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Fairness or equity in health financing is critical to ensuring universal health coverage (UHC). While equity in health financing is generally about financing health services according to ability-to-pay, misconceptions exist among policymakers, decision-makers and some researchers about what constitutes financing health services according to ability-to-pay or an equitably financed health system. This commentary characterizes three misconceptions of equitable health financing-(1) the misconception of fair contribution, (2) the pro-poor misconception and (3) the misconception of cross-subsidization. The paper also uses these misconceptions to clearly illustrate what constitutes equity in health financing, highlighting the importance of income distribution. The misconceptions come from the authors' extensive engagements with policymakers and practitioners, especially in Africa. A clear understanding of equity in health financing provides an avenue to significant progress towards UHC and improving a country's income distribution., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Significant maternal and child deaths occur in sub-Saharan Africa (SSA) even with existing effective interventions. Antenatal care (ANC), for example, is an intervention that improves the health of pregnant women and their babies, but only 52% of pregnant women in SSA had the recommended minimum of four ANC visits between 2011 and 2016. While significant socioeconomic inequalities in ANC visits have been reported to the disadvantage of the poor, little is known about the depth of ANC coverage and associated inequalities. This paper introduces 'deficits' (i.e. the number of ANC visits that are needed to reach the recommended minimum of four ANC visits) and 'surpluses' (i.e. the number of ANC visits over and above the recommended minimum of four ANC visits) to assess socioeconomic inequalities in the indicator and depth of the 'deficits' and 'surpluses' in ANC visits. Using the latest available Demographic and Health Survey data for 36 SSA countries and concentration indices, the paper found that 'deficits' in ANC visits are more prevalent among poorer women compared to 'surpluses' that are concentrated among the rich. On average, women with 'deficits' in ANC visits require about two more ANC visits to reach the recommended four ANC visits, and women with 'surpluses' exceeded the recommended minimum by about two ANC visits. The factors that explain a substantial share of the socioeconomic inequalities in ANC 'deficits' and 'surpluses' in SSA include wealth, education and area of residency, which are essentially the social determinants of health inequalities. For policy response, it is suggested that education is a significant channel to affect the other social determinants of inequalities in ANC coverage reported in the paper. Thus, countries must prioritize quality education as addressing education, especially among women in SSA, will significantly reduce disparities in ANC service utilization and accelerate progress towards universal health coverage., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Financing incidence analysis (FIA) assesses how the burden of health financing is distributed in relation to household ability to pay (ATP). In a progressive financing system, poorer households contribute a smaller proportion of their ATP to finance health services compared to richer households. A system is regressive when the poor contribute proportionately more. Equitable health financing is often associated with progressivity. To conduct a comprehensive FIA, detailed household survey data containing reliable information on both a cardinal measure of household ATP and variables for extracting contributions to health services via taxes, health insurance and out-of-pocket (OOP) payments are required. Further, data on health financing mix are needed to assess overall FIA. Two major approaches to conducting FIA described in this article include the structural progressivity approach that assesses how the share of ATP (e.g. income) spent on health services varies by quantiles, and the effective progressivity approach that uses indices of progressivity such as the Kakwani index. This article provides some detailed practical steps for analysts to conduct FIA. This includes the data requirements, data sources, how to extract or estimate health payments from survey data and the methods for assessing FIA. It also discusses data deficiencies that are common in many low- and middle-income countries (LMICs). The results of FIA are useful in designing policies to achieve an equitable health system.

Globally, in 2013 over 6 million children younger than 5 years died from either an infectious cause or during the neonatal period. A large proportion of these deaths occurred in developing countries, especially in sub-Saharan Africa. Immunization is one way to reduce childhood morbidity and deaths. In Nigeria, however, although immunization is provided without a charge at public facilities, coverage remains low and deaths from vaccine preventable diseases are high. This article seeks to assess inequalities in full and partial immunization coverage in Nigeria. It also assesses inequality in the 'intensity' of immunization coverage and it explains the factors that account for disparities in child immunization coverage in the country. Using nationally representative data, this article shows that disparities exist in the coverage of immunization to the advantage of the rich. Also, factors such as mother's literacy, region and location of the child, and socio-economic status explain the disparities in immunization coverage in Nigeria. Apart from addressing these issues, the article notes the importance of addressing other social determinants of health to reduce the disparities in immunization coverage in the country. These should be in line with the social values of communities so as to ensure acceptability and compliance. We argue that any policy that addresses these issues will likely reduce disparities in immunization coverage and put Nigeria on the road to sustainable development., (© The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

