HEALTH CARE FINANCING MODEL-IMPLICATION FOR SERVICE DELIVERY AND ACCESS

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HEALTH CARE FINANCING MODEL-IMPLICATION FOR SERVICE DELIVERY AND ACCESS

Abstract

Healthcare financing is a critical determinant of the quality, accessibility, and sustainability of health services. This study investigates the implications of various healthcare financing models on service delivery and access, with a focus on how these models influence the efficiency, equity, and overall effectiveness of healthcare systems.

The research explores different financing models, including tax-based systems, social health insurance, private health insurance, and out-of-pocket payments, analyzing their impact on both service providers and patients. By examining case studies from different countries, the study identifies the strengths and weaknesses of each model in terms of ensuring universal health coverage, reducing financial barriers to access, and improving health outcomes.

The findings reveal that no single financing model is universally superior; rather, the effectiveness of a model depends on the specific economic, social, and political context of a country. Tax-based systems tend to provide the most equitable access to healthcare services but may be constrained by limited government revenue. Social health insurance models offer a sustainable financing mechanism but require a well-structured administrative system to avoid inefficiencies. Private insurance can drive service quality but may lead to inequalities in access, while out-of-pocket payments often result in financial hardship for patients.

The study concludes that a mixed financing model, tailored to the local context, is most likely to achieve the dual goals of efficient service delivery and equitable access to healthcare. Policy recommendations include the need for stronger regulatory frameworks, increased public funding for health, and the promotion of innovative financing mechanisms to bridge the gaps in service delivery and access.

This research provides valuable insights for policymakers, healthcare providers, and stakeholders aiming to improve healthcare financing strategies to enhance service delivery and ensure equitable access to health services for all.

CHAPTER ONE:

INTRODUCTION

1.1 Background to the Study

Health care financing is a critical determinant of health service delivery and access in any health system. In recent years, the rising costs of health care, coupled with the increasing demand for quality services, have necessitated the exploration of innovative financing models. These models aim to ensure sustainable funding for health services while improving access and quality for all segments of the population. Health care financing models can vary widely, including public funding, private insurance, out-of-pocket expenditures, and community-based health financing, each with its unique implications for service delivery and accessibility.

In many low- and middle-income countries, inadequate health care financing has been a major barrier to achieving universal health coverage. Limited financial resources often result in insufficient health infrastructure, a shortage of healthcare professionals, and inadequate medical supplies, ultimately hindering the quality of care provided. Moreover, the lack of equitable financing mechanisms can exacerbate health disparities, leaving vulnerable populations with limited access to essential health services.

Understanding the relationship between health care financing models and their implications for service delivery and access is essential for policymakers and stakeholders aiming to improve health outcomes. This study explores various health care financing models, their effectiveness in delivering services, and their impact on access to healthcare for different populations.

National patterns of health financing depend to differing degrees on resources from governments, social and private insurance schemes, foreign donors, non‐governmental organizations, communities and households. Low and middle income countries (LMIC) tend to rely on a combination of scarce government resources, donor funded projects and typically high levels of household contributions.

As a result of increasing budget deficits throughout the developing world in the 1980s, a decline in quantity and quality of publicly subsidized health services led to higher dependence on patient payments through the introduction of user fees, supported both by UNICEF (through the Bamako Initiative which promoted ‘community financing’ of primary health care) and the World Bank (World Bank 1987; Griffin 1988; Shaw 1995). In the 1990s issues were soon raised about the negative impacts that user fees could have on equity and access (Creese 1991; Gilson 1995; Gilson 1997). African countries gradually favoured the introduction of a number of financial mechanisms aiming to reduce the risks of ‘catastrophic’ payments at point of use (Mwabu 1990, World Bank 1997). More recently, attention has been drawn to new innovative schemes to address equity issues. Performance‐based contracts have been introduced to improve both efficiency and equity in health on the supply‐side (Loevinsohn 2005; Jacobs 2006), and demand‐side incentives targeted at poor people are attracting increased attention amongst policy‐makers and donors (Rubio 2003; Rivera 2004).

However, it is recognised that the poorest populations remain excluded from basic health care in a lot of countries. Even services established as highly cost‐effective are failing to reach those in need (Gwatkin 2004), and there is increasing evidence that those with least access are the poorest and most vulnerable groups (Castro‐Leal 2000; Gwatkin 2001). Limited access and low utilization of important basic health services are in turn contributory factors for the persistence of disease and low life expectancy.

