Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries

How West African countries prioritize health

BACKGROUND

The goal of Universal Health Coverage (UHC) is to ensure that everyone is able to obtain the health services they need without suffering financial hardship. UHC remains a mirage if government health expenditure is not improved. Health priority refers to general government health expenditure as a percentage of general government expenditure. It indicates the priority of the government to spend on healthcare from its domestic public resources. Our study aimed to assess health priorities in the Economic Community of West African States (ECOWAS) using the health priority index from the WHO's Global Health Expenditure Database.

METHOD

We extracted and analysed data on health priority in the WHO's Global Health Expenditure Database across the 15 members of the ECOWAS (Benin, Burkina Faso, Cabo Verde, Cote d'Ivoire, The Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, and Togo) from 2010 to 2018 to assess how these countries prioritize health. The data are presented using descriptive statistics.

RESULTS

Our findings revealed that no West African country beats the cutoff of a minimum of 15% health priority index. Ghana (8.43%), Carbo Verde (8.29%), and Burkina Faso (7.60%) were the top three countries with the highest average health priority index, while Guinea (3.05%), Liberia (3.46%), and Guinea-Bissau (3.56%) had the lowest average health priority in the West African region within the period of our analysis (2010 to 2018).

CONCLUSION

Our study reiterates the need for West African governments and other relevant stakeholders to prioritize health in their political agenda towards achieving UHC.

Equitable Access to State-of-the-Art Medical Technology-a Malaysian Mini-Public-Private Partnership Case Study

BACKGROUND

The provision of equitable and affordable health care has become increasingly challenging as advanced technology is introduced, particularly in developing countries. We explored the hypothesis that focused, small-scale mini-public-private partnerships have a potential role in providing equitable and affordable access to advanced technology for the benefit of all patients in developing nations, particularly middle-income countries.

METHODS

A clinician-led financial plan was developed at the University of Malaya to create the Centre for Image Guidance and Minimally Invasive Therapy (CIGMIT) to provide an integrated platform for high-end care for Malaysian patients of all ages, both public and private, requiring complex neurosurgical and spinal procedures and stereotactic and intensity-modulated radiotherapy. The challenges faced during development of the plan were documented together with an audit of patient throughput and analyses of financial risk and return.

RESULTS

CIGMIT opened in 2015. Patient throughput, both public and private, progressively increased in all facilities. In 2015-2019, 37,724 patients used the Centre's facilities. CIGMIT has become progressively more profitable for the University of Malaya, the public and private hospitals, and the investor. CIGMIT has weathered the challenges posed by coronavirus disease 19.

CONCLUSIONS

Focused, small-scale mini-public-private partnerships have a potential role in providing advanced technology for the benefit of patients in developing nations, particularly middle-income countries, subject to an approach that balances equity of access between public and private health care systems with fair reward.

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050

BACKGROUND

The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020.

METHODS

We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050.

FINDINGS

In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7-8·8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5-0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0-25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied.

INTERPRETATION

Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all.

FUNDING

Bill & Melinda Gates Foundation.

What alternative and innovative domestic methods of healthcare financing can be explored to fix the current claims reimbursement challenges by the National Health Insurance Scheme of Ghana? Perspectives of health managers

BACKGROUND

Low-and-middle -income countries (LMICs), to achieve sustainable universal health coverage (UHC) governments are implementing local and sustainable methods of healthcare financing. However, in Ghana, there is limited evidence on these local methods for healthcare financing to inform policy. This study aimed at exploring health managers views on alternative domestic and sustainable methods of healthcare financing for UHC under the National Health Insurance Scheme (NHIS).

METHODS

A qualitative study using in-depth interviews with 16 health facility managers were held. The health facilities and participants were selected using convenience and purposive sampling methods. A written consent was obtained from participants prior to participation in the interview. Data was transcribed verbatim and analyzed using thematic framework approach.

