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Equity in Health Care Financing in Low- and Middle-Income Countries: A Systematic Review of Evidence from Studies Using Benefit and Financing Incidence Analyses

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  • Augustine Asante
  • Jennifer Price
  • Andrew Hayen
  • Stephen Jan
  • Virginia Wiseman

Abstract

Introduction: Health financing reforms in low- and middle- income countries (LMICs) over the past decades have focused on achieving equity in financing of health care delivery through universal health coverage. Benefit and financing incidence analyses are two analytical methods for comprehensively evaluating how well health systems perform on these objectives. This systematic review assesses progress towards equity in health care financing in LMICs through the use of BIA and FIA. Methods and Findings: Key electronic databases including Medline, Embase, Scopus, Global Health, CinAHL, EconLit and Business Source Premier were searched. We also searched the grey literature, specifically websites of leading organizations supporting health care in LMICs. Only studies using benefit incidence analysis (BIA) and/or financing incidence analysis (FIA) as explicit methodology were included. A total of 512 records were obtained from the various sources. The full texts of 87 references were assessed against the selection criteria and 24 were judged appropriate for inclusion. Twelve of the 24 studies originated from sub-Saharan Africa, nine from the Asia-Pacific region, two from Latin America and one from the Middle East. The evidence points to a pro-rich distribution of total health care benefits and progressive financing in both sub-Saharan Africa and Asia-Pacific. In the majority of cases, the distribution of benefits at the primary health care level favoured the poor while hospital level services benefit the better-off. A few Asian countries, namely Thailand, Malaysia and Sri Lanka, maintained a pro-poor distribution of health care benefits and progressive financing. Conclusion: Studies evaluated in this systematic review indicate that health care financing in LMICs benefits the rich more than the poor but the burden of financing also falls more on the rich. There is some evidence that primary health care is pro-poor suggesting a greater investment in such services and removal of barriers to care can enhance equity. The results overall suggest that there are impediments to making health care more accessible to the poor and this must be addressed if universal health coverage is to be a reality.

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  • Augustine Asante & Jennifer Price & Andrew Hayen & Stephen Jan & Virginia Wiseman, 2016. "Equity in Health Care Financing in Low- and Middle-Income Countries: A Systematic Review of Evidence from Studies Using Benefit and Financing Incidence Analyses," PLOS ONE, Public Library of Science, vol. 11(4), pages 1-20, April.
    • Handle: RePEc:plo:pone00:0152866
    DOI: 10.1371/journal.pone.0152866
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    4. Augustine Asante & Nicola Man & Virginia Wiseman, 2020. "Evaluating Equity in Health Financing Using Benefit Incidence Analysis: A Framework for Accounting for Quality of Care," Applied Health Economics and Health Policy, Springer, vol. 18(6), pages 759-766, December.
    5. Anelisa Jaca & Thobile Malinga & Chinwe Juliana Iwu-Jaja & Chukwudi Arnest Nnaji & Joseph Chukwudi Okeibunor & Dorcas Kamuya & Charles Shey Wiysonge, 2022. "Strengthening the Health System as a Strategy to Achieving a Universal Health Coverage in Underprivileged Communities in Africa: A Scoping Review," IJERPH, MDPI, vol. 19(1), pages 1-21, January.
    6. Jane W. Gitahi & Amos Njuguna, 2018. "Implications of Contributions to Equity in Access of Health Care: A Case of Community Based Health Insurance Schemes in Kenya," Global Journal of Health Science, Canadian Center of Science and Education, vol. 10(2), pages 1-90, February.
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    9. Reyhaneh Mojdehkar & Katayoun Jahangiri & Kamran Hajinabi & Leila Riahi, 2021. "Adapted fairness benchmarks for the evaluation of Iran health system reform," International Journal of Health Planning and Management, Wiley Blackwell, vol. 36(6), pages 2118-2128, November.
    10. David M. Dror & Atanu Majumdar & Nihar Jangle, 2019. "Estimating capital requirements to scale health microinsurance serving rural poor populations," The Geneva Papers on Risk and Insurance - Issues and Practice, Palgrave Macmillan;The Geneva Association, vol. 44(3), pages 410-444, July.
    11. Chaw-Yin Myint & Milena Pavlova & Khin-Ni-Ni Thein & Wim Groot, 2019. "A systematic review of the health-financing mechanisms in the Association of Southeast Asian Nations countries and the People’s Republic of China: Lessons for the move towards universal health coverag," PLOS ONE, Public Library of Science, vol. 14(6), pages 1-18, June.
    12. Robert Kolesar & Sambo Pheakdey & Bart Jacobs & Narith Chan & Samedy Yok & Martine Audibert, 2019. "Expanding Social Health Protection in Cambodia: An assessment of the current coverage potential and gaps, and social equity considerations," CERDI Working papers halshs-02018867, HAL.
    13. Saad, Suhaila & Mohamed Nor, Norashidah, 2018. "Health Expenditure and Economic Development in Low-and Middle-Income Countries," Jurnal Ekonomi Malaysia, Faculty of Economics and Business, Universiti Kebangsaan Malaysia, vol. 52(3), pages 181-189.
    14. Abdur Razzaque Sarker & Marufa Sultana & Khorshed Alam & Nausad Ali & Nurnabi Sheikh & Raisul Akram & Alec Morton, 2021. "Households' out‐of‐pocket expenditure for healthcare in Bangladesh: A health financing incidence analysis," International Journal of Health Planning and Management, Wiley Blackwell, vol. 36(6), pages 2106-2117, November.
    15. Leila Doshmangir & Edris Hasanpoor & Gerard Joseph Abou Jaoude & Behzad Eshtiagh & Hassan Haghparast-Bidgoli, 2021. "Incidence of Catastrophic Health Expenditure and Its Determinants in Cancer Patients: A Systematic Review and Meta-analysis," Applied Health Economics and Health Policy, Springer, vol. 19(6), pages 839-855, November.
    16. Robert J. Kolesar & Sambo Pheakdey & Bart Jacobs & Narith Chan & Samedy Yok & Martine Audibert, 2020. "Expanding social health protection in Cambodia: An assessment of the current coverage potential and gaps, and social equity considerations," International Social Security Review, John Wiley & Sons, vol. 73(1), pages 35-63, January.
    17. Carolina Bloch, 2020. "Social spending in South Asia—an overview of government expenditure on health, education and social assistance," Research Report 44, International Policy Centre for Inclusive Growth.

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