The effects of public and private health care expenditure on health status in sub-Saharan Africa: New evidence from panel data analysis

Background: Health care expenditure has been low over the years in developing regions of the world. A majority of countries in these regions, especially sub-Saharan Africa (SSA), rely on donor grants and loans to finance health care. Such expenditures are not only unsustainable but also inadequate considering the enormous health care burden in the region. The objectives of this study are to determine the effect of health care expenditure on population health status and to examine the effect by public and private expenditure sources. Methods: The study used panel data from 1995 to 2010 covering 44 countries in SSA. Fixed and random effects panel data regression models were fitted to determine the effects of health care expenditure on health outcomes. Results: The results show that health care expenditure significantly influences health status through improving life expectancy at birth, reducing death and infant mortality rates. Both public and private health care spending showed strong positive association with health status even though public health care spending had relatively higher impact. Conclusion: The findings imply that health care expenditure remains a crucial component of health status improvement in sub-Saharan African countries. Increasing health care expenditure will be a significant step in achieving the Millennium Development Goals. Further, policy makers need to establish effective public-private partnership in allocating health care expenditures

Trend and determinants of contraceptive use among women of reproductive age in Ghana

The study examined the trend in contraceptive use among sexually active women of reproductive age in Ghana. The study also investigated the socioeconomic determinants of contraceptive use. Cross tabulations and logistic regression analyses were performed on data from the Ghana Demographic and Health Surveys 1988 - 2008. The results indicate low contraceptive use among women with marked variation in contraceptive use across various socioeconomic groups and administrative regions. Evidence from the logistic regressions suggests that improving education and reducing poverty are critical in improving contraceptive use and reducing unmet need for family planning. Child survival, access to family planning services and knowledge of contraceptive methods were also found to be significant determinants of contraceptive use. The importance of improving financial and infrastructural access to contraceptives was confirmed by the findings of the study.

HIV/AIDS-related stigma and HIV test uptake in Ghana: evidence from the 2008 Demographic and Health Survey

The study examined the association between HIV test uptake and socioeconomic characteristics of individuals, including HIV-related stigma behaviours. The study also investigated the socioeconomic determinants of HIV-related stigma in Ghana. Cross tabulations and logistic regression techniques were applied to data from the 2008 Ghana Demographic and Health Survey. The results showed significantly low HIV test uptake and some level of HIV-related stigma prevalence in Ghana. Higher wealth status, educational attainment and HIV-related stigma were significant determinants of HIV test uptake. Aside wealth status and education, rural place of residence and religious affiliation were positive and significant determinants of HIV-related stigma. The findings call for comprehensive HIV education including treatment, prevention and care. Legislations to discourage stigma and improve HIV-testing will be critical policy steps in the right direction.

Fiscal space for health in Sub-Saharan African countries: an efficiency approach

The study argues that potential savings from efficiency could be effective alternative to increasing health system financing in SSA. Health system efficiency estimates were derived from the Data Envelopment Analysis and Stochastic Frontier Analysis and used to compute potential gains from efficiency. Data was sourced from the World Bank's world development indicators for 45 SSA countries in 2011. The results reveal that average potential saving in health expenditure from improved efficiency was 0.10% and 0.75% of GDP per capita in the DEA and SFA models, respectively. The results also showed that a 1% increase in efficiency of health expenditure reduced infant mortality rate by 0.91% compared to 0.40% reduction in infant mortality if health expenditure increased by 1%. The results imply that in the face of significant economic challenges and burden on government budget, improving health expenditure efficiency to create some fiscal space will be an important step

Fiscal space for health in Sub-Saharan African countries: an efficiency approach

The study argues that potential savings from efficiency could be effective alternative to increasing health system financing in SSA. Health system efficiency estimates were derived from the Data Envelopment Analysis and Stochastic Frontier Analysis and used to compute potential gains from efficiency. Data was sourced from the World Bank's world development indicators for 45 SSA countries in 2011. The results reveal that average potential saving in health expenditure from improved efficiency was 0.10% and 0.75% of GDP per capita in the DEA and SFA models, respectively. The results also showed that a 1% increase in efficiency of health expenditure reduced infant mortality rate by 0.91% compared to 0.40% reduction in infant mortality if health expenditure increased by 1%. The results imply that in the face of significant economic challenges and burden on government budget, improving health expenditure efficiency to create some fiscal space will be an important step

Examining patient choice and provider competition under the National Health Insurance Fund outpatient cover in Kenya: does it enhance access and quality of care?

