Uitnodiging Evaluating Health Care Financing Reforms in Africa Reforms Financing Care Health Evaluating Africa is experiencing steady economic growth but trends in U bent van harte uitgenodigd voor the health status of the population are lagging behind. This het bijwonen van de openbare verdediging van het proefschrift: provides an opportunity for health care financing reforms to improve equitable access to good quality health care. The aim Evaluating Health Care of this thesis is to provide evidence about the effectiveness Financing Reforms in Africa of health care financing reforms, such as health insurance door Igna Bonfrer and performance based financing, implemented in different African countries over the last decade. This evidence can help op donderdag 11 juni 2015 om policy makers to take well informed decisions about reforms 15.30u precies in de Senaatszaal necessary to achieve Universal Health Coverage by 2030. (Erasmus gebouw) van de Erasmus Universiteit Rotterdam, Campus Woudestein, Burgemeester Igna Bonfrer is currently a researcher at the institute of Health Oudlaan 50 te Rotterdam. Policy and Management, Erasmus University Rotterdam. De verdediging zal in het She will do her post-doctoral research at Harvard University, Engels zijn. funded through a NWO Rubicon fellowship. In this research she plans to evaluate the effects of Obama Care, specifically aspects related to performance based financing. Na afloop van de verdediging bent U van harte welkom op de receptie in de foyer van het Erasmus Paviljoen. Igna Bonfrer Igna Paranimfen Evaluating Hedwig Blommestein Health Care Financing Reforms Saskia de Groot Contact in Africa [email protected] Igna Bonfrer Evaluating Health Care Financing Reforms in Africa Het evalueren van hervormingen in de financiering van de gezondheidszorg in Afrika Igna Elisabeth Johanna Bonfrer Copyright 2015 © Igna Bonfrer ISBN: 978-94-6259-643-6 Cover design: Ellen Gerrits and Martien Bonfrer Photographic images: Igna Bonfrer Design and layout: Legatron Electronic Publishing, Rotterdam Printing: Ipskamp Drukkers, Enschede No part of this thesis may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission from the author or, when appropriate, from the publishers of the publications. Evaluating Health Care Financing Reforms in Africa Het evalueren van hervormingen in de financiering van de gezondheidszorg in Afrika Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof.dr. H.A.P. Pols en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op donderdag 11 juni 2015 om 15.30 uur door Igna Elisabeth Johanna Bonfrer geboren te Leiden Promotiecommissie Promotoren Prof.dr. E.K.A. van Doorslaer Prof.dr. M. Grimm Overige leden Prof.dr. O.A. O’Donnell Prof.dr. A. Bedi Prof.dr. B. Meessen Copromotor Dr. E. Van de Poel Content Chapter 1 Introduction 7 Chapter 2 How do health shocks affect agricultural households? 17 Evidence from rural Kenya Chapter 3 Does the distribution of health care utilization match needs in Africa? 47 Chapter 4 The effects of Ghana’s National Health Insurance Scheme on maternal 75 health care utilization Chapter 5 Introduction of performance based financing in Burundi was 95 associated with improvements in care and quality Chapter 6 The effects of performance incentives on utilization and quality of 121 maternal and child care in Burundi Chapter 7 Effects of a subsidized voluntary health insurance on insured 143 and uninsured in Nigeria Chapter 8 Conclusion and policy recommendations 165 References 175 Summary 189 Samenvatting 197 List of publications and submissions 204 PhD portfolio Igna Bonfrer 207 About the author 213 Dankwoord 215 Chapter 1 Introduction 8 Chapter 1 Africa is on a steady economic growth path. Over the last decade, most Sub-Saharan African (SSA) countries outperformed European and North-American countries’ growth rates, as shown in Figure 1. A number of SSA countries are among the fastest growing economies in the world, coming from very low income levels, and moderate growth is predicted for most of these countries (International Monetary Fund, 2014; Rodrik, 2014). However, trends in the health status of the African population are lagging behind. Since 1990, most regions in the world have achieved a reduction in child mortality of at least 60 percent and Eastern Asia even reduced the number of children not reaching their fifth birthday by 74 percent. Over that same period, SSA achieved a reduction of only 45 percent (calculations based on Millennium Development Goals Report (2014)). Not only do trends in health status lag behind in SSA, the levels are also considerably lower. Almost half of all child deaths worldwide occur in SSA and disparities in child mortality between the poor and the better off are increasing. SSA has the highest maternal mortality ratio with 510 deaths per 100,000 live births, 70 percent of new HIV infections occur in this region (United Nations, 2014) and frequent outbreaks of other infectious diseases like Ebola create an important