Abstract
BackgroundMalawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016.MethodsWe relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group.ResultsSocioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively.ConclusionsThrough its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.
Highlights
Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity
Full list of author information is available at the end of the article
Descriptive statistics of health service utilization by individuals belonging to different socioeconomic quintiles and the unity subsidies/costs of health services at health facility typologies included in this study are reported in the Additional file 1
Summary
Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Understanding the distributional impact of health spending over time due to these policies has received limited attention. While UHC ranks high on the global health agenda, low-and middleincome countries, especially in sub-Saharan Africa (SSA), still face high health inequalities [2, 3]. Being aware of these inequalities and the urgent need to overcome them, SSA countries and their development partners are progressively increasing investments and efforts to build and sustain more inclusive health systems. Reforms aimed at UHC, including user fee removal policies, targeted subsidies, and performance-based financing, have been implemented across SSA with the explicit aim of reducing existing inequalities in access [4,5,6]. While evidence on the equity impact of these reforms is increasing, [7,8,9] limited information is available on whether and how implementing these reforms has altered the distributional incidence of health spending
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