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Poverty and Inequality
Strategies for Health
Insurance for Equity in
Less Developed Countries
(SHIELD)
The SHIELD project, funded by the European Commission
and the Canadian International Development Research
Centre, aimed to identify the major equity challenges
in the health systems of three African countries (Ghana,
Tanzania and South Africa) through an understanding of
financing incidence (which socio-economic groups pay for
which aspect of health care) and benefit incidence (who
benefits from health care and to what extent).
Research Projects
It also modelled the equity and sustainability
implications of alternative health financing options in
each country and evaluated the political feasibility of
these options from a stakeholder-analysis perspective.
This research has provided a unique evidence base for
health-system reform in African (and other low- and
middle-income) countries. It has confirmed that paying
for health care out of one’s earnings is not indicative
of a progressive society, and that health schemes
which require contributions from individuals who are
not formally employed could have dire consequences.
Instead, in lower-income countries, consideration
should be given to charging taxes as a healthcare-
funding mechanism. Results from the study also
highlighted that the benefits from using health services
are not distributed across socio-economic groups in
line with their relative share of need for care (or burden
of ill-health) and that the access factors influencing this
benefit incidence constitute the greatest challenge
facing many health systems in Africa.
The modelling of alternative financing structures has
informed reform policies in the study countries. A large
number of publications have arisen from this work,
including a special issue of
Health Policy and Planning
and
an overview paper in
The Lancet.
Four SHIELD researchers
(two from Ghana, one from South Africa and one from
Tanzania) graduated with PhDs based on aspects of the
project, three of whom were supervised at UCT.
Collaborating partners have included UCT’s Health
Economics Unit and the Centre for Health Policy,
University of the Witwatersrand, in South Africa;
Navrongo Health Research Centre and Health Research
Unit, Ghana Health Service in Ghana; Ifakara Health
Institute in Tanzania; London School of Hygiene and
Tropical Medicine; Koninklijk Instituut voor de Tropen
in the Netherlands; Karolinska Medical Management
Centre in Sweden; and Antwerp Institute for Tropical
Medicine in Belgium.
Researching Equity in
Access to Health Care
(REACH)
Over a five-year period (2007–2012), the REACH project
explored access barriers to health care.
Focusing on three healthcare interventions (maternal
health deliveries, tuberculosis care and anti-retroviral
therapy for HIV), the project mapped inequities in
service utilisation and access nationally, conducted
in-depth studies in four health ‘sub-districts’ (rural and
urban), and identified relevant responses in the policy
and practice environment. Funded by a Teasdale-Corti
Team Grant, which was administered by Canada’s
International Development Research Centre, the
project was a collaboration between UCT’s Health
Economics Unit, the Centre for Health Policy (University
of Witwatersrand) and McMaster University in Canada.
The research team comprised a multidisciplinary team
of economists, anthropologists, clinicians, and health-
systems and policy researchers within each stage of the
research programme.
Amixed-methods programme of research that specifically
focused on developing amultidimensional understanding
of access inequities in South Africa’s public health
system was implemented. Triangulating findings across
methods, interventions and sites, this approach afforded
numerous insights into access inequity in South Africa.
An understanding of the access dynamics underlying
inequitable access fed into, and was shaped by, the
active engagement of user partners across the course of
the project. Additionally, report-back meetings, seminars
and workshops allowed the research team to sensitise a
number of stakeholders (researchers, academics, public-
sector managers, front-line health workers and civil
society groups) to the range of access constraints that
need to be addressed, providing insights into practical
strategies for doing this, and creating opportunities for
taking the research into action.