Policy makers in low income countries and donor organisations need good quality information on the effects of alternative financing approaches. Systematically reviewing existing literature is an important first step in discovering existing evidence available. However, despite some decades of experience and research on this subject, few reviews have adopted a systematic approach, with the notable exception of Ekman 2004. Yet this review has a precise narrow scope. It encompasses only one type of financial mechanism (community‐based health insurance) and specifically focuses on resource mobilization and financial protection. In contrast, our proposed review will have a broader perspective as far as the interventions are concerned and will concentrate on other outcomes which are related to improving access or equity of access to health services.

Due to increasing recognition of the lack of access of most vulnerable populations to adequate health services, the aim of this review is to gather evidence on the impact of different financial mechanisms on access to health services. We assume that there are two main drivers of such access 1) availability of services geographically and 2) the cost to the household of accessing these services. We are therefore principally interested in evidence on how financing mechanisms can help extend coverage of services or modify economic barriers to access to health care.

Health financing mechanisms are often delineated into the three main functions they are supposed to fulfil : collection of revenues, pooling of funds and purchase of services (Schieber 1997; WHO 2000; Preker 2004). The low tax base which means that government financing is not an important source of funding relative to wealthier countries (Schieber 1997).

Donor financing, which may go directly to providers, to households or to the government.

A number of different healthcare providers in the public and private sectors including drug sellers, GPs, NGOs and government clinics and hospitals.

Increasing interest in contracting with private providers or non‐governmental organizations to scale up service delivery rapidly (Loevinsohn 2005; Palmer 2006).

The predominance of out of pocket spending by households to finance their healthcare needs. This is in the form of direct payments, payment into an insurance scheme, or by purchase of a ‘health card’ that gives access to services for a defined period of time.

Each of the three functions of a health financing system identified by WHO are of interest. Besides, some recently introduced schemes that may also increase access but do not lie within these categories will also be included. These original approaches have been introduced to complete ‘traditional’ mechanisms in order to improve equity) in access to care, for instance by stimulating the demand side with vouchers or conditional cash transfers.

This protocol presents the methodology that will be followed for four related systematic reviews. It is expected that studies of interest for the overarching question which this review seeks to address (the impact on access of financial mechanism) will fall into four sub‐categories. Each of these sub‐categories will be treated as a separate systematic review. They will be: introduction, removal or change in the level of user fees;

risk protection mechanisms, including community‐based, social or private health insurance, and pre‐payment schemes; contracting out and other forms of privatization/use of private sector providers to improve access to care (Lagarde 2009a); demand side interventions such as vouchers or conditional cash transfers (Lagarde 2009b).

Aspects of financing shown in the diagram that will not be included in the review are those related to the raising of funds through the national tax system. Disbursement of funds raised through taxation may be included, but only if it is related to one of the interventions highlighted above e.g. conditional cash transfers.

According to Anton & Onofre (2013) a common feature of all health systems from emerging economies is the shortage of financial resources. Mukasa (2012) established the challenges of Ugandan public hospitals, his study never ascertained the exact effect of the available financing strategies on health service delivery which data analysis gap will be addressed by running regression analysis to establish whether financing strategies have any significant effect on health service delivery in Lyantonde hospital. The study aimed at investigating the effect of healthcare financing on health service delivery at Lyantonde Hospital.

There is a convergence in opinion that adequate public financing as a health intervention affects the quality and uptake of health services which ultimately insures citizens against catastrophic health expenditures (Verguet, Olson, Babigumira, Desalegn, Johansson, Kruk, Levin, Nugent, Pecenka, Shrime, Memirie, Watkins, & Jamison, 2015). Indeed, public health sector financing for many countries comes from tax revenues, donor funds, and out-of-pocket expenditure (Verguet et al., 2015). But despite such anticipation, many countries are yet to harness the above significance. Like in India, their health care system is punctuated by low levels and uneven spread of public spending on health care hence poor quality of health care services as the system over-depends on poor population’s out of pocket funding (Govinda & Mita, 2012). While in Brazil, Massuda, Hone, Leles, de Castro, and Atun (2018) established that structural problems persisted in terms of low public funding and suboptimal resource allocation which was consequently illuminating large regional disparities in access to healthcare services.

