged drug selections. Cash and carry in Ghana, hospital fees in Kenya, and community insurance schemes in Guinea Bissau are some financing schemes in SSA. The International Network for the Rational Use of Drugs is operating in Ghana, Nigeria, the Sudan, and Tanzania. Training courses in drug supply management are held in Ghana, Tanzania, and Zimbabwe.     

台湾地区二代健保改革对大陆医保基金公平性及可持续性的启示

本文对我国台湾地区二代全民健保的改革背景、筹资和支付机制方面的改革措施进行分析。结果发现,二代健保通过调整费率,增收补充保费,扩充筹资来源,采用多元支付方式和辅助手段控制医药费用的增长,明确给付项目及标准,新增卫生技术评估作为决策依据等手段,极大缓解了财务赤字,目前已重新实现财务平衡。其多元的筹资方式、总额控费和按病种付费相结合的支付制度和为医疗质量和医保报销项目制定的评价标准等都值得大陆地区借鉴。     

Health financing policy formulation in the Eastern Caribbean

Stakeholders formulating policies on national health insurance (NHI) in the Eastern Caribbean have circled the abstract concept called NHI like the proverbial blind men explaining the elephant. Definitions of NHI have shifted depending on their perspectives and philosophical leanings, their understanding of the issues, and their degree of influence on the process. Based on NHI feasibility studies, market research, and stakeholder analysis conducted in five countries, this article analyses the policy formulation stage of NHI development in these tiny countries. Given the level of economic development and the existing administrative capacity of the governments, this 'phase one' NHI could be a pragmatic first step in introducing a health insurance component into the social security systems of the countries, and gradually reforming other aspects of the health sector. The article is structured around key questions which help to define the positions and relationships of key stakeholders, and then evaluate NHI plans in terms of economic viability, equity, administrative feasibility and efficiency, cost containment incentives, and political palatability. These are the elements that--in combination with economic and political context--will determine the success or failure of NHI in the Eastern Caribbean.     

Social movements and health insurance: a critical evaluation of voluntary, non-profit insurance schemes with case studies from Ghana and Cameroon

This paper assesses the performance of voluntary, non-profit health insurance schemes and their potential contribution to health in the two African countries of Ghana and Cameroon. Based on fieldwork conducted in the two countries during the main rainy season (June-July) of 1996, the paper examines whether and in which way the presence or absence of a social movement component might affect the performance of voluntary, non-profit insurance schemes in attaining some key objectives of improving access to health care among the target population, as well as achieving equity, efficiency and financial viability. The paper makes this assessment by examining the performances of each of two case studies according to the criteria of social movement, efficiency, equity, access and financial results. Based on case studies of a community financing insurance scheme in Ghana and a mutual aid insurance association in Cameroon, the study concludes that the evidence is not sufficient to confirm that the presence or absence of such a social movement dynamic per se accounts for the perceived performance of either of the schemes. However, it is also argued that the dynamic of social movement could enhance the design and performance of a scheme, especially the efficiency and quality of health care. Such enhancement is possible provided that the scheme is set up in such a way as to benefit from the specific contribution of a movement component, in particular, if the scheme engages in direct negotiations with providers over the price and quality of care and makes direct payment contracts with such providers. A good scheme design is therefore one of the real keys to success. Moreover, it is arguable that a non-social movement based scheme can incorporate elements of a social movement (such as greater community participation, accountability and autonomy) in the course of time. It is argued that this process would enhance the success of a non-movement-based scheme. The study finally presents some lessons and suggestions from the examination of the schemes which could be of benefit in the design, implementation and evaluation of similar schemes.     

Should we abolish the private health insurance industry?

Health care financing can be based on one of two conflicting principles: health care as a right versus the insurance principle. The former assures equal access to care for all people regardless of income, while the latter requires each grouping in society to pay its own way. In the United States, health financing has utilized both principles, with employer-sponsored group health insurance approximating health care as a right. However, the insurance principle is increasingly eroding this right. In five major areas, the private health insurance industry has serious flaws: it has contributed to health care inflation; it wastes billions in administrative and marketing costs; it is unfair to many groups in society; it has undermined the positive features of health maintenance organization reform; and it has far too much political and economic power. In order to establish health care as a right as the guiding principle of U.S. health care financing, the private health insurance industry and the insurance principle should be abolished.     