RESULTS

Health managers across all the health facilities mentioned delayed and erratic claims reimbursement to health facilities as the main challenge. Participants attributed the main reason to lack of funds by the National Health Insurance Authority (NHIA). They said the delayed and irregular payments has been a challenge to efficient delivery of quality healthcare to clients. That in some instances they have been compelled to demand cash or out-of-pocket payment from insured clients or insurance card bearers to be able to render needed healthcare services to them. Participants think that to ensure regular reimbursement of claims to the health facilities by the NHIA, the managers think alternative local sources of funding need to be explored to fill the funding gap. To put in place this, they suggested the need to start levying special taxes on natural resources such as crude oil and gas, gold, bauxite, cocoa, mobile money transfers, airtime and increasing the proportion of levies on the existing Value Added Tax (VAT).

CONCLUSION

The study provides important insights into potential innovative alternative domestic sources for raising additional funds to finance healthcare services in Ghana. Despite the potential of these sources, it is important for governments and health policy makers in Ghana and other LMICs who are working towards implementing innovative local methods using special levies on mobile communication services and natural resources to finance their UHC, to implement those that best suit their economies to ensure equity for better health.

Qualitative analysis of Iranian sixth five-year economic, social, and cultural development plan from universal health coverage perspective

BACKGROUND

This research analyzed the Sixth Five-Year Economic, Social, and Cultural Development Plan of the Islamic Republic of Iran (6NPD) to shed light on how the plan addresses the Universal Health Coverage (UHC).

METHODS

This research was a qualitative study. We systematically analyzed 'Secs. 14 -Health, Insurance, Health & Women, and Family' in the 6NPD. Through a content analysis, we converted this section into meaning units and coded them. Coding was guided through the conceptual framework 'Six Building Blocks of Health System' and the key principles of UHC.

RESULTS

Six themes and twenty-one subthemes were identified. The subthemes of financing include a fair and secured process of resource pooling, payment methods, revenue generation for the health sector, and a definition of a basic benefits package. The subthemes of governance and leadership consist of social insurance policies' integration, compliance of providers, a designation of the Ministry of Health and Medical Education (MoHME) as the regulator and the steward of health resources, a payer-provider split, and stakeholders' participation. The subthemes of health workforce emphasizes balancing the quality and quantity of the health workforce with populations' health needs and the health system's requirements. The subthemes of health information systems consist of the electronic health records for Iranians, information systems for organization and delivery functions, and information systems for the financing function. The subthemes of the organization and delivery consider improving effectiveness and efficiency of healthcare delivery, strengthening the family physician program and referral system, and extending the pre-hospital emergency system. Lastly, access to medicine focuses on the design and implementation of an essential drug list and drug systems for approving the coverage and provision of generic medicine.

CONCLUSIONS

The 6NPD introduced policies for strengthening the 6 building blocks of the health system. It introduced policies to improve financing particularly resource pooling and the sustainability of financial resources. As mandated by 6NPD, centering the health system's governance/leadership in MoHME may exacerbate the existing conflict of interests and provoke various arguments, which impede the enforcement of rules and regulation. The 6NPD is a step forward in terms of improving financial protection, yet several other policies need to be made to adequately meet the requirement of UHC regarding equity and effective coverage.

Budgeting for comprehensive sexual and reproductive health and rights under universal health coverage

Achieving universal health coverage (UHC) for sexual and reproductive health (SRH) requires informed budgeting that is aligned with UHC objectives. We draw data from Adding It Up 2019 (AIU-2019) to provide critical new country-level and regional, intervention-specific costs for the provision of SRH services. AIU-2019 is a cost-outcomes analysis, undertaken from the health system perspective, which estimates the costs and impacts of offering SRH care in low- and middle-income countries. We present direct cost estimates for 109 SRH interventions and find that human resources comprise the largest category of direct SRH service costs and that the most expensive services in the model are largely preventable. We use scenario analysis to explore the synergistic costs and impacts of providing SRH interventions in clusters, focussing on chlamydia and gonorrhoea treatment, provision of safe abortion and post-abortion care services, and safe childbirth services. When costs are considered for the preventive and impacted services in these three clusters, there are cost savings for some of the impacted services in the packages and for the abortion-related package overall. The direct cost estimates from our analysis can be used to guide UHC budgeting and planning efforts. Having these cost estimates and understanding the potential for cost savings when providing comprehensive SRH services are critical for efforts to fulfil the rights and needs of all individuals, including the most marginalised, to access this essential care.

