Assessing the feasibility and appropriateness of introducing a national health insurance scheme in Malawi

Background:In May 2015 the Malawian Ministry of Health(MOH)contacted the German Development Cooperation to seek technical assistance from the P4H Network for Social Health Protection for an“Assessment of the appropriateness and feasibility of National Health Insurance in Malawi”against two alternative options:continuing with a tax(and donor)-funded National Health Service,and introducing a purchaser-provider split without a revenue collection function.Methods:A health financing benchmarking matrix was agreed with MOH,with six domains corresponding to six objectives:revenue mobilisation,technical efficiency,equity,financial risk protection,policy coordination,and health outcomes.The assessment comprised key informant interviews with Malawian stakeholders,a review of the relevant literature and datasets,rapid assessments of the Malawi Revenue Authority(MRA)and the Unified Beneficiary Registry(UBR),and projections of the National Health Insurance Scheme’s(NHIS)revenue collection costs and benefits.Results:A key finding was that introducing NHIS in Malawi would increase revenues for health,but these would come predominantly from the formal sector and would be unlikely to cover the health sector funding gap.The performance of existing poverty identification and targeting mechanisms was not commensurate with the requirements of a NHIS.Incentives to enrol in NHI are insufficient to reach scale unless service fees be introduced,which would negatively affect equity and financial risk protection.The assessment identified the Purchaser Scenario as the most favourable reform model.Conclusions:As ever more countries look towards implementing National Health Insurance,the proposed assessment framework can provide an orientation for evidence-based policy making in the area of health financing.

Delivering reproductive health services through non-state providers in Pakistan:understanding the value for money of different approaches

Background:Delivering Reproductive Health Results(DRHR)programme used social franchising(SF)and social marketing(SM)approaches to increase the supply of high quality family planning services in underserved areas of Pakistan.We assessed the costs,cost-efficiency and cost-effectiveness of DRHR to understand the value for money of these approaches.Methods:Financial and economic programme costs were calculated.Costs to individual users were captured in a pre-post survey.The cost per couple years of protection(CYP)and cost per new user were estimated as indicators of cost efficiency.For the cost-effectiveness analysis we estimated the cost per clinical outcome averted and the cost per disability-adjusted life year(DALY)averted.Results:Approximately£20 million were spent through the DRHR programme between July 2012 and September 2015 on commodities and services representing nearly four million CYPs.Based on programme data,the cumulative cost-efficiency of the entire DRHR programme was£4.8 per CYP.DRHR activities would avert one DALY at the cost of£20.Financial access indicators generally improved in programme areas,but the magnitude of progress varies across indicators.Conclusions:The SF and SM approaches adopted in DRHR appear to be cost effective relative to comparable reproductive health programmes.This paper adds to the limited evidence on the cost-effectiveness of different models of reproductive health care provision in low-and middle-income settings.Further studies are needed to nuance the understanding of the determinants of impact and value for money of SF and SM.