Equity and efficiency in the geographic allocation of public health resources in Mozambique. PhD

207 Pages·2016·5.15 MB·English

Anselmi,L(2015)Equityandefficiencyinthegeographicallocationof
public health resources in Mozambique. PhD thesis, London School
of Hygiene & Tropical Medicine.
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Equity and efficiency in the geographic
allocation of public health resources in
Mozambique

LAURA ANSELMI

Thesis submitted in accordance with the requirements for the degree
of
Doctor of Philosophy

University of London
February 2015

Department of Global Health and Development
Faculty of Public Health and Policy
LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE

No funding received
Declaration

I, Laura Anselmi, confirm that the work presented in this thesis is my own. Where information
has been derived from other sources, I confirm that this has been indicated in the thesis.

Signed: February, 2015
Full name: Laura Anselmi

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Abstract

Equitable and efficient health financing is crucial to improve health care provision, still
inequitable in many low- and middle-income countries. The allocation of financial resources
across geographic areas is important to increase the capacity to effectively provide services
and their availability to the neediest population. However, how resources are transformed into
service and finally reach the intended beneficiaries, depends on local health care management,
on the supply-side, and on constraints to service use, on the demand-side. Equity and efficiency
in the geographic allocation of public expenditure in Mozambique, and their determinants, are
explored in this thesis.
First, inequities in the distribution of public health expenditure, assessed using a method based
on Benefit Incidence Analysis, diminished over time due to improved resource allocation.
However, inequities in health care use remain and limit the benefit from public health
expenditure for the poor and neediest population. The difference between horizontal and
vertical equity, assessed for each source of public health expenditure by raking individuals
according to their economic wealth or to their need for health care, reveals initial discrepancies
in government and donor expenditure targets and the potential trade-offs between equity
objectives.
Second, inefficiencies in health care provision, assessed using Stochastic Frontier Analysis, exist
at district level. Efficiency could be increased both in health administrations, where financial
resources are managed to guarantee the availability of material resources, such as staff and
equipment, and in health facilities, where those are used to deliver health care services.
Heterogeneity in efficiency across districts depends on geographic, demographic,
administrative and health system characteristics.
Third, results from an econometric model of demand for health care revealed that proximity
to health facilities increases the probability of seeking care and that the availability of adequate
staff and equipment can encourage service use by those who live near a health facility. Demand
side constraints, mostly economic, prevent use even when services are available.
Results suggest that resource allocation policies are insufficient on their own to improve the
distribution of public health expenditure. Extending health facility coverage and tackling
demand-side barriers are needed to increase service use among and mitigate potential equity-
efficiency and horizontal-vertical equity trade-offs. Increasing the efficiency of district health
administrations and health facilities can contribute to increase service use among those who
live close to a health facility.
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Acknowledgements