Assessment of equity in healthcare financing and benefits distribution in Tanzania: a cross-sectional study protocol

INTRODUCTION

Achieving universal health coverage goal by ensuring access to quality health service without financial hardship is a policy target in many countries. Thus, routine assessments of financial risk protection, and equity in financing and service delivery are required in order to track country progress towards realising this universal coverage target. This study aims to undertake a system-wide assessment of equity in health financing and benefits distribution as well as catastrophic and impoverishing health spending by using the recent national survey data in Tanzania. We aim for updated analyses and compare with previous assessments for trend analyses.

METHODS AND ANALYSIS

We will use cross-sectional data from the national Household Budget Survey 2017/2018 covering 9463 households and 45 935 individuals cross all 26 regions of mainland Tanzania. These data include information on service utilisation, healthcare payments and consumption expenditure. To assess the distribution of healthcare benefits (and in relation to healthcare need) across population subgroups, we will employ a benefit incidence analysis across public and private health providers. The distributions of healthcare benefits across population subgroups will be summarised by concentration indices. The distribution of healthcare financing burdens in relation to household ability-to-pay across population subgroups will be assessed through a financing incidence analysis. Financing incidence analysis will focus on domestic sources (tax revenues, insurance contributions and out-of-pocket payments). Kakwani indices will be used to summarise the distributions of financing burdens according to households' ability to pay. We will further estimate two measures of financial risk protection (ie, catastrophic health expenditure and impoverishing effect of healthcare payments).

ETHICS AND DISSEMINATION

We will involve secondary data analysis that does not require ethical approval. The results of this study will be disseminated through stakeholder meetings, peer-reviewed journal articles, policy briefs, local and international conferences and through social media platforms.

The UK's contribution to cancer control in low-income and middle-income countries

Cancer mortality rates in low-income and middle-income countries (LMICs) are unacceptably high, requiring both collaborative global effort and in-country solutions. Experience has shown that working together in policy, clinical practice, education, training, and research leads to bidirectional benefit for LMICs and high-income countries. For over 60 years, the UK National Health Service has benefited from recruitment from LMICs, providing the UK with a rich diaspora of trained health-care professionals with links to LMICs. A grassroots drive to engage with partners in LMICs within the UK has grown from the National Health Service, UK academia, and other organisations. This drive has generated a model that rests on two structures: London Global Cancer Week and the UK Global Cancer Network, providing a high-value foundation for international discussion and collaboration. Starting with a historical perspective, this Series paper describes the UK landscape and offers a potential plan for the future UK's contribution to global cancer control. We also discuss the opportunities and challenges facing UK partnerships with LMICs in cancer control. The UK should harness the skills, insights, and political will from all partners to make real progress.

A quantitative analysis of sources of changes in government expenditures on health, 2000 to 2015: what can we learn from experience to date?

Background: Achieving universal health coverage (UHC) requires increased domestic financing of health by low-income countries (LICs) and middle-income countries (MICs). It is critical to understand how much governments have devoted to health from domestic sources and how much growth might be realistic over time. Methods: Using data from WHO's Global Health Expenditure Database, we examined how the composition of current health expenditure changed by financing source and the sources of growth in health expenditures from 2000-2015 across different income groups. We disaggregated how much growth in government expenditures on health from domestic sources was due to economic growth, growth in government spending as a share of GDP, and reallocations in government expenditures towards health. Results: Lower MICs (LMICs) and upper MICs (UMICs), as a group, saw a significant reduction in out-of-pocket expenditures and a significant growth in government expenditures on health from domestic sources as a share of current health expenditures over the period. This trend indicates likely progress in the pathway to UHC. For LICs, these trends were more muted. Growth in government expenditure on health from domestic sources was driven primarily by economic growth in LICs, LMICs, and UMICs. Growth in government expenditure on health due to increased government spending as a share of GDP was high in UMICs. For the high-income country group, where economic growth was relatively slower and government spending was already high with strong tax bases, the largest driver of growth in government expenditure on health from domestic sources was reallocation of the government budget towards health. Conclusions: Dialogue on domestic resource mobilization needs to emphasize overall economic growth and growth in the government spending as a share of GDP as well as the share of health in the government budget.

