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Health Financing

High-impact research on health financing to improving health service delivery and equity in low and middle-income countries

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About

With our partners and stakeholders, we design health financing initiatives to inform research and policy.

About
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Researchers in the Department of Global Health and Development (GHD) undertake a wide portfolio of research on health financing in low and middle-income countries. Our research projects aim to:

  • evaluate the effect of payment-for-performance initiatives on health systems and population outcomes, including how these incentive schemes affect equity
  • understand the distributional effects of the different sources of financing for health
  • investigate how to finance efficient, equitable and quality primary care
  • track financial flows, in terms of aid and domestic financing to specific health areas, such as reproductive, maternal, new-born and child health
  • understand the drivers of the levels and allocation of financing both across and within countries
  • study how humanitarian crises affect financing for health care, and its accessibility and affordability
  • investigate financing arrangements for vulnerable groups such as refugees.

The research portfolio extends to many different settings, including East and West Africa, South East Asia and Brazil.

Team
Team Block

Melisa
Martinez-Alvarez

Assistant Professor

Dina
Balabanova

Associate Professor

Rachel
Cassidy

Research Fellow

Anna
Foss

Associate Professor

Giulia
Greco

Assistant Professor

Kara
Hanson

Professor

Lauren
Hashiguchi

Research Degree Student

Jessica
King

Research Fellow

Roxanne
Kovacs

Research Fellow

Julia
Lohmann

Assistant Professor

Sandra
Mounier-Jack

Associate Professor

Catherine
Pitt

Associate Professor

Timothy
Powell-Jackson

Associate Professor

Zia
Sadique

Assistant Professor

Neha
Singh

Assistant Professor

Virginia Wiseman

Projects
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Unpacking the effect of the national pay for performance scheme (PMAQ) on inequalities in the financing and delivery of primary care in Brazil

Pay for performance (P4P), or the provision of financial rewards based on the achievement of pre-specified performance indicators, is a popular mechanism for trying to improve the availability, quality and utilisation of essential health services.

An ongoing project, Equi-PMAQ investigates how Brazil's national P4P scheme for improving primary care access and quality (PMAQ) has affected socioeconomic inequalities in the financing and delivery of primary care and the extent to which different incentive designs affect these outcomes. The Brazilian experience provides a unique opportunity to explore this question as:

  • municipalities have autonomy in the design and delivery of incentives to providers in their area
  • extensive secondary data are available on socioeconomic status, financing and quality of care
  • the scheme is potentially the largest in the world, with substantial heterogeneity between areas

Equi-PMAQ aims to:

  • examine socio-economic inequalities in the quality of primary care under PMAQ
  • examine whether PMAQ has changed the level of primary funding, as well as socio-economic inequalities in the distribution of funding
  • develop a typology of PMAQ incentive designs and investigate factors associated with the adoption of different designs by municipalities
  • explore the mechanisms through which PMAQ affects the level of funding and quality of care and the distribution of these outcomes at the municipal level and below

Publications

Team

From the London School of Hygiene & Tropical Medicine:

  • Josephine Borghi
  • Timothy Powell-Jackson
  • Roxanne J. Kovacs
  • Neha Singh

Other team members:

  • Soeren Rud Kristensen
  • Matt Sutton, Everton Silva
  • Garibaldi Dantas Gurgel
  • Luciano Bezerra Gomes
  • Adriana Falangola
  • Helena Shimiz
  • Jorge Maia Barreto
  • Juliana Sampaio
Performance-Based Financing in Burkina Faso

In 2013, the World Bank and the government of Burkina Faso launched a Performance-Based Financing (PBF) pilot programme to improve the utilization and quality of services for maternal, newborn child health (MNCH) in six regions and twelve districts in the rural zones of Burkina Faso. The programme systematically targeted poor and vulnerable populations in order to measure its effect on the coverage, quality, and equity of health services across socio-economic groups.

In addition to the traditional PBF, the pilot program includes two demand-side interventions:

  • community-based insurance
  • subsidised health services for poor and vulnerable populations

The project aimed to evaluate to impact of the PBF interventions on utilization and quality of a wide range of primary care services, with a specific focus on equity effects, as well as on a number of intermediate variables such as health worker motivation.

Methods included a large-scale quantitative impact evaluation (RCT nested in a quasi-experimental controlled before-and-after design) and an explanatory qualitative study.

Publications

People

People involved: Julia Lohmann (LSHTM); non-LSHTM core staff: Manuela De Allegri, Stephan Brenner, Jean-Louis Koulidiati (Heidelberg University, Germany); Hervé Hien, Serge Somda (Centre MURAZ, Burkina Faso); Paul-André Somé (Nanebor Consult, Burkina Faso); Paul Jacob Robyn, Saidou Hamadou (World Bank); in collaboration with the Ministry of Health, Burkina Faso

PEMBA: performance-based financing mechanisms for health system strengthening in Africa

Performance based financing (PBF) has been proposed as a strategy to strengthen health systems, to improve service delivery and population health. PBF consists of financial incentives to health care providers and their managers based on the achievement of pre-defined quantity and/or quality targets related to service delivery. Over 40 low- and middle-income countries (LMICs) are implementing PBF schemes with substantial financial support from international donors.

