Determinants of health insurance ownership among South African women

BACKGROUND: Studies conducted in developed countries using economic models show that individual- and household- level variables are important determinants of health insurance ownership. There is however a dearth of such studies in sub-Saharan Africa. The objective of this study was to examine the relationship between health insurance ownership and the demographic, economic and educational characteristics of South African women. METHODS: The analysis was based on data from a cross-sectional national household sample derived from the South African Health Inequalities Survey (SANHIS). The study subjects consisted of 3,489 women, aged between 16 and 64 years. It was a non-interventional, qualitative response econometric study. The outcome measure was the probability of a respondent's ownership of a health insurance policy. RESULTS: The χ(2 )test for goodness of fit indicated satisfactory prediction of the estimated logit model. The coefficients of the covariates for area of residence, income, education, environment rating, age, smoking and marital status were positive, and all statistically significant at p ≤ 0.05. Women who had standard 10 education and above (secondary), high incomes and lived in affluent provinces and permanent accommodations, had a higher likelihood of being insured. CONCLUSION: Poverty reduction programmes aimed at increasing women's incomes in poor provinces; improving living environment (e.g. potable water supplies, sanitation, electricity and housing) for women in urban informal settlements; enhancing women's access to education; reducing unemployment among women; and increasing effective coverage of family planning services, will empower South African women to reach a higher standard of living and in doing so increase their economic access to health insurance policies and the associated health services

Health Economics: Potential Applications in HIV/AIDS Control in Africa

There is growing evidence that HIV/AIDS has enormous negative impact on health status and economic development of individuals, households, communities and nations in the African region [33]. Thus, there is urgent need for various disciplines to demonstrate how they can contribute in curbing the spread of this deadly disease in the African region. This paper, using an extended version of Professor Alan Williams [32] schema as the conceptual framework, attempts to demonstrate how health economics can be used to inform policy and managerial choices related to HIV/AIDS advocacy, prevention, treatment and management. It argues that the discipline of health economics (and economics generally) is extremely valuable in: measuring health impacts of the disease and interventions; evaluating the relationships between health care-seeking behaviour of individuals and health system specific attributes; the estimation of determinants of compliance of HIV/AIDS patients with treatment regimen; establishing of health institutions efficiency in combating AIDS; guiding choices of HIV/AIDS interventions; assessing the relationships between HIV/AIDS, development, poverty, and trade; programme planning, monitoring and evaluation; and assessing health system's overall performance. The paper is a modest attempt to show how the discipline of health economics can elucidate, and help in resolving practical and conceptual issues in HIV/AIDS control in Africa

A literature review of the disruptive effects of user fee exemption policies on health systems

BACKGROUND: Several low- and middle-income countries have exempted patients from user fees in certain categories of population or of services. These exemptions are very effective in lifting part of the financial barrier to access to services, but they have been organized within unstable health systems where there are sometimes numerous dysfunctions. The objective of this article is to bring to light the disruptions triggered by exemption policies in health systems of low- and middle-income countries. METHODS: Scoping review of 23 scientific articles. The data were synthesized according to the six essential functions of health systems. RESULTS: The disruptions included specifically: 1) immediate and significant increases in service utilization; 2) perceived heavier workloads for health workers, feelings of being exploited and overworked, and decline in morale; 3) lack of information about free services provided and their reimbursement; 4) unavailability of drugs and delays in the distribution of consumables; 5) unpredictable and insufficient funding, revenue losses for health centres, reimbursement delays; 6) the multiplicity of actors and the difficulty of identifying who is responsible ('no blame' game), and deficiencies in planning and communication. CONCLUSIONS: These disruptive elements give us an idea of what is to be expected if exemption policies do not put in place all the required conditions in terms of preparation, planning and complementary measures. There is a lack of knowledge on the effects of exemptions on all the functions of health systems because so few studies have been carried out from this perspective

User fees in private non-for-profit hospitals in Uganda: a survey and intervention for equity

BACKGROUND: In developing countries, user fees may represent an important source of revenues for private-non-for-profit hospitals, but they may also affect access, use and equity. METHODS: This survey was conducted in ten hospitals of the Uganda Catholic Medical Bureau to assess differences in user fees policies and to propose changes that would better fit with the social concern explicitly pursued by the Bureau. Through a review of relevant hospital documents and reports, and through interviews with key informants, health workers and users, hospital and non-hospital cost was calculated, as well as overall expenditure and revenues. Lower fees were applied in some pilot hospitals after the survey. RESULTS: The percentage of revenues from user fees varied between 6% and 89% (average 40%). Some hospitals were more successful than others in getting external aid and government subsidies. These hospitals were applying lower fees and flat rates, and were offering free essential services to encourage access, as opposed to the fee-for-service policies implemented in less successful hospitals. The wide variation in user fees among hospitals was not justified by differences in case mix. None of the hospitals had a policy for exemption of the poor; the few users that actually got exempted were not really poor. To pay hospital and non-hospital expenses, about one third of users had to borrow money or sell goods and property. The fee system applied after the survey, based on flat and lower rates, brought about an increase in access and use of hospital services. CONCLUSION: Our results confirm that user fees represent an unfair mechanism of financing for health services because they exclude the poor and the sick. To mitigate this effect, flat rates and lower fees for the most vulnerable users were introduced to replace the fee-for-service system in some hospitals after the survey. The results are encouraging: hospital use, especially for pregnancy, childbirth and childhood illness, increased immediately, with no detrimental effect on overall revenues. A more equitable user fees system is possible

Impact of disaster-related mortality on gross domestic product in the WHO African Region