部分国家政府举办公立医院的经验与启示

世界各国不论经济发达与否,均举办一定数量的公立医院。公立医院的重要地位和作用是：弥补市场缺陷、体现政府保障居民健康权益的责任,并在控制医药费用、提高卫生服务公平可及性、有效利用资源等方面发挥重要作用。不同卫生保健体制国家的公立医院功能定位具有不同特点：国民卫生服务体系国家强调政府主导卫生筹资,公立医院为人群提供免费或廉价的基本卫生服务;社会健康保险体制国家以德国为例,公立医院除承担一般性功能外主要提供住院服务;商业健康保险体制国家以市场为主导,公立医院的作用在于调节市场失灵,在医疗服务体系中发挥基础性但非主体性作用,并履行一定的社会职责。各国政府通过探索公立医院改革,如实行“管办分离”,以明确政府举办公立医院的职责。国际经验对我国的启示是：政府应举办一定数量的公立医院,为其承担大部分筹资,完善监管政策,促使其落实社会职能和责任;公立医院要通过高效率运行,为群众提供高质量的服务,并要代表国家医疗服务体系的先进水平,起到示范作用;政府进行公立医院改革要以转变政府职能为前提,并保障公立医院的社会功能;公立医院的功能应适应国家医药卫生体制的制度环境。     

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

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.     

Do prevailing theories sufficiently explain perceptions and health‐seeking behavior of Ghanaians?

The challenges faced by African countries that have pioneered a national health insurance scheme (NHIS) and the lessons learned can be of great value to other countries, contemplating the introduction of such a health financing system. In 2003, Ghana initiated the NHIS to provide access to healthcare for people in both the formal and informal sectors. The paper assesses the applicability of four theoretical models to explain the perceptions and decisions of Ghanaians to participate in the NHIS. To contextualize these models, we used qualitative data from individual and group interviews of Ghanaians. These interviews form part of the study “towards a client‐oriented health insurance system in Ghana” to explain the uptake of the Ghanaian social health insurance. The paper argues for a new integrated model to provide a better understanding of clients' perceptions on illness, healthcare and health insurance. Such a model should highlight trust as a fundamental factor influencing the decision of Ghanaians to enroll in the NHIS. Copyright © 2013 John Wiley & Sons, Ltd.     

Does universal health insurance make health care unaffordable? Lessons from Taiwan

This paper examines the performance of Taiwan's National Health Insurance (NHI), a universal health insurance program, implemented in 1995, that covers comprehensive services. The authors address two key questions: Did the NHI cause Taiwanese health spending to escalate to an "unaffordable" level? What are the benefits of the NHI? They find that Taiwan's single-payer NHI system enabled Taiwan to manage health spending inflation and that the resulting savings largely offset the incremental cost of covering the previously uninsured. Under the NHI, the Taiwanese have more equal access to health care, greater financial risk protection, and equity in health care financing. The NHI consistently receives a 70 percent public satisfaction rate.     

The distribution of net benefits under the National Health Insurance programme in Taiwan

The redistributive effects of a social insurance programme are determined by how the programme is paid for-who pays and how much do they pay?-and how the benefits are distributed. As a result, the redistributive effects of a social health insurance programme should be evaluated on the basis of its net benefit-the difference between benefits and payment. Among the rich body of empirical analysis on equity in health care financing, however, most studies have relied on partial analysis, assessing equity by source of financing while ignoring the benefit side, or looking at equity in benefits but ignoring the funding side. Either approach risks misleading findings. In this study, therefore, the primary objective was to assess the distribution of net benefits across income groups under Taiwan's National Health Insurance (NHI) programme. This study observed a nationally representative sample of 74 012 NHI enrolees from 1996 to 2000. The unique NHI databases in Taiwan provide comprehensive enrolment and utilization information, and allowed linkage to each enrolee's income tax files. In addition to crude estimates, two-part models and ordinary least-square models were used to adjust inpatient and outpatient benefits for health care needs (age, sex, major disease status and physical disability). After adjusting for health care needs, the distribution of net benefits showed an apparent pro-poor pattern, with the lowest income group receiving the highest net benefits (NT$3353) and the top income group receiving the lowest net benefits (-NT$3072) in 1996. Although a clear pro-poor pattern was observed among those enrolees who paid wage-based premiums, this vertically equitable pattern was less evident among the enrolees who paid fixed premiums. Overall, a trend of increasing net benefits was observed in all income groups between 1996 and 2000, and all the NHI enrolees can be considered better off over time. In addition to contributing to the limited literature on equity in net benefits, the study provides an important policy reference to developing countries with large underground economies and relatively small populations of regular wage-earners as it indicates that using fixed premiums as a major financing scheme may pose a serious equity concern and policy challenge.     

National health insurance reform in South Africa

Background

A recent health reform proposal in South Africa proposes universal access to a comprehensive package of healthcare services in the public sector, through the implementation of a national health insurance (NHI) scheme. Implementation of the scheme is likely to involve the introduction of a payroll tax. It is implied that the introduction of the payroll tax will significantly reduce the size of the private health insurance market.

Objective

The objective of this study was to estimate the impact of an NHI payroll tax on the demand for private health insurance in South Africa, and to explore the broader implications for health policy.

Methods

The study applies probit regression analysis on household survey data to estimate the change in demand for private health insurance as a result of income shocks arising from the proposed NHI.

