POLICY DIALOGUES Distributional Effects of Healthcare Spending: Lessons from Burkina Faso, Malawi, and Zambia December 2020 – No. 19 | UE-AFD Research Facility on Inequalities
respond to the global appeal to ‘leave
MAIN MESSAGE The
distribution
of
both
public
healthcare spending and overall healthcare spending has become increasingly egalitarian in Burkina Faso, Malawi, and Zambia, according to a new study. Nevertheless, there remain significant regional differences within countries. In addition, limitations in data availability make it difficult to assess the extent of evolving forms of inequalities. Policy interventions are required both to tackle inequalities in spending, and to invest in improving data quality for more accurate analysis to inform decision-making.
CONTEXT & MOTIVATION Across sub-Saharan Africa, countries are investing in reforming their health financing policies to achieve Universal Health Coverage (UHC). These actions
no one behind’, which means that expansions in coverage need to
METHODS The study combines data on health
embrace measures to include the most vulnerable groups, notably the
service utilization rates by socioeconomic group with data on the unit
very poor.
cost of healthcare services to assess the extent to which spending has
UHC-oriented
health
financing
reforms include targeted and nontargeted user fee exemption
been distributed in an egalitarian manner.
mechanisms, performance-based financing, and state-subsidized
The study considers two kinds of spending on health: public spending
health insurance schemes. These reforms aim to increase equity in
(including recurrent government spending) and overall spending on
access to quality healthcare services. In turn, equity in access rests first on
health (including donor and private spending) – and two sets of services:
an equitable distribution of resources. This means that all socio-economic
curative services and maternal care
groups should benefit equally from public and overall spending in the healthcare sector.
services. To capture changes over time, the study repeats the analysis at three
This study uses the tool of Benefit
points in time for each country. The study uses descriptive geo-spatial
Incidence Analysis to examine the distribution of healthcare spending
analysis to visualize disparities in both public and overall health spending
over
across regions, provinces, or districts
time
in
three
sub-Saharan
countries.
within a country.
Authors Martin RUDASINGWA, Edmund YEBOAH, Emmanuel BONNET, Valéry RIDDE, Paul André SOMÉ, Adamson MUULA, Bona Mukoshya CHITAH, Chrispin
Key words Health, curative, maternal, standing, inequality
MPHUKA, Manuela DE ALLEGRI Geography Burkina Faso, Malawi, Zambia
Themes Health Financing; Health Inequality; Health Spending; Curative Healthcare; Institutional Delivery
Find out more about this project: afd.fr/en/carte-des-projets/assessing-equity-health-spending-sub-saharanafrica
RESULTS Lesson 1: Across countries, the distribution of both public and overall spending has become increasingly egalitarian over time. This suggests that implementation of UHC reforms, such as public subsidies and user fee removal policies, has been effective in increasing the proportion of health financing resources reaching poorer segments of society. Lesson 2: Across countries, the distribution of public spending has tended to be more egalitarian or pro-poor than the distribution of overall spending. This highlights the importance of public spending. It is likely to reflect the fact that the analysis of overall spending includes private spending, where the least poor spend more on healthcare services. The analytical tool used in this study does not account for the regressive nature of private spending, but only for its total value across socio-economic
ones are able to seek secondary or tertiary care, even if this choice
health facilities. In all other countries, private (and donor)
entails additional costs.
spending on private facilities is not
Lesson 4: In both Burkina Faso and
traceable.
Zambia, but not in Malawi, there has been greater inequality in
Lesson 7: Health service utilization data differ substantially across
spending on institutional delivery services than on curative services.
countries. countries
This is indicative that user fee removal policies may be effective
representative service utilization data more recent than for 2017. This
in increasing health service utilization and ensuring an
means that inevitably the results produced do not truly reflect
egalitarian distribution of financial resources more for curative
today’s reality in relation to the distributional incidence of
services than for maternal care
healthcare spending.
services.
First, none of the provide nationally
Second, surveys follow different
Lesson 5: Across countries, but especially in Burkina Faso and
sampling and data collection strategies, so it is not possible to
Malawi, there are remarkable differences across regions,
capture exactly the same information and generate exactly
provinces, or districts that cannot easily be explained by the reach
comparable results. In particular, only in Malawi service utilization
and content of the UHC reforms being implemented. This suggests
data can be traced all the way to the district level, making truly
that analysis at the aggregate national level runs the risk of
disaggregated
overshadowing internal disparities.
analysis
of
distributional incidence feasible.
groups.
Lesson
is
Lesson 8: NHA data do not provide allocation values disaggregated
Lesson 3: Across countries, the
challenging in all countries, particularly in relation to data
by regions, provinces or districts. This means that heterogeneity and
extraction from National Health Accounts (NHA). The structure of
the matching geo-spatial analysis serve only as an initial insight into
NHA data differs across countries, making it impossible to generate
the magnitude of the disparities within a country. A more accurate
fully comparable analyses. For example, only in Malawi it is
analysis based on data reflecting the actual allocation of financial
possible to generate analysis that captures spending on private
resources
distribution of both public and overall spending has been more egalitarian at lower levels of care (health centers) than at higher levels (hospitals). This is likely to reflect health service utilization patterns, in which poorer segments of society use primary care near where they live, while less poor
6:
Data
acquisition
across
regions,
provinces, or districts is needed.
RECOMMENDATIONS
Public investment is needed in measures to close data gaps – for example, by promoting continuous monitoring of health service utilization patterns by socio-economic status and detailed tracing of spending in the healthcare sector.
More evidence is needed on the sources of geographical disparities across settings and measures implemented to close existing gaps.
Policy attention is required to the inequalities in the distributional incidence (which is particularly persistent in maternal healthcare spending) to understand their sources and address them with adequate measures.
Publishing Director Rémy Rioux Editor-in-Chief Thomas Melonio
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