Background: While patient choice and provider competition are predicted to influence provider behaviour for enhancing access and quality of care, evidence on provider perceptions and response to patient choice and provider competition is largely missing in low-resource settings such as Kenya. We examined provider and purchaser perceptions about whether patient choice and provider competition influenced provider behaviour and enhanced access and quality of outpatient care in Kenya. Methods: We conducted a qualitative study to explore this across two purposefully selected counties. We conducted 15 in-depth interviews (IDIs) with health facility managers and National Health Insurance Fund (NHIF) staff across the two counties. We examined these across five areas summarised as either local market conditions or patient feedback following the Vengberg framework. Results: NHIF members’ choice of outpatient facilities compelled private and faith-based providers to compete for members while public providers did not view choice as a way of spurring competition. Besides, all providers did not receive any information regarding the exit of NHIF members from their facilities. Providers felt that that information would be crucial for their planning, especially in enhancing service accessibility and quality of care. Most providers ensured the availability of drugs, provided a wider range of services and leveraged on marketing to attract and retain NHIF members. Finally, providers highlighted their redesign of service delivery to meet NHIF members’ needs whilst enhancing the quality-of-care aspects such as waiting time and having qualified health workers. Conclusion: There is a need for NHIF to share NHIF members’ exit information with providers to support their service delivery arrangements in response to NHIF members’ needs. Besides, this study contributes evidence on patient choice and provider competition and their influence on access and quality of care from a low-resource setting country which is crucial as NHIF transitioned to the Social Health Authority

Assessing the choice of national health insurance fund contracted outpatient facilities in Kenya: a qualitative study

Objective To assess National Health Insurance Fund (NHIF) members' level of understanding, experiences, and factors influencing their choice of NHIF-contracted outpatient facilities in Kenya. Methods We conducted a cross-sectional qualitative study with NHIF members in two purposefully selected counties (Nyeri and Makueni counties) in Kenya. We collected data through 15 focus group discussions with NHIF members. Data were analysed using a framework analysis approach. Results Urban-based NHIF members had a good understanding of the NHIF-contracted outpatient facility selection process and the approaches for choosing and changing providers, unlike their rural counterparts. While NHIF members were required to choose a provider before accessing care, the number of available alternative facilities was perceived to be inadequate. Finally, NHIF members identified seven factors they considered important when choosing an NHIF-contracted outpatient provider. Of these factors, the availability of drugs, distance from the household to the facility and waiting time at the facility until consultation were considered the most important. Conclusion There is a need for the NHIF to prioritise awareness-raising approaches tailored to rural settings. Further, there is a need for the NHIF to contract more providers to both spur competition among providers and provide alternatives for members to choose from. Besides, NHIF members revealed the important factors they consider when selecting outpatient facilities. Consequently, NHIF should leverage the preferred factors when contracting healthcare providers. Similarly, healthcare providers should enhance the availability of drugs, reduce waiting times whilst improving their staff's attitudes which would improve user satisfaction and the quality of care provided

National responses to global health targets: exploring policy transfer in the context of the UNAIDS '90-90-90' treatment targets in Ghana and Uganda.

Global health organizations frequently set disease-specific targets with the goal of eliciting adoption at the national-level; consideration of the influence of target setting on national policies, programme and health budgets is of benefit to those setting targets and those intended to respond. In 2014, the Joint United Nations Programme on HIV/AIDS set 'ambitious' treatment targets for country adoption: 90% of HIV-positive persons should know their status; 90% of those on treatment; 90% of those achieving viral suppression. Using case studies from Ghana and Uganda, we explore how the target and its associated policy content have been adopted at the national level. That is whether adoption is in rhetoric only or supported by programme, policy or budgetary changes. We review 23 (14 from Ghana, 9 from Uganda) national policy, operational and strategic documents for the HIV response and assess commitments to '90-90-90'. In-person semi-structured interviews were conducted with purposively sampled key informants (17 in Ghana, 20 in Uganda) involved in programme-planning and resource allocation within HIV to gain insight into factors facilitating adoption of 90-90-90. Interviews were transcribed and analysed thematically, inductively and deductively, guided by pre-existing policy theories, including Dolowitz and Marsh's policy transfer framework to describe features of the transfer and the Global Health Advocacy and Policy Project framework to explain observations. Regardless of notable resource constraints, transfer of the 90-90-90 targets was evident beyond rhetoric with substantial shifts in policy and programme activities. In both countries, there was evidence of attempts to minimize resource constraints by seeking programme efficiencies, prioritization of programme activities and devising domestic financing mechanisms; however, significant resource gaps persist. An effective health network, comprised of global and local actors, mediated the adoption and adaptation, facilitating a shift in the HIV programme from 'business as usual' to approaches targeting geographies and populations

The poverty and inequality nexus in Ghana: a decomposition analysis of household expenditure components

The study examined the linkages between inequality in household expenditure components and total inequality and poverty in Ghana. Using micro data from the sixth round of the Ghana Living Standards Survey conducted in 2012/2013, marginal effects and elasticities were computed for both within-and between-component analysis. The results suggest that, in general, reducing within-component inequality significantly reduces overall poverty and inequality in Ghana, compared to between-component inequality. Specifically, inequality in education and health expenditure components were the largest contributors to overall poverty and inequality. The findings imply that policies directed towards reducing within-component inequality will be more effective than those directed towards between-component inequality. Specifically, the findings of the study corroborates with tax policies (such as Value Added Tax and National Health Insurance Levy in the case of Ghana) that provide exemptions for educational, health and agricultural inputs. This will lead to reduction in overall poverty and inequality by reducing inequality within these expenditure components. The results were robust to the choice of poverty line and consistent for both rural and urban locations