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RESEARCH FOR
POOLING AND FINANCIAL RISK PROTECTIONCovering the informal sector The informal sector is highly diverse and its composition varies across and within countries. Health care coverage is particularly low among the near-poor who do not benefit from targeted interventions but constitute the bulk of the informal sector. For these groups, out-of-pocket payments persist as a way of funding services despite being grossly inequitable and contributing towards household poverty.
RESYST research in this area comprises reviewing the evidence and compiling country experiences of extending health coverage to the informal sector. Our review has identified significant challenges to using contributory schemes to cover the informal sector: low membership means small risk pools, schemes are only able to offer a limited package of services, and they often require additional payments at point of use. Even for mandatory schemes,
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REVENUE COLLECTION
Increasing domestic resources for health The experience of Thailand has demonstrated that Universal Health Coverage can be achieved at low cost; however, insufficient funding impedes progress towards UHC in many countries. More money for health is needed from domestic resources rather than donor funding, which can be both unstable and unsustainable.
RESYST has generated new evidence showing that governments in three settings (Lagos State in Nigeria, South Africa, and Kenya) have increased domestic tax revenue without raising rates by expanding the tax base and improving the efficiency of tax collection systems. However, in these three countries, the share of revenue allocated towards health has not increased.
UNIVERSAL HEALTH COVERAGE
“The rallying call to pursue universal health coverage presents a unique opportunity to build health systems that are responsive to the needs of the population. But this dream will not be realised unless each government creates the fiscal space to fund health services adequately and develops the strategic purchasing capacity required to ensure equitable access to quality services. None of this is feasible without strong governance.”
RESEARCH ON FINANCING FOR
Whilst Universal Health Coverage is high on national and international agendas, many low and middle-income countries face significant challenges in expanding access to health services and financial protection to all people. Adequately addressing these challenges requires evidence, generated through research, which takes into account the complexity of countries’ diverse health systems and addresses the needs of their populations.
RESYST is conducting a programme of research for UHC across several low and middle-income countries in Africa and Asia. The research focuses on three key components of a health financing system for UHC: revenue collection, pooling and financial risk protection, and strategic purchasing.
A critical challenge for Ministries of Health is to find ways to make a better case for health during budget negotiations so as to expand the share of government spending on health. This includes demonstrating the economic and social benefits of health investments, improvements and achievements in health service delivery, and efficient use of money.
International actors, including WHO and donor organisations, have a role in helping Ministries of Health to develop the technical and analytical capacity to effectively advocate for health and demonstrate the benefits of UHC.
REGULATION: setting policy frameworks, setting standards a
nd monito
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EVEN
UE CO
LLECTION
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RISK PROTECTION
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e.g. Single pool covering whole population or other mechanism for promoting cross-subsidies across pools
e.g. Different insurance schemes covering different socio-economic groups with very different benefits
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UNIVERSAL HEALTH
COVERAGE
Sour
ces o
f
reve
nue
How funds flow to different levels, services, geographic areas and interventions
Services that the population are
entitled to from the pooled funds
Methods that promote
equity, efficiency and quality e.g. salary, fee-for-
service, capitation
e.g. User fees to public sector, informal payments, fees paid to private providers
e.g. Taxes (general revenue,
earmarked tax), health insurance contributions
(mandated or voluntary)
Provider payment methods Benefi t package R
esource allocatio
n
Universal systems
Tiered systems
Dire
ct pa
ymen
ts
Pre-payments
countries face challenges in collecting contributions from the informal sector.
Countries that have had significant success in extending coverage, such as Rwanda (through its Community Based Health Insurance Scheme) and Thailand (through its tax-funded Universal Coverage Scheme) have demonstrated strong political support for the concept of UHC which is backed up by legislative, technical and regulatory frameworks, and accompanied by focused efforts on reaching poor and vulnerable groups.
More information:http://resyst.lshtm.ac.uk/research-projects/covering-informal-sector
More information:http://resyst.lshtm.ac.uk/research-projects/case-studies-improving-tax-collection
Professor Di McIntyreRESYST financing theme co-leader
Director, Health Economics Unit, University of Cape Town.
3STRATEGIC PURCHASINGMulti-country purchasing studyPurchasing is the critical link between resources mobilised for UHC and the effective delivery of quality services: strategic purchasing involves a number of key steps: determining which services will be provided, taking into account factors such as national health priorities as well as cost-effectiveness; choosing service providers, giving consideration to quality, efficiency and equity; and determining how services will be purchased, including contractual arrangements and provider payment mechanisms.
Through the multi-country RESYST Purchasing Study we are gathering information about the nature of purchasing arrangements in a range of settings in Africa and Asia, covering purchasers that include government ministries, social health insurance funds, and voluntary insurance funds. Through this research we intend to inform discussions about how purchasing arrangements can be structured to better support progress to UHC.
More information: http://resyst.lshtm.ac.uk/research-projects/multi-country-purchasing-study
RESYST is an international research consortium which aims to enhance the resilience and responsiveness of health systems to promote health and health equity and reduce poverty.
RESYST is funded by UK aid from the UK Government, however the views expressed do not necessarily reflect the UK Government’s official policies.
Dr Viroj TangcharoensathienRESYST financing theme co-leader
Senior Advisor, International Health Policy Program, Thailand
“Several Asian countries including Vietnam, the Philippines and China, have invested large amounts of funding for UHC into social health insurance schemes. Yet, despite some achievements, many people are still being pushed into poverty by the high cost of health care, and it is the relatively wealthy populations who are benefiting the most from public health spending.
The design of purchasing arrangements (such as benefit packages, or the way that providers are paid) has a substantial effect on how effectively and equitably health funds are used. Health financing organisations need to strengthen their governance and capacity to design and implement strategic purchasing to achieve UHC goals.”
http://resyst.lshtm.ac.uk@RESYSTresearch
COVERAGE OF SERVICES
UHC is not only about funding; a vital element of UHC is ensuring that there are enough trained health workers to provide services to everybody. Currently, many countries face a severe and persistent shortage of qualified health workers, especially in rural areas.
Attracting and retaining nurses in rural areasIn South Africa, RESYST researchers have sought to address the challenge of how to attract health workers to rural areas by tracking a cohort of nursing graduates and monitoring their employment decisions over several years. Evidence suggests that nurses who are exposed to rural life, either through training or as part of their upbringing, are more likely to work in rural posts.
New research has found that decisions about job location are also affected by a characteristic intrinsic to each individual - the dedication of nurses towards their patients. The more dedicated nurses are, as measured by their generosity towards patients in an economic experiment, the more likely they are to choose a rural job.
To ensure a higher proportion of nurses choose rural posts, the recruitment processes of nursing students could try and ascertain the extent to which potential candidates show signs of dedication towards patients. Also nurses’ curricula and experience during their studies could be adapted to cultivate positive attitudes towards patients.
More information: http://resyst.lshtm.ac.uk/research-projects/monitoring-nurses-job-choices