The PEMBA project assesses the effects of PBF on the health system in Zimbabwe and Mozambique. The research goes beyond examining average programme effects and focuses on identifying causal pathways and ‘active ingredients’ of the programme, and how these vary across settings.

The project aims to:

  • map key differences in PBF scheme design and context in each of the two countries
  • develop a theory of change for how PBF affects service delivery and health outcomes through changes to health system inputs
  • evaluate the short and longer term impact of PBF on health system inputs in each country
  • evaluate the short and longer term impact of PBF on service delivery and health outcomes in each country
  • identify the specific causal pathway(s) through which PBF results in service delivery and health outcome effects
  • evaluate whether PBF effects on health system inputs, service delivery and health outcomes differ according to: scheme design; health facilities readiness; contextual factors; population characteristics; and implementation of concurrent interventions
  • develop a framework of conceptual links between PBF design, its effects on the health system and policy, and ultimately on health outcomes that can be adapted to other countries as well as inform regional and global policy

Publications

Team

From the London School of Hygiene & Tropical Medicine:

  • Josephine Borghi
  • Neha S Singh
  • Roxanne Kovacs

Other team members:

COSMIC: Complexity Science Modelling performance-based financing mechanisms for health system strengthening in Africa

This study uses system dynamic modelling (SDM) and agent based modelling (ABM) to:

  • understand how low-income country health systems respond to payment for performance (P4P) schemes
  • identify potential adverse events
  • examine how variations in the design of P4P schemes affect health system response and patient outcomes
  • identify which designs would optimise programme impact
  • examine how these methods can be adapted for use by international donors and decision makers in these settings to inform their investments in health systems

The project aims to:

  • develop a SDM and an ABM of the Tanzanian health system and its response to a P4P programme
  • validate the SDM and ABM in the Tanzanian setting
  • compare the SDM and ABM developed
  • examine the generalisability of SDM and ABM developed (in Objective 1) to the Zambian setting
  • generate policy-relevant recommendations and translate them to decision makers to optimise the design of P4P for maximum, sustained impact on maternal and child health in Tanzania and Zambia
  • build capacity among decision makers and researchers on SDM and ABM to strengthen health systems and improve maternal and child health outcomes in low- and middle-income countries (LMIC)

Publications

Team

From the London School of Hygiene & Tropical Medicine:

  • Josephine Borghi
  • Neha S Singh
  • Rachel Cassidy
  • Anna Foss

Other team members:

  • Agnes Semwanga
  • Peter Binyaruka
  • Nkenda Sachingongu
  • Chitalu Miriam Chama-Chiliba
  • Karl Blanchert
  • Zaid Chalabi
  • Nicholaus Mziray
  • John Mtei
Countdown 2030: Data Analysis Centre (DAC) on Health Financing for Reproductive Maternal Newborn and Child Health (RMNCH)

This project builds on over 10 years of research tracking aid to RMNCH and domestic financing in selected countries for Countdown 2030. This grant includes ongoing monitoring of global aid flows for RMNCH, while focusing on country-level tracking and analysis of financing for health and RMNCH, and related capacity development activities.

The project aims to:

  • generate annual updates of aid flows to RMNCH globally, by country and by donor, using Muskoka2 for the period 2018–20
  • review and propose methods for tracking domestic and external funding at country level
  • conduct and support analytical work on health financing at country level
  • build capacity to track funding and analyse financing at country level
  • build a data depository of relevant health financing data

Publications

Team

From the London School of Hygiene & Tropical Medicine:

  • Josephine Borghi
  • Catherine Pitt
  • Melisa Martinez-Alvarez

Other team members:

  • Peter Binyaruka
RECAP: Research capacity strengthening and knowledge generation to support preparedness and response to humanitarian crises and epidemics

Within Work Package 3: financing health, we are:

  • examining access and affordability of care for refugees and vulnerable host populations in Northern Uganda
  • investigating the effect of the Ebola outbreak on access to maternal and child health services and the affordability of health care in Sierra Leone
  • working with International Red Cross (IRC) to examine how costs of cash transfer programmes vary across contexts and according to programme design variations.
  • building capacity in health systems and economics methods

Publications

Team

From the London School of Hygiene & Tropical Medicine:

  • Sandra Mounier-Jack
  • Neha Singh
  • Jess King
  • Giulia Greco
  • Zia Sadique
  • Josephine Borghi

Other team members:

  • Pallavi Prabhakar (Uganda)
  • Munshi Sullaiman (Uganda)
  • Michael Amara (Sierra Leone)
  • Caitlin Tulloch (IRC)
Lancet Global Health Commission on Financing PHC

This project, a Lancet Global Health Commission supported by the Bill and Melinda Gates Foundation, reflects on the key challenges in financing primary health care to develop an evidence-led agenda for action. Through a multidisciplinary and international collaboration, it examines the successes and lessons from previous country experiences, while acknowledging the constraints under which many countries operate. The report of the Commission – planned for October 2021 – will focus on country-relevant policy solutions that aim for transformational change.

