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POLICY DIALOGUES Inequalities in Healthcare Spending on Curative Services: Evidence from Zambia February 2021 - No. 25 | UE-AFD Research Facility on Inequalities

MAIN MESSAGE Both public spending and overall spending on curative services have become more egalitarian in Zambia with the rollout of Universal Health Coverage policies across the country. New research finds that the distribution of benefits from public spending remains consistently propoor, except at public hospitals. But while the distribution of benefits from overall spending has become more equitable across levels and types of healthcare, equality has not yet been achieved. Differences between provinces in the distribution of public and overall benefits have become smaller over time, with displaying

only a

two provinces pro-least-poor

distribution of health spending. Further policy action is needed to consolidate current equity gains by tackling the remaining sources of

pocket expenditures by households

introduction of ‘performance-based

28%,

financing’ in a total of 30 districts across 8 provinces. The program

and

the

rest

covered

development partners. Over 90% of health service provision takes place within the public sector. Since 1992, this has focused mainly on provision of primary care services delivered in a decentralized way. Between 2006 and 2012, user charges initially introduced in 1992 were progressively removed for all primary care services: first in rural areas; then in semi-urban areas; and finally nationwide.

introduced supply-side incentives tied to provision of a wide range of primary health services, including both maternal and curative care. METHODS This study uses Benefit Incidence Analysis to analyze the distribution of healthcare spending for curative services over time. The objective is to understand the extent to which

But many higher-level public facilities

spending on curative services has been distributed so as to reach

retain ‘fee-for-service’ wings, providing higher quality care and

people across different socioeconomic groups in light of recent

shorter waiting times for patients who can afford them. Despite the removal

reforms. To compute

of user fees for primary care in the public sector, inadequate funding

curative services, the study uses data from the 2006 and 2010 rounds of the

continues

Living Conditions Monitoring Survey, and the 2014 Zambia Household

hamper

equitable

access to services.

inequality.

In 2015, the government proposed the introduction of a social health

CONTEXT & MOTIVATION

insurance scheme to cover all citizens progressively, but no concrete steps

In 2013, total healthcare spending in Zambia was nearly 5% of GDP, with the

have yet been taken towards its implementation. Between 2011 and

government contributing 38%, out-of-

2014, the government piloted the

utilization

rates

Health Utilization and Expenditure Survey. The study looks at spending by type of provider (public, mission) and/or by level of care (health center, hospital) utilization

and, rates

by aggregating across types of

provider and levels of care.

Authors Bona Mukoshya CHITAH, Chrispin MPHUKA, Martin RUDASINGWA, Edmund YEBOAH, Emmanuel

Key words Health, Curative, Spending, Inequality, Distribution

BONNET, Valéry RIDDE, Manuela DE ALLEGRI Geography Zambia

Themes Health Financing, Health Inequality, Health Spending, Curative Healthcare

Find out more about this project: afd.fr/en/carte-des-projets/assessing-equity-health-spending-sub-saharanafrica

for

The unit costs are based on data from National Health Accounts on: recurrent public spending on

Distributional incidence of public and overall spending on curative services by level of care and over time

curative services; donor spending on curative services; and household

(a) Public spending on curative services 0,6

out-of-pocket expenditures on curative services. The study also uses descriptive geo-spatial analysis to visualize disparities in both public and

p<0.01

consistently

pro-poor

over

time,

Total public spending

Concentration index

The distribution of public spending on curative services remains

p<0.1 p<0.01

-0,4

overall spending on curative services across regions. RESULTS

p<0.01

0,1

over time. Looking at distributional incidence by type of provider and level of care, it becomes evident that the pattern for total public spending is largely driven by the distributional incidence at the level of public health centers and mission health facilities. In contrast, public hospitals have consistently displayed a pro-leastpoor distribution (see Figure 1). This may be due to public hospitals that continue to impose user fees for certain services and therefore end up attracting wealthier patients. There is increased equality in overall spending, with spending at public health centers and mission health facilities becoming more pro-poor

p<0.01

Public health centers

Public hospitals

Mission health facilities

(b) Overall spending on curative services 0,6 p<0.05 p<0.01 p<0.01 -0,4

p<0.01

Total health spending

p<0.01

p<0.05

Public health centers

except at public hospitals Total public spending displays an increasingly pro-poor distribution

p<0.01

2006

2010

Public hospitals

Mission health facilities

2014

The distributional incidence of overall

public

spending on curative services has been increasingly pro-poor across all

curative services have decreased substantially over time, largely

types of provider and levels of care (see Figure 1). This may be an

reflecting the overall increase in equality at the national level. While in

indication that both donor and private resources are allocated to

2006, provinces display a diverse set of pro-poor, least-pro-poor and

compensate for the inequalities in the distributional incidence of public

egalitarian patterns, by 2014, almost all provinces display a pro-poor

spending at higher levels of care. Explaining this somewhat counter-

pattern in the distributional incidence

intuitive finding may require further

and

overall

spending

of both public and overall spending.

qualitative investigation.

Only two provinces (Muchinga and Northwestern) display values

Geographical disparities in distributional incidence have been

indicating a distributional incidence of both public and overall spending

decreasing substantially for both

that favors the least poor. But the magnitude of the value is negligible

public and overall spending Provincial disparities distributional incidence

in of

the both

as it approaches the line of equality.

RECOMMENDATIONS 

Continued investment in reforms is essential to sustain an egalitarian or pro-poor distribution of health benefits in the healthcare sector.



It is advisable to investigate the source of decreasing geographical disparities over time to identify what lessons can be learned and adapted to other contexts.



It is essential to investigate the source of persisting inequities in the distribution of public spending at the level of public hospitals and to design measures to counteract observed inequality.

Publishing Director Rémy Rioux Editor-in-Chief Thomas Melonio

Agence française de développement (AFD) 5, rue Roland Barthes | 75012 PARIS | France

For other publications of the Policy dialogues collection: https://www.afd.fr/en/collection/policy-dialogues