I am extremely grateful to Mylene Lagarde and Kara Hanson, my supervisor and co-supervisor,
for guiding me in the long process of transforming a question into a thesis. I think I could not
have been in better hands and your passion and attitude to research have inspired me along
this journey. Mylene, thank you for engaging with my research and my ideas, for always
pushing me to go a bit further and for your patience in teaching me the rigour required to
transform an idea into a substantial piece of work. I have learnt a lot. Kara, thank you for always
keeping an eye on the big picture, for letting me explore but making sure I would realise when
I was going off-track.
I am also grateful to Nicholas Mays, my advisor, for sharing his experience and knowledge and
contributing to the direction that this work has taken.
I am indebted to Aurelia Lepine, Chiara Binelli, Simon Quinn, Chiara Gigliarano, John Ataguba,
Laura Fumagalli, Elena Fumagalli and Vincenzo Salvucci for the technical advice provided in the
analysis. A special thank goes to Di McIntyre, Rene Lowenson, Gavin Mooney and Matthew
Sutton, with whom I had the luck to discuss my project and from whom I had insightful
comments.
I would like to acknowledge all the colleagues I have worked with at the Ministry of Health of
Mozambique. Thank you for sharing your knowledge, for being patient and open minded, for
reminding me how things work, for helping me in dealing with the data and for always making
me feel “da casa”, even while sitting here in London. Thank you for giving me the motivation
to pursue this work. Gertrudes Machatine, Celia Goncalves and Ernesto Mazivila, thank you
first for getting me involved into resource allocation and for facilitating the institutional
support received. Quinhas Fernandes, thank you for the help in making sense of the data and
for the invaluable inputs received for this research. Daniel Simone, Virginia Guibunda,
Costantino Muendane, Mario Tsaquice, Brigida Senete, Julio Langa thank you for the many
hours spent together in DPC and for making me learn most I know about health planning. Jorge
Perrolas, Alirio Chirindza, Lionel Senete, Ligia Vilanculos, Henario Sitoi, Salomao Lourenco,
Dabula, Manuel Macebe, Fernando Vidal, Francisco Langa, Adelaide Mbebe, thank you for the
invaluable insights into finance, budgeting and human resources and for the help with the
expenditure data. Bina Langa, Amisse Momade, Samuel Cossa, Eduarda Ribeiro, Cidalia Baloi,
Silvia Bignamini, Dora Polana, Claudia Risso, thank you for making it possible to use health
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facility data. Special thanks to Ferruccio Vio, Amelia Cumbi, Lluis Vinyals, Amanda Tyrrell,
Giuliano Russo and Laia Cirera for sharing your knowledge and for being available for a chat
and a feed-back.
I am also grateful to Sebastiao Dimene, Julio Diaz, and Alessandro Pisani at the Ministry of
Finance and to Zita Joaquim, Egidio Cuteia, Marisa Alves, David Rosengfield and Caroline Slaven
at the Ministry of Planning and Development. I have learned a lot from you on how budgeting
and resource allocation work in theory, and in practice, in Mozambique.
I am indebted to Pedro Duce at the National Institute of Statistics and Vincenzo Salvucci and
Sam Jones at the Ministry of Planning and Development for the support in using Census and
Household Budget Survey data.
I have been lucky enough to go through this journey with a number of special people.
Igor Felice, Lina Beltran, Alberto Musatti, Karina Cancelinha, Erika Beuzer, Silvia Bottone, Silvia
Bignamini, Valentina Gil, Leone Tarabusi, Matteo Gillerio, Francesca Salvi, Sara Stevano,
Caroline Slaven, Vincenzo Salvucci, Novella Maugeri and Damiano Stella thank you for the great
time, adventures and discoveries we had in Mozambique, but most of all thank you because I
knew I could count on you.
Giulia Pellegrini, Chiara Mariotti, Simona Montanari, Eloisa Dodero, Francesca Salvi, thank you
for sharing the daily life in London and for being encouraging and supportive. Elisa Ricciuti,
Maria Paola Bertone, Giulia Greco, thank you for the Italian chatty coffee breaks and the phd
talks. Your friendship is precious.
Meghna Ranganathan, Judith Kabajulizi, Warisa Panichkriangkra, Suri Thaiprayoon, Kim Jeong,
David Lugo, Solomon Salve, Bernadette Hensen, Elizabeth Starmann, Melisa Alvarez-Martinez,
Emma Garnett, Gunilla Backman, Daniel Cauchi, Ahmad Salehi, Chima Onoka, Gemini Mtei,
Jillian Stein, Ana Amaya, Tazio Vanni, Rik Viergever, Yoko Laurence, Lauren Hutchinson, Ruth
Willis, Adrianna Murphy, Andy Guise, Triantafyllos Pliakas, thank you for the time and chats in
Tavistock Place. I have learnt from you all and I hope our paths will keep crossing.
I am grateful to all my family and friends in Italy, for never making me lack support. Thank you
to my auntie Elda, to Giulia and to Sara and Morena, in particular.
Most importantly, thank you to my parents, Luigi and Mariella, and to my brother Marco for
constantly being on my side, even from far, in this one more adventure, as always before.

