Table 3.

Summary of the study findings—multiple funding flows and healthcare provider behaviour

	Multiple funding flows	Resource shifting	Service shifting	Cost shifting
Burkina Faso	Multiple financing mechanisms cover different population groups. Both not-for-profit and for-profit voluntary health insurance mechanisms operate in the health system. New healthcare financing schemes, funded by donor agencies, are being piloted, including SHI for maternal and child health. The tax-funded system charges user fees.	Human resources and time allocated to fulfil PBF reporting requirements. Health providers prioritize activities funded by PBF (e.g. health providers dedicate more time to outreach activities funded by PBF).	No examples identified	No examples identified
Kenya	A universalist health financing mechanism (NHIF) using multiple funding pools. A number of financing mechanisms exist, including not-for-profit and for-profit voluntary health insurance mechanisms. The tax-funded system charges user fees.	The civil servants’ scheme has special arrangements to deal with drug stockouts. Special civil servant clinics operate within public hospitals. ‘Amenity’ wards are available to NHIF beneficiaries (i.e. involving shifting staff, special equipment, additional beds).	Uninsured patients requiring long-term care or elective surgery are encouraged to enrol in NHIF.	No examples identified
Morocco	Multiple financing mechanisms cover different population groups. SHI targets formal sector workers. Both not-for-profit and for-profit voluntary health insurance mechanisms operate in the system. The tax-funded system charges user fees, except for those covered by ‘the Scheme for the Poor’.	Quicker attention given to patients covered by NHIS or by private insurance (e.g. shorter waiting times for appointments with specialists)	Patients covered by the medical assistance scheme are asked to purchase medicine from private pharmacies or pay OOP at public pharmacies.	No examples identified
Nigeria	Multiple financing mechanisms cover different population groups. Mandatory health insurance targets formal sector workers (5% of the population). Both not-for-profit and for-profit voluntary health insurance mechanisms operate in the system. The tax-funded system charges user fees.	Hospitals allocate more resources to the treatment of NHIS patients than fee-paying patients (e.g. dedicated doctors and consulting rooms).	Doctors prescribe medicine not included on the NHIS-approved drug list. NHIS clients are shifted from capitation to fee-for-service payments (i.e. from less profitable to more profitable funding flows). User fee clients are shifted from non-commercial (public-funded) to commercial (privately funded) laboratories in the hospital.	NHIS patients are charged higher rates than patients paying user fees for the same service (e.g. laboratory investigations).
Tunisia	Multiple financing mechanisms cover different population groups. SHI targets formal sector workers. Both not-for-profit and for-profit voluntary insurance mechanisms operate in the health system. The tax-funded system charges user fees.	No examples identified	Vulnerable patients who are covered by fee exemption schemes are often asked to purchase drugs from private pharmacies.	Private clinics sometimes charge patients insured with CNAM higher rates for the same service than they charge patients paying user fees.
Vietnam	A universalist health financing mechanism (SHI with 86% of the population enrolled) is supported by a number of smaller health financing mechanisms. A value-added ‘on-demand’ service charges user fee.	Hospitals invest in high-tech equipment and facilities for on-demand services and assign better qualified health workers to deliver on-demand services.	Patients with health insurance cards and user fee patients are shifted to on-demand areas if they can afford to pay. SHI patients are required to purchase drugs or other technical services from private facilities.	No examples identified