Such challenges in both public financing and health service delivery have not spared the African continent as inadequate funding sources was earmarked to be curtailing financing health care delivery in Ghana (Addae-Korankye, 2013). This is not too different from the Malawian perspective where Donor sources accounts for 74% of funds, 19% from Government, and 7% from out of pocket which distribution has benefited mostly urban citizens (Borghi, Munthali, Million, & Martinez-Alvarez, 2018). In East Africa, Tanzanian hospitals face insufficient public funding and untimely disbursement of funds from the central government (Magaka&Swere, 2016),while most hospital services in Kenya are being funded by out of pocket payments that are being interpreted as regressive (Munge& Briggs, 2014). As for Burundi, acute shortage of health service providers like including skilled birth attendants because of low public funding, traditional birth attendants have become the first point of call for many pregnant women (Che-Chi &Urdal, 2018).

Uganda has not been exceptional either. This is because despite the enactment of a number of public finance management reforms since the 1990s to strengthen the country’s health system, various cases of inefficiencies in health care such as drug stock-outs, increase of out-of-pocket payments and decrease of government spending in Ugandan hospitals which continued to contribute towards high incidences of catastrophic health expenditures (Okech, 2014). In fact, the country’s health sector has remained significantly under-funded, mainly relying on private sources of finance, especially out-of-pocket spending that has reduced employee morale, drug stock outs, and worsened the state of medical facilities, and increased costs of services breeding corruptionrelated tendencies in government hospitals (Nabukeera, 2016).

Though there exists eye-catching evidence that the state of service delivery in Ugandan hospitals requires immediate attention, Lyantonde hospital deserves priority. This is because though citizens continue to demand for timely, quality, accessible and sustainable services, the apparent financing challenges coupled with evidence of poor performance on core parameters of service delivery at the hospital created urgent need for a study to establish the effect of health care financing on health service delivery at Lyantonde Hospital.

1.2 Statement of the Problem

Despite significant investments in health care, many countries continue to face challenges in delivering equitable and accessible health services. Inefficient financing models often lead to gaps in service delivery, with marginalized communities disproportionately affected. Inadequate funding can result in a lack of essential services, long waiting times, and compromised quality of care, contributing to poor health outcomes.

This research aims to address the critical question of how different health care financing models impact service delivery and access to healthcare. By examining existing models, the study seeks to identify the strengths and weaknesses of each and explore potential solutions to enhance health service delivery.

1.3 Objectives of the Study

The primary objective of this study is to analyze the implications of various health care financing models on service delivery and access to healthcare. Specifically, the study aims to:

Identify the different health care financing models utilized in various health systems.

Examine the impact of these financing models on the quality of health services delivered.

Assess the accessibility of health care services for various population segments under different financing models.

Explore potential reforms and best practices for improving health care financing to enhance service delivery and access.

1.4 Research Questions

The study seeks to answer the following research questions:

What are the predominant health care financing models used in different health systems?

How do these financing models affect the quality of health services provided?

What is the relationship between health care financing and accessibility of services for different populations?

What reforms or best practices can be implemented to improve health care financing and service delivery?

1.5 Significance of the Study

This study is significant for several reasons. Firstly, it contributes to the understanding of how health care financing models influence service delivery and access, providing valuable insights for policymakers, health administrators, and stakeholders. Secondly, by identifying the strengths and weaknesses of existing models, the research can guide efforts to develop more effective financing mechanisms that promote equity in health care access.

Furthermore, the findings can inform discussions around health system reforms and the implementation of best practices in health care financing. Ultimately, this research aims to contribute to the achievement of universal health coverage and improved health outcomes for all populations.

1.6 Scope of the Study

This study focuses on various health care financing models and their implications for service delivery and access to health care. The research will cover multiple health systems, including those in low-, middle-, and high-income countries, to provide a comprehensive analysis of different models and their effectiveness. The study will examine both public and private financing mechanisms and their impact on the quality and accessibility of health services.

1.7 Definition of Terms

Health Care Financing: The methods and mechanisms through which funds are generated, allocated, and spent in the health sector.

Service Delivery: The provision of health care services to patients, including the availability, quality, and timeliness of care.

Access to Health Care: The ability of individuals to obtain necessary health services when needed, influenced by factors such as availability, affordability, and acceptability.

Universal Health Coverage: A health care system that ensures all individuals have access to necessary health services without financial hardship.

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