threat to population health. In addition to these infectious diseases, increased levels of non-communicable diseases associated with economic development create a “double burden of disease” (Maher et al., 2010). This combination of a high disease burden and steady economic growth creates both the need and the opportunity for health care financing reforms to improve equitable access to good quality health care, the topic of this thesis. Greater than or equal to 6 Between 4 and 6 Between 2 and 4 Between 0 and 2 Less than zero Not sucient data Figure 1 | Average annual growth in GDP per capita in percent over 2003-2013 (calculations based on World Development Indicators) Introduction 9 Universal Health Coverage The need for universal access to health care of good quality features high on policy agendas worldwide. This year will see the closing of the United Nations Millennium Development 1 Goals which contain three directly health related goals (United Nations, 2014) and the start of the Sustainable Development Goals. The latter are expected to include the aim to achieve Universal Health Coverage (UHC) by 2030: providing good quality care to everyone who needs it, without causing financial hardship. In practice this means financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable medicines and vaccines for all (Open Working Group of the General Assembly, 2014). The World Health Organization has developed a simplified graphical representation of the different dimensions of the policy choices that need to be made on the path to UHC, as shown in Figure 2. The entire cube should be filled to achieve UHC but before getting at that stage policy makers have to decide on: i) breadth, reflecting who is covered, ii) depth, reflecting which type of services and of what quality are covered and iii) height, reflecting financial protection i.e. the proportion of costs covered. Direct costs: proportion of the costs Reduce covered cost sharing Include and fees other services Extend to non-covered Current pooled funds Services: which services Population: who is covered? are covered? Figure 2 | Three dimensions to consider when moving towards universal health coverage (World Health Organization, 2010a) 10 Chapter 1 Evaluating health care financing reforms Different health care financing strategies that have been implemented over the last decade in specific SSA countries, can prove to be important tools on the path towards UHC. The aim of this thesis is to provide evidence about the effectiveness of these health care financing reforms in improving equitable access to good quality health care. This evidence is necessary for policy makers taking decisions about the specific steps their country will take to achieve UHC by 2030. Improving access and financial protection Health care financing strategies can focus on the demand side or the supply side of the health care sector. Demand side strategies, targeted at individuals or households, generally aim to improve financial protection and access to health care for those in need of preventive, acute or chronic care. An important constraint to healthcare access derives from the large out-of- pocket payments (OOP) incurred at the point of use. A popular demand side strategy across SSA is the implementation of health insurance schemes. In 2004 estimates already indicated the existence of approximately 900 schemes (of which many are operating only very locally) in Sub-Saharan Africa (De Allegri et al., 2009). Such schemes can serve as a means to protect households from the risk of medical expenses which can be large relative to modest incomes (van Doorslaer et al., 2007) and therefore cause households to fall into poverty (Wagstaff and van Doorslaer, 2003). The health insurance schemes that are introduced across SSA show a wide organizational variety, including obligatory (national) social health insurance (SHI) schemes, voluntary private health insurance (PHI) schemes and Community Based Health Insurance (CBHI) schemes operating at regional or local level. In theory we would expect health insurance to contribute to UHC because risk pooling reduces the costs of using health care, in turn improving financial protection and access. However, whether in practice health insurance is a recommendable strategy for SSA is heavily debated. Drawing conclusions about this based on the available impact evaluations is difficult because of the heterogeneity across schemes in terms of risk pools, benefit packages, premiums and other organizational aspects. A number of studies have tried to provide evidence on the potential of health insurance for low and middle income countries (LMIC). King et al. (2009) found that Seguro Popular, a voluntary subsidized health insurance scheme in Mexico, reduced catastrophic expenditure but had no effect on health care utilization or health outcomes. Wagstaff et al. (2009) find increased health care utilization but also increased OOP spending after extension of insurance to the poor in China.