A fuzzy multi-criteria framework to identify barriers and enablers of the next-generation vaccine supply chain

Purpose

Due to the introduction of new vaccines in the child immunization program and inefficient vaccine supply chain (VSC), the universal immunization program (UIP), India is struggling to provide a full schedule of vaccination to the targeted children. In this paper, the authors investigate the critical factors for improving the performance of the existing VSC system by implementing the next-generation vaccine supply chain (NGVSC) in India.

Design/methodology/approach

The authors design a fuzzy multi-criteria framework using a fuzzy analytical hierarchical process (FAHP) and fuzzy multi-objective optimization on the basis of ratio analysis (FMOORA) to identify and analyze the critical barriers and enablers for the implementation of NGVSC. Further, the authors carry out a numerical simulation to validate the model.

Findings

The outcome of the analysis contends that demand forecasting is the topmost supply chain barrier and sustainable financing is the most important/critical enabler to facilitate the implementation of the NGVSC. In addition, the simulation reveals that the results of the study are reliable.

Social implications

The findings of the study can be useful for the child immunization policymakers of India and other developing countries to design appropriate strategies for improving existing VSC performance by implementing the NGVSC.

Originality/value

To the best of the authors’ knowledge, the study is the first empirical study to propose the improvement of VSC performance by designing the NGVSC.

How much healthcare is wasted? A cross-sectional study of outpatient overprovision in private-for-profit and faith-based health facilities in Tanzania

Overprovision-healthcare whose harm exceeds its benefit-is of increasing concern in low- and middle-income countries, where the growth of the private-for-profit sector may amplify incentives for providing unnecessary care, and achieving universal health coverage will require efficient resource use. Measurement of overprovision has conceptual and practical challenges. We present a framework to conceptualize and measure overprovision, comparing for-profit and not-for-profit private outpatient facilities across 18 of mainland Tanzania's 22 regions. We developed a novel conceptualization of three harms of overprovision: economic (waste of resources), public health (unnecessary use of antimicrobial agents risking development of resistant organisms) and clinical (high risk of harm to individual patients). Standardized patients (SPs) visited 227 health facilities (99 for-profit and 128 not-for-profit) between May 3 and June 12, 2018, completing 909 visits and presenting 4 cases: asthma, non-malarial febrile illness, tuberculosis and upper respiratory tract infection. Tests and treatments prescribed were categorized as necessary or unnecessary, and unnecessary care was classified by type of harm(s). Fifty-three percent of 1995 drugs prescribed and 43% of 891 tests ordered were unnecessary. At the patient-visit level, 81% of SPs received unnecessary care, 67% received care harmful to public health (prescription of unnecessary antibiotics or antimalarials) and 6% received clinically harmful care. Thirteen percent of SPs were prescribed an antibiotic defined by WHO as 'Watch' (high priority for antimicrobial stewardship). Although overprovision was common in all sectors and geographical regions, clinically harmful care was more likely in for-profit than faith-based facilities and less common in urban than rural areas. Overprovision was widespread in both for-profit and not-for-profit facilities, suggesting considerable waste in the private sector, not solely driven by profit. Unnecessary antibiotic or antimalarial prescriptions are of concern for the development of antimicrobial resistance. Option for policymakers to address overprovision includes the use of strategic purchasing arrangements, provider training and patient education.

Galvanizing Collective Action to Accelerate Reductions in Maternal and Newborn Mortality and Prevention of Stillbirths

With less than 10 years remaining to achieve the sustainable development goals, there is an urgent need for collective action to accelerate progress for maternal and newborn health and prevention of stillbirths. We outline a new global initiative, AlignMNH, designed to create opportunities to better align efforts and drive improvements.

e-income countries from a provider's perspective: a systematic review

INTRODUCTION

Maternal health services are effective in reducing the morbidity and mortality associated with pregnancy and childbirth. We conducted a systematic review on costs of maternal health services in low-income and middle-income countries from the provider's perspective.

