ArticlesEquity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage
Introduction
There is a growing focus on the goal of universal coverage in health systems. For example, the World Health Report 2010 on universal coverage of health care1 and the associated declaration of the World Health Assembly2 urged member states to “aim for affordable universal coverage and access for all citizens on the basis of equity and solidarity”.2 Several countries, such as India3 and South Africa,4 have lately developed policy proposals to pursue this goal. The generally accepted core of universal coverage is that the health system should be financed in accordance with the ability to pay, and benefits received in accordance with the need for health care (panel 1). Analytical methods are available to assess health systems relative to these principles, notably in the form of financing incidence analysis (assessing whether health-care financing methods are progressive, regressive, or proportional), and benefit incidence analysis (assessing the monetary value of service benefits received by different socioeconomic groups). However, debate on the relative merits of different approaches to financing of health care has tended to proceed without good evidence on the equity of present arrangements, and has made generalisations that lack a sufficiently strong evidence base—eg, certain forms of tax financing are regressive in low-income countries and public services are exploited more by richer groups. As countries plan their paths to universal coverage, and debate grows on the relative merits of financing mechanisms including various types of tax financing, social health insurance, community-based insurance, and out-of-pocket payments, it is crucial that better evidence be made available on equity implications. We report the results of a three-country study on the equity of health-system financing and service use.
Section snippets
Countries assessed
We selected Ghana, South Africa, and Tanzania because they are all considering how best to develop their health systems towards universal coverage, and they represent systems at different stages of development (panel 2). Ghana began implementing a national health insurance scheme in 2004, with elements covering both the formal and informal sectors. South Africa has just released a Green Paper on introducing a national health-insurance scheme.4 Tanzania in recent decades has introduced various
Results
Direct taxes were progressive in all three countries. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania (figure 1). Out-of-pocket payments were regressive and overall health-care financing was progressive in all three countries.
Figure 2 shows the differences between the countries in the relative progressivity of indirect taxes. All forms of indirect tax (value-added tax [VAT], fuel levies, and excise duties) were regressive in South Africa. By contrast, VAT
Discussion
Despite very different arrangements for health-care financing in the three countries (panel 2), we consistently identified that financing was progressive in all three, although there were wide variations in the relative progressivity of different funding sources across countries. Although the finding that total health-care financing was progressive is perhaps not unexpected, since richer groups might be more able to contribute to the cost of their health care, we note that all public sources of
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