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[MANILA] Equity in healthcare coverage has remained an elusive goal for most developing countries. Evidence points to a pro-rich distribution of total healthcare benefits and progressive financing, according to a study on healthcare financing in low- and middle-income countries (LMICs).
In the Asia-Pacific and Sub-Saharan Africa, healthcare financing benefits the better off more than the poor, says a study in PLOS One (11 April). While the distribution of benefits at the primary healthcare level favours the poor, hospital level services benefit the rich more, who also shoulder more of the burden of healthcare financing.
The study also cites impediments to making healthcare more accessible to the poor that “must be addressed if universal healthcare is to be a reality”.
The researchers, led by Augustine Asante from the School of Public Health and Community Medicine at the University of New South Wales in Sydney, Australia, reviewed data from 24 scientific studies and electronic databases, as well as reports from the World Bank, UK Department of International Development, Asian Development Bank, World Health Organization, US Agency for International Development, and the Organisation for Economic Co-operation and Development.
What makes the study more interesting is its focus on benefit and financing incidence analyses in evaluating how well health systems in LMICs perform. The probe into financing incidence showed whether public spending on health is progressive or not towards achieving universal healthcare.
According to the research findings, an estimated 1.3 billion people in developing countries worldwide do not have access to effective and affordable healthcare. Of those who have access, about 170 million are forced to spend more than 40 per cent of their household income on medical treatment.
‘Pushed into poverty’
Highlighting “financial barriers” that limit access to health services, the study says that in 33 mostly low-income countries, direct out-of-pocket payments represented more than half of total health expenditures.
“There is a high probability of many households in LMICs are being pushed into poverty when faced with substantial medical expenses, particularly when these are combined with a loss of income due to ill-health,” the study says.
There is increasing recognition that measures to promote financial protection through universal health coverage now represent major components in global efforts to fight poverty. This is reflected in the UN Sustainable Development Goals, specifically Goal 3 on “Good Health and Wellbeing”.
There are a few bright spots, however, notes the study. Three Asian countries — Malaysia, Sri Lanka, and Thailand — have been able to maintain a pro-poor distribution of healthcare benefits and progressive financing. In particular, Malaysia and Thailand seem to have established a strongly pro-poor distribution of healthcare benefits at all levels of the health system.
There is a “progressive distribution” across all health financing sources in the Asia-Pacific, specifically in Bangladesh, Indonesia, Malaysia, Mongolia, Nepal, the Philippines, Sri Lanka and Vietnam. But in Sub-Saharan Africa, out-of-pocket and voluntary and private health insurance payments are “repressive”.
Overall, policymakers in LMICs, especially those in Sub-Saharan Africa, need to increase their efforts to shift government resources towards the poor if the goal of universal health coverage is to be realised.
“Governments should do more to target the poor in the delivery of healthcare services,” lead author Asante tells SciDev.Net. “It is heartening to learn that the rich bear the lion’s share of the burden of financing healthcare in the majority of the LMICs included in the study, but unfortunately the services are also distributed in their favour. This is not good for equity!”
Asked if any policymaker from any developing country has contacted the research group to seek further guidance on how to use the study’s findings, Asante replies, “Not yet”.
A more recent report (11 May) on “health systems leapfrogging in emerging economies”, released by the Geneva-based World Economic Forum (WEF) and the Massachusetts-based Boston Consulting Group (BCG), says replicating the health systems of developed economies “is not the answer”.
The traditional bilateral and transactional models — where the government contracts out a particular project to a private organisation — could lead developing countries into “financially untenable situations” in view of the high cost of tackling communicable and non-communicable diseases, says the report produced by a team led by Arnaud Bernaert, senior director at the WEF Global Health and Healthcare Industries.
In these traditional schemes, where the private sector is viewed as a vendor rather than a partner, results can also be hampered by bureaucracy and tend to “generate distrust and debates” about their effectiveness in delivering health outcomes.
Examples of such transactional modes include “health development-type” and “infrastructure-type” public private partnerships (PPPs). Under the first PPP type, private groups provide health products and services to low-income communities through in-kind or financial contributions. Sustainability is a challenge when the private groups fail to keep up with their commitments and the public sector is forced to fill the gap.
In the infrastructure-type PPPs, the government delegates to the private sector the tasks of planning, constructing and maintaining health facilities. The WEF-BCG joint study notes that owing to their “transactional and task-oriented” nature, such PPPs do not have a holistic view of the health outcome to be achieved or the most cost-efficient, fast, and scalable path.
The report proposes leapfrogging to an “ecosystem” approach that involves “closer and more efficient cooperation” between the public, private and civil society sectors that changes over time. Sustainability is a key objective.
The report points to a number of cases in developing countries where mobilising and coordinating an ecosystem of large corporations, start-ups, NGOs, international and academic institutions, along with health policymakers, provided opportunities to transform health systems.
With the inclusion of health systems in the SDGs, “emerging economies will need to mobilise significant additional funding to meet these targets”.
This piece was produced by SciDev.Net’s South-East Asia & Pacific desk.
Augustine Asante and others Equity in Health Care Financing in Low- and Middle-Income Countries: A Systematic Review of Evidence from Studies Using Benefit and Financing Incidence Analyses (PLOS One, 11 April 2016)
Lisandro Zarate and others Health Systems Leapfrogging in Emerging Economies (World Economic Forum Reports, 11 May 2016)