There is a global challenge for health systems to ensure equity in both the delivery and financing of health care. However, many African countries still do not have equitable health systems. Traditionally, equity in the delivery and the financing of health care are assessed separately, in what may be termed 'partial' analyses. The current debate on countries moving toward universal health systems, however, requires a holistic understanding of equity in both the delivery and the financing of health care. The number of studies combining these aspects to date is limited, especially in Africa. An assessment of overall health system equity involves assessing health care financing in relation to the principles of contributing to financing according to ability to pay and benefiting from health services according to need for care. Currently South Africa is considering major health systems restructuring toward a universal system. This paper examines together, for both the public and the private sectors, equity in the delivery and financing of health care in South Africa. Using nationally representative datasets and standard methodologies for assessing progressivity in health care financing and benefit incidence, this paper reports an overall progressive financing system but a pro-rich distribution of health care benefits. The progressive financing system is driven mainly by progressive private medical schemes that cover a small portion of the population, mainly the rich. The distribution of health care benefits is not only pro-rich, but also not in line with the need for health care; richer groups receive a far greater share of service benefits within both public and private sectors despite having a relatively lower share of the ill-health burden. The importance of the findings for the design of a universal health system is discussed.

In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-of-pocket payments and health insurance for the informal sector are regressive. The distribution of health care benefits is generally pro-rich. This paper explores the factors influencing these distributions in the three countries. Qualitative data were collected through focus group discussions and in-depth interviews with insurance scheme members, the uninsured, health care providers and managers. Household surveys were also conducted in all countries. Flat-rate contributions contributed to the regressivity of informal sector voluntary schemes, either by design (in Tanzania) or due to difficulties in identifying household income levels (in Ghana). In all three countries, the regressivity of out-of-pocket payments is due to the incomplete enforcement of exemption and waiver policies, partial or no insurance cover among poorer segments of the population and limited understanding of entitlements among these groups. Generally, the pro-rich distribution of benefits is due to limited access to higher level facilities among poor and rural populations, who rely on public primary care facilities and private pharmacies. Barriers to accessing health care include medical and transport costs, exacerbated by the lack of comprehensive insurance coverage among poorer groups. Service availability problems, including frequent drug stock-outs, limited or no diagnostic equipment, unpredictable opening hours and insufficient skilled staff also limit service access. Poor staff attitudes and lack of confidence in the skills of health workers were found to be important barriers to access. Financing reforms should therefore not only consider how to generate funds for health care, but also explicitly address the full range of affordability, availability and acceptability barriers to access in order to achieve equitable financing and benefit incidence patterns.

South Africa is considering introducing a universal health care system. A key concern for policy-makers and the general public is whether or not this reform is affordable. Modelling the resource and revenue generation requirements of alternative reform options is critical to inform decision-making. This paper considers three reform scenarios: universal coverage funded by increased allocations to health from general tax and additional dedicated taxes; an alternative reform option of extending private health insurance coverage to all formal sector workers and their dependents with the remainder using tax-funded services; and maintaining the status quo. Each scenario was modelled over a 15-year period using a spreadsheet model. Statistical analyses were also undertaken to evaluate the impact of options on the distribution of health care financing burden and benefits from using health services across socio-economic groups. Universal coverage would result in total health care spending levels equivalent to 8.6% of gross domestic product (GDP), which is comparable to current spending levels. It is lower than the status quo option (9.5% of GDP) and far lower than the option of expanding private insurance cover (over 13% of GDP). However, public funding of health services would have to increase substantially. Despite this, universal coverage would result in the most progressive financing system if the additional public funding requirements are generated through a surcharge on taxable income (but not if VAT is increased). The extended private insurance scheme option would be the least progressive and would impose a very high payment burden; total health care payments on average would be 10.7% of household consumption expenditure compared with the universal coverage (6.7%) and status quo (7.5%) options. The least pro-rich distribution of service benefits would be achieved under universal coverage. Universal coverage is affordable and would promote health system equity, but needs careful design to ensure its long-term sustainability.

Benefit incidence analysis (BIA) considers who (in terms of socio-economic groups) receive what benefit from using health services. While traditionally BIA has focused on only publicly funded health services, to assess whether or not public subsidies are 'pro-poor', the same methodological approach can be used to assess how well the overall health system is performing in terms of the distribution of service benefits. This is becoming increasingly important in the context of the growing emphasis on promoting universal health systems. To conduct a BIA, a household survey dataset that incorporates both information on health service utilization and some measure of socio-economic status is required. The other core data requirement is unit costs of different types of health service. When utilization rates are combined with unit costs for different health services, the distribution of benefits from using services, expressed in monetary terms, can be estimated and compared with the distribution of the need for health care. This paper aims to provide an introduction to the methods used in the 'traditional' public sector BIA, and how the same methods can be applied to undertake an assessment of the whole health system. We consider what data are required, potential sources of data, deficiencies in data frequently available in low- and middle-income countries, and how these data should be analysed.