A brief summary: health systems of Uganda, Zambia, Tanzania and South Africa

To improve the delivery of emergency care; awareness of the health system and in-country factors that influence the delivery of healthcare services are needed. Recently I visited Uganda, Tanzania and Zambia. This blog aims to compare relevant existing health data between these countries and South Africa as my point of reference. Data is according to WHO country profiles and World Bank.

Country Data Uganda Zambia Tanzania South Africa
1 World Bank income class Low Lower-middle Low Upper- middle
2 Population (thousands) 37579 14539 49253 52776
3 % of population under age of 15years 48% 47% 45% 30%
4 % of population living in urban areas 15% 40% 30% 64%
5 Total expenditure on health as % of GDP 9.8% 5% 7.3% 8.9%
6 Government expenditure as % of total expenditure on health 44% 58.3% 36.3% 14%
7 Out of Pocket expenditure as % of health (OOP) 69.1% 66.7% 52.1% 13.8%
8 Private prepaid plans as % of private expenditure on health 0.3% 3.5% 1.5% 61.1%

Interpretation

Number 2 -4

Population is relative to the size of the country and when expressed as population per sq.km of land; Uganda is the most populated country of the four; 188 ppsqkm, followed by Tanzania (59ppsqkm), South Africa (45ppsqkm) and then Zambia (21ppsqkm).

Zambia has the lowest population density and 60% of the population live in rural areas. Due to the distances between referral facilities and external factors including infrastructure, transport facilities etc.  Zambia probably face the most challenges to improve access to emergency care

In Uganda, only 15% of the population lives in urban areas. Due to the high population in rural areas, access and availability of care are also challenging.

Number 5- 8

An important question to consider when talking about health systems is: who is spending how much and for what.  The answer to this determines whether people can access care. In Africa (and other developing countries) the expenditure measurements is typically divided into three categories:

  • The government’s direct expenditure to health care services
  • Private expenditure on health care, divided into out-of-pocket expenditure and medical insurance
  • External sources including foreign aid and non-profit organisations contributions

Government’s Expenditure on health

Total expenditure on health as % of GDP demonstrates the level of resources channelled to health in relation to the wealth of the country.  GDP (Gross Domestic Product) are defined as the total market value of all goods and services produced within a country per year.

The government expenditure on health shows the relative weight of government resources in the total expenditure of health.  It provides an indication of the need and priority of healthcare in government policy and budget.  The amount of resources that are assigned to the health sector as %GDP also provides clues about the relative size of the health sector.

In Zambia there is a large difference between healthcare as %GDP and government expenditure. This is interesting and it appears slightly disproportionate in comparison to the other countries.  I’m not sure of the reason, one possible explanation is that Zambia might be training more healthcare professionals (government expenditure includes training of healthcare professionals).  However, this is unconfirmed.

In 2001, all heads of state of the African Union pledged to commit 15% of their national (domestic) budgets to healthcare.  This was to not only to improve healthcare but also to show the African government’s commitment to improving healthcare.  It is observed that none of the four countries adheres to the pledge.

Low government health spending is associated with high out of pocket (OOP) expenditure resulting in catastrophic health expenditure and increased mortality and morbidity.  Furthermore, when government restricts the expenditure on healthcare, they may reduce training budgets thus creating additional barriers to access care.

Private expenditure on health

OOP expenditure is described by WHO as a measure providing insight into the relative weight of direct payments in total health expenditure. If the OOP expenditure is high, a single visit to a health facility may result in catastrophic health expenditure. In Uganda and Zambia the OOP expenditure is very high. It is concerning and OOP expenditure as a government policy is doomed to fail in lower income countries.

Number 7 demonstrates the importance of not only considering single measures.  At first glance it appears as if OOP in South Africa is low.  However health insurance (private prepaid plans) are not included in this measurement; it is shown in number 8.

Private prepaid plans includes expenditures of pooled resources with no government control. It shows the relative weight of voluntary health insurance payments in total health expenditure. This includes voluntary health insurance, medical aids and direct payments for health by non-profit organisations. South Africa has a very high rate of private prepaid plans (81%) in comparison to Uganda’s 0.3%.  OOP expenditure and private prepaid plans are characterised by limited regulations; exposing the population to exploitation and catastrophic expenditure.

External sources to fund healthcare is not discussed here.

Summary

In this blog I’ve only touched on the health systems, and some of the potential vicious cycles. It would be interesting to explore each of these cycles. Watch this space!

Please feel free to comment!

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