BACKGROUND: Disaster-related mortality is a growing public health concern in the African Region. These deaths are hypothesized to have a significantly negative effect on per capita gross domestic product (GDP). The objective of this study was to estimate the loss in GDP attributable to natural and technological disaster-related mortality in the WHO African Region. METHODS: The impact of disaster-related mortality on GDP was estimated using double-log econometric model and cross-sectional data on various Member States in the WHO African Region. The analysis was based on 45 of the 46 countries in the Region. The data was obtained from various UNDP and World Bank publications. RESULTS: The coefficients for capital (K), educational enrolment (EN), life expectancy (LE) and exports (X) had a positive sign; while imports (M) and disaster mortality (DS) were found to impact negatively on GDP. The above-mentioned explanatory variables were found to have a statistically significant effect on GDP at 5% level in a t-distribution test. Disaster mortality of a single person was found to reduce GDP by US$0.01828. CONCLUSIONS: We have demonstrated that disaster-related mortality has a significant negative effect on GDP. Thus, as policy-makers strive to increase GDP through capital investment, export promotion and increased educational enrolment, they should always keep in mind that investments made in the strengthening of national capacity to mitigate the effects of national disasters expeditiously and effectively will yield significant economic returns

Quality of care for the treatment for uncomplicated malaria in South-East Nigeria: how important is socioeconomic status?

Introduction: Ensuring equitable coverage of appropriate malaria treatment remains a high priority for the Nigerian government. This study examines the health seeking behaviour, patient-provider interaction and quality of care received by febrile patients of different socio-economic status (SES) groups. Methods: A total of 1642 febrile patients and caregivers exiting public health centres, pharmacies and patent medicine dealers were surveyed in Enugu state, South-East Nigeria to obtain information on treatment seeking behaviour, patient-provider interactions and treatment received. Socioeconomic status was estimated for each patient using exit survey data on household assets in combination with asset ownership data from the 2008 Nigeria Demographic and Health Survey. Results: Among the poorest SES group, 29% sought treatment at public health centres, 13% at pharmacies and 58% at patent medicine dealers (p < 0.01). Very few of those in the richest SES group used public health centres (4%) instead choosing to go to pharmacies (44%) and patent medicine dealers (52%, p < 0.001). During consultations with a healthcare provider, the poorest compared to the richest were significantly more likely to discuss symptoms with the provider, be physically examined and rely on providers for diagnosis and treatment rather than request a specific medicine. Those from the poorest SES group were however, least likely to request or to receive an antimalarial (p < 0.001). The use of artemisinin combination therapy (ACT), the recommended treatment for uncomplicated malaria, was low across all SES groups. Conclusions: The quality of malaria treatment is sub-optimal for all febrile patients. Having greater interaction with the provider also did not translate to better quality care for the poor. The poor face a number of significant barriers to accessing quality treatment especially in relation to treatment seeking behaviour and type of treatment received. Strategies to address these inequities are fundamental to achieving universal coverage of effective malaria treatment and ensuring that the most vulnerable people are not left behind

Individual Heterogeneity in the Returns to Schooling: Instrumental Variables Quantile Regression Using Twins Data

Considerable effort has been exercised in estimating mean returns to education while carefully considering biases arising from unmeasured ability and measurement error. Recent work has investigated whether there are variations from the “mean” return to education across the population with mixed results. We use an instrumental variables estimator for quantile regression on a sample of twins to estimate an entire family of returns to education at different quantiles of the conditional distribution of wages while addressing simultaneity and measurement error biases. We test whether there is individual heterogeneity in returns to education and find that: more able individuals obtain more schooling and that higher ability individuals (those further to the right in the conditional distribution of wages) have higher returns to schooling consistent with a non-trivial interaction between schooling and unobserved abilities in the generation of earnings. The estimated returns are never lower than 9 percent and can be as high as 13 percent at the top of the conditional distribution of wages but they vary significantly only along the lower to middle quantiles. Our findings may have meaningful implications for the design of educational policies

Improving access to health care for malaria in Africa: a review of literature on what attracts patients

BACKGROUND: Increasing access to health care services is considered central to improving the health of populations. Existing reviews to understand factors affecting access to health care have focused on attributes of patients and their communities that act as 'barriers' to access, such as education level, financial and cultural factors. This review addresses the need to learn about provider characteristics that encourage patients to attend their health services. METHODS: This literature review aims to describe research that has identified characteristics that clients are looking for in the providers they approach for their health care needs, specifically for malaria in Africa. Keywords of 'malaria' and 'treatment seek*' or 'health seek*' and 'Africa' were searched for in the following databases: Web of Science, IBSS and Medline. Reviews of each paper were undertaken by two members of the team. Factors attracting patients according to each paper were listed and the strength of evidence was assessed by evaluating the methods used and the richness of descriptions of findings. RESULTS: A total of 97 papers fulfilled the inclusion criteria and were included in the review. The review of these papers identified several characteristics that were reported to attract patients to providers of all types, including lower cost of services, close proximity to patients, positive manner of providers, medicines that patients believe will cure them, and timeliness of services. Additional categories of factors were noted to attract patients to either higher or lower-level providers. The strength of evidence reviewed varied, with limitations observed in the use of methods utilizing pre-defined questions and the uncritical use of concepts such as 'quality', 'costs' and 'access'. Although most papers (90%) were published since the year 2000, most categories of attributes had been described in earlier papers. CONCLUSION: This paper argues that improving access to services requires attention to factors that will attract patients, and recommends that public services are improved in the specific aspects identified in this review. It also argues that research into access should expand its lens to consider provider characteristics more broadly, especially using methods that enable open responses. Access must be reconceptualized beyond the notion of barriers to consider attributes of attraction if patients are to receive quality care quickly