Igna Bonfrer

Increasing equitable access to health care is a main challenge African policy makers are facing. The Ghanaian government implemented the National Health Insurance Scheme in 2004 and the aim of this study is to evaluate its early effects on maternal and infant healthcare use. We exploit data on births before and after the intervention and apply propensity score matching to limit the bias arising from self-selection into the health insurance. About forty percent of children had a mother who is enrolled in this insurance. The scheme significantly increased the proportion of pregnancies with at least four antenatal care visits with 7 percentage points and had a significant effect on attended deliveries (10 percentage points). Caesarean sections increased (6 percentage points) and the number of children born from an unwanted pregnancy decreased (7 percentage points). Insurance enrollment had almost no effect on child vaccinations. Among the poorest forty percent of the sample, the effects of the scheme on antenatal care and attended deliveries were similar. However, the effects of the scheme on caesarean sections were about half the size (3 percentage points) and the reduction in unwanted pregnancies was larger (10 percentage points) compared to the effects in the full sample. We conclude that in the first years of operation, the National Health Insurance Scheme had a modest impact on the use of antenatal and delivery care. This is important for other African countries currently introducing or considering a national health insurance as a means towards universal health coverage.

Risks are a central part of life for households in low-income countries and health shocks in particular are associated with poverty. Formal mechanisms protecting households against the financial consequences of shocks are largely absent, especially among poor rural households. Our aim is to identify the relative importance of health shocks and to explore factors associated with coping behaviour and foregone care. We use a cross-sectional survey among 1226 randomly selected agricultural households in Kenya. In our sample, illness and injury shocks dominate all other shocks in prevalence. Almost 2% of households incurred catastrophic health expenditure in the last year. Using a probit model we identified the main coping strategies associated with facing a health shock: (1) use savings, (2) sell assets and (3) ask for gifts or loans. One in five households forewent necessary care in the last 12 months. We conclude that health shocks pose a significant risk to households. Implementing pre-payment or saving mechanisms might help protect households against the financial consequences of ill health. Such mechanisms, however, should take into account the competing shocks that agricultural households face, making it almost impossible to reserve a share of their limited resources for the protection against health shocks only.

Several governments in low- and middle-income countries have adopted performance-based financing to increase health care use and improve the quality of health services. We evaluated the effects of performance-based financing in the central African nation of Burundi by exploiting the staggered rollout of this financing across provinces during 2006-10. We found that performance-based financing increased the share of women delivering their babies in an institution by 22 percentage points, which reflects a relative increase of 36 percent, and the share of women using modern family planning services by 5 percentage points, a relative change of 55 percent. The overall quality score for health care facilities increased by 45 percent during the study period, but performance-based financing was found to have no effect on the quality of care as reported by patients. We did not find strong evidence of differential effects of performance-based financing across socioeconomic groups. The performance-based financing effects on the probability of using care when ill were found to be even smaller for the poor. Our findings suggest that a supply-side intervention such as performance-based financing without accompanying access incentives for poor people is unlikely to improve equity. More research into the cost-effectiveness of performance-based financing and how best to target vulnerable populations is warranted.

An equitable distribution of healthcare use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). We examine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries. For almost all countries studied, healthcare utilization is considerably higher among the rich. When decomposing these inequalities we find that wealth is the single most important driver. In 12 of the 18 countries wealth is responsible for more than half of total inequality in the use of care, and in 8 countries wealth even explains more of the inequality than need, education, employment, marital status and urbanicity together. For the richer countries, notably Mauritius, Namibia, South Africa and Swaziland, the contribution of wealth is typically less important. As the bulk of inequality is not related to need for care and poor people use less care because they do not have the ability to pay, healthcare utilization in these countries is to a large extent unfairly distributed. The weak average relationship between need for and use of health care and the potential reporting heterogeneity in self-reported health across socio-economic groups imply that our findings are likely to even underestimate actual inequities in health care. At a macro level, we find that a better match of needs and use is realized in those countries with better governance and more physicians. Given the absence of social health insurance in most of these countries, policies that aim to reduce inequities in access to and use of health care must include an enhanced capacity of the poor to generate income.