Primary Health Care (PHC) is recognised as a necessary pathway to achieving Universal Health Coverage (UHC) in low- and middle-income countries (LMICs) (WHO, 2019). Yet PHC receives insufficient investment, jeopardising most LMICs’ hope of achieving this ambition (Stenberg, Hanssen, Brindley, & et al, 2019).  How primary healthcare is financed is vital if LMICs are to make progress in ensuring their citizens can benefit from good quality, efficient and equitable primary health care available to all without causing financial hardship.

The project aims to:

  • generate actionable recommendations for national governments and global institutions on how financing for PHC can be increased and used effectively to achieve PHC targets, thereby contributing to UHC
  • generate new evidence on levels and patterns of expenditure on PHC, and the gaps in PHC investment in relation to costs and needs
  • review country experience and best practices of expanding fiscal space for PHC through different approaches to increasing spending, changing incentives and innovations to optimize the organisation of PHC delivery
  • produce recommendations on options for improving governance, accountability, public financial management and information systems to enable increased financial flows and ensuring these are spent efficiently and equitably
  • generate recommendations for measuring and monitoring progress towards greater health system investment in PHC which will underpin technical work and political advocacy in support of PHC

Team

  • Kara Hanson
  • Tim Powell-Jackson
  • Dina Balabanova
  • Nouria Brikci
  • Darius Erlangga
Cambodian Health Equity and Financing Study (CHEF) 

To assess progress towards universal health coverage (UCH), countries such as Cambodia require evidence on equity in the financing and distribution of healthcare benefits. This evidence must be based on a system-wide perspective that recognises the complex roles played by the public and private sectors in many contemporary healthcare systems.

Funded by the Australian Research Council and due to complete in June 2020, CHEF aims to produce previously unavailable information on who pays for, and who benefits from, health services across the entire health system of Cambodia. The study:

  • uses financing and benefit incidence analysis to calculate the financing burden and distribution of healthcare benefits across socioeconomic groups
  • designs a cross-sectional household survey involving a random sample of 5,000 households
  • derives data on healthcare usage, living standards and self-assessed health status derived from the survey
  • supplements survey findings with secondary data from the Cambodian National Health Accounts and the Cambodian Socioeconomic Survey (CSES)
  • collects qualitative data through focus group discussions and in-depth interviews to inform the interpretation of the quantitative analyses 

This evidence comes at a critical juncture in healthcare reform in South-East Asia with so many countries seeking guidance on the equity impact of their current financing arrangements that include a complex mix of public and private providers. 

The primary objective of this study is to evaluate equity in healthcare payment and service use in Cambodia to support progress towards UHC. Specific study questions include:

  • How is the burden of healthcare payments distributed across socioeconomic groups in Cambodia?
  • How are the benefits from the health financing system (measured in terms of healthcare use) distributed across socioeconomic groups and according to level of need?
  • What are the complex range of determinants of healthcare usage and household spending on health services in Cambodia?

Publications (selected)

Team

  • Virginia Wiseman (LSHTM & Kirby Institute at the University of New South Wales)
  • Por Ir (Cambodian Institute of Public Health)
  • Marco Liverani (LSHTM)
  • Augustine Asante (University of New South Wales)
  • Andrew Hayen (University of Technology Sydney)
  • Stephen Jan (George Institute for Global Health, University of New South Wales)
Equity in Health Financing in Indonesia (ENHANCE) Study: Funded under HSRI scheme, Joint UK Councils (2018-2021)

Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the  JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken.

Primary aims of this study are to:

  • (i) measure and compare key equity outcomes - including health care utilisation, subsidies received through the use of health services, payments people make for health care, and self-assessed health – in early 2018 (study baseline) and end of 2019 (target of JKN full implementation);
  • (ii) develop and apply ‘quality-weightings’ to the benefits of health spending, to account for variation in the quality of health services utilised; and
  • (iii)document the changing context and processes for implementing UHC-reforms in Indonesia.

Publications

 

People involved (staff as well as students):  

  • Virginia Wiseman (LSHTM & Kirby Institute at the University of New South Wales),
  • Hasbullah Thabrany (University of Indonesia),
  • Soewarta Kosen (Indonesian Ministry of Health), 
  • Augustine Asante (University of New Suth Wales),
  • Andrew Hayen (University of Technology Sydney),
  • Anne Mills (LSHTM),
  • Lucy Gilson (University of Cape Town, LSHTM),
  • Stephen Jan (George Institute for Global Health, University of New South Wales),
  • Manon Haemmerli (PhD student, LSHTM),
  • Viroj Tangcharoensathien (Ministry of Public Health, Thailand),
  • Walaiporn Patcharanarumol (Ministry of Public Health, Thailand)