Results

The introduction of payroll taxes for the proposed NHI was estimated to result in a reduction to private health insurance membership of 0.73%. This suggests inelasticity in the demand for private health insurance. In the literature on the subject, this inelasticity is usually due to quality differences between alternatives. In the South African context, there may be other factors at play.

Conclusion

An NHI tax may have a very small impact on the demand for private health insurance. Although additional financial resources will be raised through a payroll tax under the proposed NHI reform, systemic problems within the South African health system can adversely affect the ability of the NHI to translate additional finances into better quality healthcare. If these systemic challenges are not adequately addressed, the introduction of a payroll tax could introduce inefficiencies within the South African health system.     

Risk-adjusted capitation. The Israeli experience.

As in a number of countries during the 1990s, Israel's health system has been undergoing structural reform based on public contracting and regulated markets. The main element of the reform was the enactment of the National Health Insurance Law (NHI), which went into effect on 1 January 1995. According to the Law, the sick funds receive risk-adjusted capitation payments, which place them fully at risk for the cost of supplying a legally mandated basket of health benefits. The paper analyses the effects of the NHI on the Israeli competitive health insurance market and discusses the major policy issues facing the Israeli system.     

Health care reform in South Korea: success or failure?

South Korea is one of the world's most rapidly industrializing countries. Along with industrialization has come universal health insurance. Within the span of 12 years, South Korea went from private voluntary health insurance to government-mandated universal coverage. Since 1997, with the intervention of the International Monetary Fund, Korean national health insurance (NHI) has experienced deficits and disruption. However, there are lessons to be drawn for the United States from the Korean NHI experience.     

Medical care reform: lessons from around the world

Once again the United States is in a ferment of health policy reform. Proposals abound but sage observers remark that national health insurance has been "just around the corner" more than once in the last forty years. This time may be different, however. Proposals from all across the ideological spectrum are converging on the notion of "managed care" which is perhaps best known in its guise as a health maintenance organization (HMO). Other forms of managed care exist but they have neither the history nor the incentives found in traditional HMOs. The discussion on national health insurance (NHI) proposals has focused on financing issues to the virtual exclusion of public health concerns. In this article, the author addresses rural health and public hospitals in the United States; two problems that have been with us for a long time. Then articles examining the Canadian and English medical care systems are reviewed, illustrating some of the weaknesses of these approaches to national medical care. Research studies relating to Europe and the developing nations are next. Once again, these are intended to highlight public health problems found in differing medical care systems. Finally, the author examines utopian views of the United States medical care system of the future: the reform proposal offered by the National Association for Public Health Policy, the experimental policy in Washington State, and a vision of a planned system. The review is intended to draw together the lessons offered by public health policy research in other countries and the United States and apply them to the issue at hand: reforming the United States medical care system.     

Research proposals submitted to the Dutch Investigative Medicine Fund; evaluation of the scientific quality by the Council for Scientific Research (NWO)

The Council for Medical and Health Research (MW-NWO) assessed the scientific quality of research proposals submitted to the Dutch Investigative Medicine Fund, and analysed if there had been changes over time in the proportion of proposals which the MW-NWO advised to reject, the role of reports of external reviewers and the most important methodological flaws. In the period 1995-1999 'reject' had been advised for an average of 50% of the proposals, with a tendency to a smaller proportion in recent years. In nearly half of the proposals the judgements of external reviewers were not in agreement with each other. There was only a weak correlation between the judgements of the reviewers and the final advice of NWO. Among the most important flaws mentioned in the NWO advice were: efficacy not proven (a prerequisite for the Fund), proposed study not needed to solve the policy problem and methodological flaws, e.g. design and power calculation not adequate, deficiencies of inclusion and exclusion criteria.     

Where do pharmaceuticals on the market originate? An analysis of the informal drug supply in Cotonou,Benin

This anthropological study, conducted in Cotonou, Benin between 2005 and 2007, investigates the informal pharmaceuticals market. It was carried out through a long-term participant observation of informal vendors and semi-directive and unstructured interviews. A classification of products sold in the informal market was developed. The fact that a high percentage of them come from Anglophone countries near Benin (Nigeria and Ghana) led to a comparison of the sources of pharmaceutical supply in these three countries as well as their current legislation regarding pharmaceutical distribution. Our study results highlight a new understanding of the phenomenon of the informal market. Nigeria and Ghana rely on a liberal pharmaceutical distribution system with little intervention from public authorities. Conversely, the government maintains considerable influence over pharmaceutical distribution in Benin. Hence, the differences between these three countries in terms of variety of supply sources and flexibility of access to drugs are understood through an investigation of Benin's informal market. Therefore, it appears that beyond issues concerning the quality of the pharmaceuticals, this phenomenon illustrates a kind of liberalization of pharmaceutical distribution and the ensuing public health issues.