Who pays for health care... and who benefits?

Transcription

1 Who pays for health care... and who benefits? SHIELD Tanzania Team Health Financing for Equity A National Forum 06 th September 2010

2 Key Questions Who is paying for health care in Tanzania and through which channels? What effect does payment for health care has on impoverishment of households? How are health care benefits distributed in the population? How does this distribution of benefits compare to need for health care?

3 Health Care Financing 3

4 Sources of Health Financing 4% 28% 45% 23% Taxes User Fees Donors Other Source: National Health Accounts 2008

5 Sources of Tax Revenue 9% 7% 16% 14% 11% Personal income tax Value Added Tax Import duty Source: TRA 43% Corporate income tax Excise tax Other

6 Key terms Equity measurement Health care payment as a % of household income across socio-economic groups Progressiveif the rich pay a higher % of income Preferred system Regressiveif the poor pay a higher % of income

7 Methods Household Budget Survey 2000/2001 SHIELD survey 2008 Sample sizes: 22,178 (HBS) 2,234(SHIELD) households Financing sources: Taxes Personal income tax, Corporate income tax, VAT, Excise tax & Import duty OOPs Insurance (CHF & NHIF) Donor funding

8 Household Income Distribution Share of Income 60% 50% 40% 30% 20% 10% 0% Poorest 20% Second Poorest 20% Middle Second Richest 20% Richest 20%

9 Tax Incidence 25% Shar re of Income 20% 15% 10% 5% 0% Poorest 20% Second Poorest 20% Middle Second Richest 20% Richest 20% Personal Income Tax Value Added Tax Import Duty Corporate Income Tax Excise Tax

10 Total Health Financing 6% Share of Income 5% 4% 3% 2% 1% 0% Poorest 20% Second Poorest 20% Middle Second Richest 20% Richest 20% ALLTAXES OOP NHIF CHF

11 Breakdown of household funding of health care 3% 1% 43% 53% ALLTAXES OOP NHIF CHF

12 OOPs & poverty in Tanzania

13 Conclusions on financing Financing through general tax is progressive and benefits all citizens Income tax most progressive but remains limited Certain taxes are regressive NHIF progressive, but beneficiaries still limited in number OOP is regressive, and damaging to the poor reduces overall progressivity of system CHF also regressive, due to focus on poor, and flat rate premium concern if premium increases and enrolment expands

14 Benefit Incidence Analysis 14

15 Benefit incidence Distribution of benefits from using health services across socio-economic groups Use of each type of health service x cost of each health service The more you use, the more you benefit The more expensive the service you use, the higher the benefit Pro poor -the poor gain more Pro rich -the rich gain more

16 Methods Utilisation data from SHIELD survey: 2,234 households (12,201 individuals) in 7 districts/councils Total monthly outpatient visits (annualised) Total annual inpatient admissions Unit cost data NHIF reimbursement rates ( ) Need =self assessed health status Focus Group discussions were conducted

17 Unit costs for outpatient care 17

18 Unit costs for inpatient care 18

19 Distribution of Public Outpatient Health Care Benefits of Benefits % Share 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Primary District hospitals Reg. & Ref. hospitals All public sector Poorest 20% 2nd poorest Middle 2nd richest Richest 20%

20 % Share of Benefits Distribution of Outpatient Benefits from Private Providers 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Primary FBOs Hospital FBOs Private for profit Pharmacy Poorest 20% 2nd poorest Middle 2nd richest Richest 20%

21 Distribution of Inpatient Benefits 90% 80% % Shar re of Benefits 70% 60% 50% 40% 30% 20% 10% 0% Health centres & Dist. Hosp Reg. & Ref. hospitals Private FBO Poorest 20% 2nd poorest Middle 2nd richest Richest 20%

22 Total Benefits by Sector 50% 45% 40% % Share of Benefits 35% 30% 25% 20% 15% 10% 5% 0% Public Private FBO Poorest 20% 2nd poorest Middle 2nd richest Richest 20% 22

23 Total Benefits Vs Need 25% 20% 15% 10% 5% 0% Poorest 20% 2nd poorest Middle 2nd richest Richest 20 % Shares of benefits Need

24 Access barriers to use of health services Affordability constrains: Distance to the district/ and referral hospital Transport costs are a considerable barrier Difficulties in paying direct treatment cost to higher level services Availability constrains: Lack of drugs and diagnostic equipment Shortage of skilled health workers in many public facilities Acceptability constrains: Quality of health care services long waiting hours, lack of diagnostic equipment Poor staff attitudes

25 Conclusions on benefits Health care services overall in Tanzania benefit the rich more than the poor. In particular, the poorest 20% receive less benefit than they need. Benefits from outpatient care in public primary facilities and pharmacy/drug shops are pro-poor. Benefits from inpatient care in public health centres, district hospitals and faith-based facilities are propoor. Benefits from formal private facilities and outpatient public hospital care are pro-rich. Overcoming access barriers and quality is critical

26 Asanteni Sana