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Contents

Declaration .................................................................................................................................. 2
Abstract ....................................................................................................................................... 3
Acknowledgements ..................................................................................................................... 4
Contents ...................................................................................................................................... 6
List of Figures ............................................................................................................................ 10
List of Tables ............................................................................................................................. 12
Abbreviations ............................................................................................................................ 14
Chapter 1 ................................................................................................................................... 15
Introduction .............................................................................................................................. 15
1.1. Equity and efficiency in public health sector resource allocation ............................ 15
1.1.1. The relevance of equity and efficiency in public health financing .......................... 15
1.1.2. Equity in health care ............................................................................................... 15
1.1.3. Efficiency in health care .......................................................................................... 16
1.1.4. The equity-efficiency trade-off in health care resource allocation ......................... 17
1.1.5. Objectives of the thesis ........................................................................................... 17
1.2. Conceptual framework ............................................................................................. 18
1.3. Outline of the thesis .................................................................................................. 19
References ............................................................................................................................ 22
Chapter 2 ................................................................................................................................... 24
Equity in the allocation of public sector financial resources in low- and middle-income
countries: a systematic literature review ................................................................................ 24
Preface .................................................................................................................................. 24
Cover sheet for ‘research paper’ .......................................................................................... 25
Licence agreement ................................................................................................................ 26
Abstract ................................................................................................................................. 28
2.1. Introduction ................................................................................................................... 29
2.2. Methods ......................................................................................................................... 29
2.3. Results ............................................................................................................................ 31
2.4. Discussion ....................................................................................................................... 37
2.5. Conclusions .................................................................................................................... 38
References ............................................................................................................................ 38
Appendix to Chapter 2 .......................................................................................................... 40
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Chapter 3 ................................................................................................................................... 46
Study setting ............................................................................................................................. 46
3.1. Mozambique: background notes ................................................................................... 46
3.2. Inequalities in health and health care ........................................................................... 46
3.3. National Health System.................................................................................................. 49
3.4. NHS financing and resource allocation .......................................................................... 50
3.5. Data used in the thesis ................................................................................................... 54
References ............................................................................................................................ 57
Chapter 4 ................................................................................................................................... 59
Going beyond horizontal equity: an analysis of health expenditure allocation across
geographic areas in Mozambique ............................................................................................. 59
Preface .................................................................................................................................. 59
Cover sheet for ‘research paper’ .......................................................................................... 60
Abstract ................................................................................................................................. 61
4.1. Introduction .............................................................................................................. 62
4.2. Study setting ............................................................................................................. 65
4.3. Data ........................................................................................................................... 66
4.4. Methods .................................................................................................................... 68
4.4.1. Measuring horizontal and vertical equity ............................................................... 68
4.4.2. Disentangling the sources of inequity ..................................................................... 73
4.4.3. Computing equity measures by type of expenditure and over time ....................... 74
4.4.4. Sensitivity analysis .................................................................................................. 74
4.5. Results ....................................................................................................................... 75
4.5.1. Horizontal equity in Mozambique in 2008 .............................................................. 75
4.5.2. Evolution of horizontal equity in Mozambique from 2008 to 2011 ........................ 76
4.5.3. Vertical equity in 2008 ............................................................................................ 77
4.5.4 Evolution of vertical equity in Mozambique from 2008 to 2011 .............................. 79
4.6. Discussion .................................................................................................................. 80
4.7. Conclusion ................................................................................................................. 84
Appendices to Chapter 4....................................................................................................... 90
Chapter 5 ................................................................................................................................. 103
Investigating efficiency in health care production: the roles of health care administrations and
providers ................................................................................................................................. 103
Preface ................................................................................................................................ 103
Cover sheet for ‘research paper’ ........................................................................................ 105
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Abstract ............................................................................................................................... 106
5.1. Introduction ................................................................................................................. 107
5.2. Study setting ................................................................................................................ 109
5.3. Methods ....................................................................................................................... 111
5.3.1. District efficiency assuming an integrated production process ............................ 111
5.3.2. District efficiency assuming a two-step production process ................................. 113
5.3.3. Testing for the effect of health administration efficiency on district and health
facility efficiency .............................................................................................................. 116
5.3.4. Data ....................................................................................................................... 118
5.4. Results .......................................................................................................................... 118
5.4.1. Descriptive statistics .............................................................................................. 118
5.4.2. Estimates of district efficiency assuming an integrated or two-step production
process ............................................................................................................................ 119
5.4.3. The effect of health administration efficiency on district and health facility
efficiency ......................................................................................................................... 124
5.4.4. Robustness checks ................................................................................................. 126
5.5. Discussion ..................................................................................................................... 127
5.6. Conclusion .................................................................................................................... 131
References .......................................................................................................................... 132
Appendices to Chapter 5..................................................................................................... 135
Chapter 6 ................................................................................................................................. 144
What is the impact of health services availability on health-seeking behaviour? Evidence from
Mozambique ........................................................................................................................... 144
Preface ................................................................................................................................ 144
Cover sheet for ‘research paper’ ........................................................................................ 146
Abstract ............................................................................................................................... 147
6.1. Introduction ................................................................................................................. 148
6.2. Setting and data ........................................................................................................... 150
6.2.1 Setting .................................................................................................................... 150
6.2.2. Data ....................................................................................................................... 151
6.3. Methods ....................................................................................................................... 154
6.3.1. Theoretical framework ......................................................................................... 154
6.3.2. Estimating the probability of seeking care............................................................ 154
6.3.3. Using an instrumental variable to assess the causal effect of health services
availability ....................................................................................................................... 156
6.3.4. Exploring heterogeneity in the effect of health care availability .......................... 159
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6.4. Results .......................................................................................................................... 159
6.4.1 Descriptive statistics ............................................................................................... 159
6.4.2. Effect of health care availability on the decision to seek care .............................. 160
6.4.3. Robustness checks ................................................................................................. 164
6.5. Discussion ..................................................................................................................... 167
6.6. Conclusion .................................................................................................................... 170
References .......................................................................................................................... 171
Appendices to Chapter 6..................................................................................................... 175
Chapter 7 ................................................................................................................................. 185
Discussion and conclusion ...................................................................................................... 185
7.1. Introduction ................................................................................................................. 185
7.2. Summary of research findings ..................................................................................... 186
7.3. Contribution of the thesis ............................................................................................ 188
7.3.1. Methodological contributions ............................................................................... 188
7.3.2. Contributions to knowledge and policy ................................................................. 190
7.4. Limitations.................................................................................................................... 191
7.4.1. Narrow focus of analysis ....................................................................................... 191
7.4.2. Limited definition of benefit .................................................................................. 192
7.4.3. Challenges associated with the definition of need................................................ 192
7.4.4. Interaction between resource allocation and supply- and demand- side policies 193
7.4.5. Generalizability ..................................................................................................... 193
7.5. Implications for policy .................................................................................................. 194
7.5.1. Setting the equity target ....................................................................................... 194
7.5.2. Achieving equitable improvements in service use ................................................ 195
7.5.3. Equity- efficiency trade off .................................................................................... 196
7.6. Areas for further research ........................................................................................... 196
7.7. Conclusions .................................................................................................................. 198
References .......................................................................................................................... 199
Appendices .............................................................................................................................. 201
Authorizations to carry out the research and to use the data from Ministry of Health, National
Institute of Statistics and Ministry of Planning and Development of Mozambique ............... 201

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