METHODS

We searched multiple peer-reviewed databases (including African Journal Online, CINAHL Plus, EconLit, Popline, PubMed, Scopus and Web of Science) and grey literature for relevant articles published from year 2000. Articles meeting our inclusion criteria were selected with quality assessment done using relevant cost-focused criteria of the Consolidated Health Economic Evaluation Reporting Standards checklist. For comparability, disaggregated costs data were inflated to 2019 US$ equivalents. Costs and cost drivers were systematically compared. Where heterogeneity was observed, narrative synthesis was used to summarise findings.

RESULTS

Twenty-two studies were included, with most studies costing vaginal and/or caesarean delivery (11 studies), antenatal care (ANC) (9) and postabortion care (PAC) (8). Postnatal care (PNC) has been least costed (2). Studies used different methods for data collection and analysis. Quality of peer-reviewed studies was assessed average to high while all grey literature studies were assessed as low quality. Following inflation, estimated provision cost per service varied (ANC (US$7.24-US$31.42); vaginal delivery (US$14.32-US$278.22); caesarean delivery (US$72.11-US$378.940; PAC (US$97.09-US$1299.21); family planning (FP) (US$0.82-US$5.27); PNC (US$5.04)). These ranges could be explained by intercountry variations, variations in provider type (public/private), facility type (primary/secondary) and care complexity (simple/complicated). Personnel cost was mostly reported as the major driver for provision of ANC, skilled birth attendance and FP. Economies of scale in service provision were reported.

CONCLUSION

There is a cost savings case for task-shifting and encouraging women to use lower level facilities for uncomplicated services. Going forward, consensus regarding cost component definitions and methodologies for costing maternal health services will significantly help to improve the usefulness of cost analyses in supporting policymaking towards achieving Universal Health Coverage.

District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018

Introduction

Despite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres.

Methods

We carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018.

Results

Child mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators.

Conclusion

The results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health.

Noncommunicable disease outcomes and the effects of vertical and horizontal health aid

Foreign health aid forms a substantial portion of health spending in many low- and middle-income countries (LMICs). It can be either vertical (funds earmarked for specific diseases) or horizontal (funds used for broad health sector strengthening). Historically, most health aid has been disbursed vertically toward key infectious diseases, with minimal allocations to noncommunicable diseases (NCDs). High NCD burden in LMICs underscores a need for increased assistance toward NCD objectives, but evidence on the outcomes of health aid for NCDs is sparse. We obtained annual data on cause-specific deaths and disability-adjusted life years (DALYs) for four leading NCDs across 116 countries, 2000-2016, and evaluated the relationship between these indicators and vertical and horizontal health aid using country fixed-effects models with 1-to-5-year lagged effects. After adjusting for fixed and time-variant country heterogeneity, vertical assistance for NCDs was significantly associated with subsequent reductions in NCD morbidity and mortality, particularly for persons under age 70 and for cardiovascular and chronic respiratory diseases. An additional dollar in per-capita NCD vertical assistance corresponded to reductions in the average annual NCD burden of 7,459 DALYs/281 deaths after one year, 7,728 DALYs/319 deaths after two years, and 8,957 DALYs/346 deaths after three years. The findings suggest that vertical assistance for NCD programs may be an appropriate mechanism for addressing short-term NCD needs in LMICs, where it may help to fill health sector gaps in NCD care, but longer-term evaluation is needed for assessing the role of horizontal assistance.

Tracheal, bronchus, and lung cancer burden and related risk factors in the United States and China

Tracheal, bronchus, and lung (TBL) cancer is the most common malignant tumor worldwide. This study aims to grasp the characteristics of the TBL cancer burden in China and the United States (USA). Data included incidence, deaths, and disability-adjusted life years (DALYs) as well as their age-standardized rates (ASRs) among different gender, age and risk factors. Joinpoint Regression Model and Age-period-cohort (APC) analysis were used to evaluate the variation tendency and effect of the risk factors. China and USA bore almost half of the TBL cancer burden, especially for males. ASRs of TBL cancer increased in China, but decreased in USA. In China, three factors related to TBL cancer deaths and DALYs related were tobacco, air pollution, and diet low in fruits; in USA, these are tobacco, occupational carcinogens, and high fasting plasma glucose. The younger the population, the less impact of birth cohort on morbidity and mortality. According to APC analysis, age effect played a key role in morbidity and mortality of TBL cancer, and the risk increased with age. Period effect kept increasing over time, while cohort effect decreased with the time of birth. Tobacco was always the top risk factor of death and DALYs in both countries. The policy should be tilted towards air pollution and a diet low in fruits in China, as well as occupational carcinogens and high fasting plasma glucose in USA. Healthcare reform in both countries should focus on planning how its health system could effectively prevent and manage TBL cancer at low cost.

