Essays on the evaluation of health financing and health system policies

This thesis comprises of four independent essays assessing health system policies whose unifying theme is the aim of progressing towards one or more of the universal health coverage (UHC) defining characteristics: Chapter 1 focuses on two different UHC characteristics (service coverage, financial risk protection), Chapter 2 focuses on service coverage, Chapter 3 focuses on financial risk protection, and Chapter 4 focuses on equity. Except Chapter 2, all chapters assess health financing policies, an important pillar of any health system that is aimed at progressing towards UHC.
Chapter 1 explores the effect of health financing system transitions from systems predominantly financed by out-of-pocket (OOP) health expenditures to systems predominantly financed by contributory social health insurance (SHI) or non-contributory government financing. To this end, I conduct a regression analysis across 124 countries, 2000-2017 period. Findings show that transitions to non-contributory government financing, rather than to SHI financing, are more likely to improve health system outcomes. The main reasons include SHI’s higher implementation costs and more limited coverage. Policymakers considering SHI reforms to progress towards UHC should interpret these results as a call for caution.
Chapter 2 investigates how Brazil Estrategia da Saude da Familia (ESF) delivered its primary healthcare (PHC) service coverage objectives, assessing via mediation analysis the contribution of different health professionals to the attainment of increased PHC service coverage. We find that a team-based PHC approach has been effective in increasing PHC service coverage, and that increasing community health workers (CHWs) density has provided the most substantial contribution to the increase in PHC services coverage driven by ESF. By implication, maintaining the ESF team-based approach to PHC delivery and expanding the role of CHWs in family health teams may thus be worthwhile policy priorities.
Chapter 3 is divided into two parts. In the first part, I show that the “OOP budget share” (i.e., OOP health expenditures as a percentage of total household expenditures) is a threshold-agnostic measure of financial risk protection. In the second part, I investigate whether there is an association between development assistance for health (DAH) and financial risk protection and, if so, for which households. The main analysis covers 65 countries with above average DAH per capita across the 2000-2016 period, merging 159 household level surveys. The results suggest that, on average, DAH is not associated with financial risk protection outcomes. However, DAH improves financial risk protection for the poorest income quintile sub-group, and when a large percentage of DAH is “on-budget” (i.e., channelled via the recipient government’s financial management systems).
Chapter 4 measures to what extent the Sierra Leone public healthcare system redistributes resources from high to low-income groups, assessing the redistribution of resources via benefit, financing and fiscal incidence analysis. The results suggest that the public healthcare system redistributes resources from higher to lower income groups, and therefore reduces income inequality. The redistribution is largely driven by PHC services being markedly pro-poor. Hence, more investments in the public health sector, with a focus on PHC, might further reduce income inequality and improve the redistributive effect of the public healthcare system in Sierra Leone.