Strategies for Health Insurance for Equity in Less Developed Countries (SHIELD)


SHIELD focused on the inequities characterising many African health systems and the growing debate about how best to promote equity while ensuring affordability and sustainability. African health systems are pluralistic, involving a complex mix of formal and informal, public and private financing and provision.

There is now consensus that pre-payment health care financing mechanisms (including tax funding and various forms of health insurance) should form the core of health systems’ funding. SHIELD explored the potential for health insurance mechanisms, particularly mandatory insurance (also known as social or national health insurance), to address inequities in pluralistic health systems in three countries (Ghana, Tanzania and South Africa). To varying degrees, all three countries have existing voluntary insurance and are incorporating elements of mandatory health insurance into their health systems. Extending insurance coverage has the potential to introduce system-wide changes that could address some of the equity and sustainability challenges facing these countries.


SHIELD sought to better understand who currently bears the burden of financing health services and who derives benefits from health care services. Once these distribution patterns are documented and the factors driving these patterns are well understood, it is feasible to adequately consider options for health system change to promote equity and efficiency.

The SHIELD project focused on:

• Determining the distribution of the current health care financing burden between socio-economic groups, i.e. the percentage of household income devoted to health care financing at different income levels, and the factors influencing this distribution;
• Evaluating the distribution of health care benefits (or the value of health service use expressed in terms of health care expenditure) across socio-economic groups and factors that influence this distribution of benefits;
• Identifying and critically evaluating current experience, and options for the likely future development, of health insurance mechanisms in relation to their likely equity impact, their affordability and sustainability, and their feasibility given the views and preferences of key stakeholders.

Much of the initial analyses drew on existing nationally representative household surveys, supplemented by data obtained directly from a range of health care financing organisations. In addition, a range of data was collected directly from users of health services and health care providers. The views of a wide range of health sector stakeholders and the general public on alternative health care financing mechanisms were also be surveyed.

For more information about SHIELD, please contact Dr Jane Goudge, Centre for Health Policy, or Prof. Di McIntyre, Health Economics Unit:


SHIELD is a collaborative project between the Health Economics Unit at the University of Cape Town and the Centre for Health Policy at the University of the Witwatersrand. Other collaborators in Africa include the Ghana Health Research Unit, and the Ifakara Health Research and Development Centre in Tanzania. The European collaborators are the London School of Hygiene and Tropical Medicine; Karolinska Institute in Sweden and the Royal Tropical Institute in the Netherlands.

Publications related to the SHIELD project:


Mills A, Ally M, Goudge J, Gyapong J, Mtei G. Progress towards universal coverage: the health systems of Ghana, South Africa and Tanzania. Health Policy and Planning. 2012 27 (Suppl 1): i4-i12.

Mills A, Ataguba, JE, Akazili J, Borghi J, Garshong B, Makawia S, Mtei G, Harris B, Macha J, Meheus F, McIntyre D. Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage. The Lancet (Online Publication). 15 May 2012: 1-8
Macha J, Harris B, Garshong B, Ataguba JE, Akazili J, Kuwawenaruwa A, Borghi J. Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa. Health Policy and Planning. 2012 27:i46-i54.


Harris B, Nxumalo N, Ataguba JE, Govender V, Chersich M, Goudge J Social solidarity and civil servants' willingness for financial cross-subsidization in South Africa: implications for health financing reform. Journal of Public Health Policy. 2011 32, S162–S183.

Harris B, Goudge J, Ataguba J, McIntyre D, Nxumalo N, Jikwana S, Chersich, M Inequities in access to health care in South Africa. Journal of Public Health Policy. 2011 32, S102–S123.

Nxumalo N, Alaba O, Harris B, Chersich MF, Goudge J Utilization of traditional healers in South Africa and costs to patients: findings from a national household survey. Journal of Public Health Policy. 2011 32, S124–S136.

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