Dynamics of Public Spending on Health and Socio-Economic Development in the European Union: An Analysis from the Perspective of the Sustainable Development Goals

In recent years, healthcare has become a fundamental pillar of the level of well-being of any society. With the aim of improving the lives of countries and societies, in 2015 the United Nations (UN) approved the 2030 Agenda for Sustainable Development. Among the Sustainable Development Goals (SDGs) set out in the Agenda are health and well-being (O3) and the reduction of inequalities (O10). The general objective of this paper is to analyse the impact that the level of socioeconomic development, as well as the evolution of inequalities, have had on public spending on health in European Union countries. The research methodology is based on the application of a regression model and statistical techniques such as sigma convergence, beta convergence and the Gini index. We can see that the levels of public spending on health per capita, the level of socio-economic development and the degree of inequality are closely related in these countries. For this reason, we suggest maintaining sustainable economic growth to reduce the economic disparities between EU countries, and also the current differences in public spending on health per capita.

Is Universal Health Coverage Affordable? Estimated Costs and Fiscal Space Analysis for the Ethiopian Essential Health Services Package

Estimating the required resources for implementing an essential health services package (EHSP) is vital to examine its feasibility and affordability. This study aimed to estimate the financial resources required to implement the Ethiopian EHSP from 2020 to 2030. Furthermore, we explored potential alternatives to increase the fiscal space for health in Ethiopia. We used the OneHealth Tool (OHT) to estimate the costs of expanding the EHSP service provision in the public sector in Ethiopia. Combinations of ingredient-based bottom-up and program-based summary costing approaches were applied. We predicted the fiscal space using assumptions for economic growth, government resource allocations to health, external aid for health, the magnitude of out-of-pocket expenditure, and other private health expenditures as critical factors affecting available resources devoted to health. All costs were valued using 2020 US dollars (USD). To implement the EHSP, 13.0 billion USD (per capita: 94 USD) would be required in 2030. The largest (50-70%) share of estimated costs was for medicines, commodities, and supplies, followed by human resources costs (10-17%). However, the expected available resources based on a business-as-usual fiscal space estimate would be 63 USD per capita for the same year. Therefore, the gap as a percentage of the required resources would be 33% in 2030. The resources needed to implement the EHSP would increase steadily over the projection period due mainly to increases in service coverage targets over time. Allocating gains from economic growth to increase the total government health expenditure could partly address the gap.

Toward universal health coverage in the post-COVID-19 era

All countries worldwide have signed up to the United Nations Sustainable Development Goals and have committed to the objective of achieving 'universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all'. During the COVID-19 pandemic and beyond, advancement toward universal health coverage (UHC) will become more difficult for many countries, demonstrating that locally led priority setting is urgently needed to provide health services with appropriate financial protection to all. Because resources are limited and no national constituency can provide an unlimited number of services to their whole population in a sustainable manner, rationing and setting priorities for the selection of interventions to be included in a defined package of services is critical. In this Perspective, we discuss how packages of essential health services can be developed in resource-constrained settings, and detail how experts and the public can decide on principles and criteria, use a comprehensive array of analytical methods and choose which services to be provided free of charge. We illustrate these main steps while drawing on a recently conducted exercise of revising the national essential health services package in Ethiopia, which we compare with examples from other countries that have defined their essential benefits packages. This Perspective also provides recommendations for other low- and middle-income countries on their pathway to UHC.

Building resource constraints and feasibility considerations in mathematical models for infectious disease: A systematic literature review

•

Mathematical model capabilities to explore complex systems now enable priority-setting to consider local resource constraints.

