Equity in financing and use of health care in Ghana, South Africa, and Tanzania: Implications for paths to universal coverage

Background Universal coverage of health care is now receiving substantial worldwide and national attention, but debate continues on the best mix of fi nancing mechanisms, especially to protect people outside the formal employment sector. Crucial issues are the equity implications of diff erent fi nancing mechanisms, and patterns of service use. We report a whole-system analysis-integrating both public and private sectors-of the equity of health-system fi nancing and service use in Ghana, South Africa, and Tanzania. Methods We used primary and secondary data to calculate the progressivity of each health-care fi nancing mechanism, catastrophic spending on health care, and the distribution of health-care benefi ts. We collected qualitative data to inform interpretation. Findings Overall health-care fi nancing was progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefi ts in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries. Interpretation Analyses of the equity of fi nancing and service use provide guidance on which fi nancing mechanisms to expand, and especially raise questions over the appropriate fi nancing mechanism for the health care of people outside the formal sector. Physical and fi nancial barriers to service access must be addressed if universal coverage is to become a reality. Funding European Union and International Development Research Centre.