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. 2024 Jan 9;39(1):4-21.
doi: 10.1093/heapol/czad100.

The redistributive effect of the public health system: the case of Sierra Leone

Jacopo Gabani  1   2 , Sumit Mazumdar  1 , Sylvester Bob Hadji  3 , Michael Matthew Amara  4
Affiliations

The redistributive effect of the public health system: the case of Sierra Leone

Jacopo Gabani et al. Health Policy Plan. .

Abstract

Universal health coverage (UHC), health equity and reduction of income inequalities are key objectives for the Sierra Leone government. While investing in health systems may drive economic growth, it is less clear whether investing in health systems reduces income inequality. Therefore, a crucial issue is to what extent the Sierra Leone public healthcare system reduces income inequality, and finances and provides healthcare services equitably. We use data from the Sierra Leone Integrated Household Survey 2018 to complete a financing and benefit incidence analysis of the Sierra Leone public healthcare system. We extend these analyses by assessing the redistributive effect of the public healthcare system (i.e. fiscal incidence analysis). We compute the redistributive effect as the change in Gini index induced by the payments for, and provision of, public healthcare services. The financing incidence of the Sierra Leone public healthcare system is marginally progressive (i.e. Kakwani index: 0.011*, P-value <0.1). With regard to public healthcare benefits, while primary healthcare (PHC) benefits are pro-poor, secondary/tertiary benefits are pro-rich. The result is that overall public healthcare benefits are equally distributed (concentration index (CI): 0.008, not statistically different from zero). However, needs are concentrated among the poor, so benefits are pro-rich when needs are considered. We find that the public healthcare system redistributes resources from better-off quintiles to worse-off quintiles (Gini coefficient reduction induced by public healthcare system = 0.5%). PHC receives less financing than secondary/tertiary care but delivers a larger reduction in income inequality. The Sierra Leone public healthcare system redistributes resources and reduces income inequality. However, the redistributive effect occurs largely thanks to PHC services being markedly pro-poor, and the Sierra Leone health system could be more equitable. Policy-makers interested in improving Sierra Leone public health system equity and reducing income inequalities should prioritize PHC investments.

Keywords: Health systems; equity; fiscal incidence; health financing; redistribution.

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Conflict of interest statement

None declared.

Figures

Figure 1.
Figure 1.
From market income to final income
Figure 2.
Figure 2.
Public financing incidence analysis
Figure 3.
Figure 3.
Concentration curves for direct and indirect tax revenues
Figure 4.
Figure 4.
Benefit incidence across income quintiles, for all services (PHUs and hospitals, inpatient and outpatient)
Figure 5.
Figure 5.
Concentration curves for healthcare needs, total benefits, PHU inpatient benefits, PHU outpatient benefits, hospital inpatient benefits and hospital outpatient benefits
Figure 6.
Figure 6.
Healthcare need across quintile groups
Figure 7.
Figure 7.
Comparison of needs and benefits
Figure 8.
Figure 8.
Net public healthcare benefits incidence across income quintiles
Figure A1.
Figure A1.
Financing incidence, concentration curves including OOP health expenditures
Figure A2.
Figure A2.
Benefit incidence, concentration curves including private providers
None
See this image and copyright information in PMC

References

    1. Abad LA, Lindert PH. 2017. Fiscal redistribution in Latin America since the nineteenth century. In: Has Latin American Inequality Changed Direction?: Looking over the Long Run, 1st edn. Cham: Springer, 243–82. doi: 10.1007/978-3-319-44621-9 - DOI
    1. Asante A, Man N, Wiseman V. 2020. Evaluating equity in health financing using benefit incidence analysis: a framework for accounting for quality of care. Applied Health Economics and Health Policy 18: 759–66. - PMC - PubMed
    1. Asante A, Price J, Hayen A, Jan S, Wiseman V. 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 11: e0152866. doi: 10.1371/journal.pone.0152866 - DOI - PMC - PubMed
    1. Ataguba JEO, Akazili J. 2010. Health care financing in South Africa: moving towards universal coverage. Continuing Medical Education 28: 74–8.
    1. Ataguba JE, Asante AD, Limwattananon S, Wiseman V. 2018. How to do (or not to do) … a health financing incidence analysis. Health Policy and Planning 33: 436–44. - PMC - PubMed