•

Common objectives of model-based analyses incorporating constraints are to assess real-world feasibility or allocate resources efficiently.

•

Constraints may be incorporated via (i) model-based estimation; (ii) linkage of mathematical and health system models; or (iii) optimisation.

•

Models can then project constrained intervention effects and costs and resource requirement s for delivering interventions at full scale.

•

'Health system constraints' should be systematically defined for routine operationalisation in model-based priority-setting.

Priority setting for infectious disease control is increasingly concerned with physical input constraints and other real-world restrictions on implementation and on the decision process. These health system constraints determine the ‘feasibility’ of interventions and hence impact. However, considering them within mathematical models places additional demands on model structure and relies on data availability. This review aims to provide an overview of published methods for considering constraints in mathematical models of infectious disease.

We systematically searched the literature to identify studies employing dynamic transmission models to assess interventions in any infectious disease and geographical area that included non-financial constraints to implementation. Information was extracted on the types of constraints considered and how these were identified and characterised, as well as on the model structures and techniques for incorporating the constraints.

A total of 36 studies were retained for analysis. While most dynamic transmission models identified were deterministic compartmental models, stochastic models and agent-based simulations were also successfully used for assessing the effects of non-financial constraints on priority setting. Studies aimed to assess reductions in intervention coverage (and programme costs) as a result of constraints preventing successful roll-out and scale-up, and/or to calculate costs and resources needed to relax these constraints and achieve desired coverage levels. We identified three approaches for incorporating constraints within the analyses: (i) estimation within the disease transmission model; (ii) linking disease transmission and health system models; (iii) optimising under constraints (other than the budget).

The review highlighted the viability of expanding model-based priority setting to consider health system constraints. We show strengths and limitations in current approaches to identify and quantify locally-relevant constraints, ranging from simple assumptions to structured elicitation and operational models. Overall, there is a clear need for transparency in the way feasibility is defined as a decision criteria for its systematic operationalisation within models.

A global investment framework for the elimination of hepatitis B

BACKGROUND & AIMS

More than 292 million people are living with hepatitis B worldwide and are at risk of death from cirrhosis and liver cancer. The World Health Organization (WHO) has set global targets for the elimination of viral hepatitis as a public health threat by 2030. However, current levels of global investment in viral hepatitis elimination programmes are insufficient to achieve these goals.

METHODS

To catalyse political commitment and to encourage domestic and international financing, we used published modelling data and key stakeholder interviews to develop an investment framework to demonstrate the return on investment for viral hepatitis elimination.

RESULTS

The framework utilises a public health approach to identify evidence-based national activities that reduce viral hepatitis-related morbidity and mortality, as well as international activities and critical enablers that allow countries to achieve maximum impact on health outcomes from their investments - in the context of the WHO's 2030 viral elimination targets.

CONCLUSION

Focusing on hepatitis B, this health policy paper employs the investment framework to estimate the substantial economic benefits of investing in the elimination of hepatitis B and demonstrates how such investments could be cost saving by 2030.

LAY SUMMARY

Hepatitis B infection is a major cause of death from liver disease and liver cancer globally. To reduce deaths from hepatitis B infection, we need more people to be tested and treated for hepatitis B. In this paper, we outline a framework of activities to reduce hepatitis B-related deaths and discuss ways in which governments could pay for them.

Advancing the Population Needs-Based Health Workforce Planning Methodology: A Simulation Tool for Country Application

Although the conceptual underpinnings of needs-based health workforce planning have developed over the last two decades, lingering gaps in empirical models and lack of open access tools have partly constrained its uptake in health workforce planning processes in countries. This paper presents an advanced empirical framework for the need-based approach to health workforce planning with an open-access simulation tool in Microsoft^® Excel to facilitate real-life health workforce planning in countries. Two fundamental mathematical models are used to quantify the supply of, and need for, health professionals, respectively. The supply-side model is based on a stock-and-flow process, and the need-side model extents a previously published analytical frameworks using the population health needs-based approach. We integrate the supply and need analyses by comparing them to establish the gaps in both absolute and relative terms, and then explore their cost implications for health workforce policy and strategy. To illustrate its use, the model was used to simulate a real-life example using midwives and obstetricians/gynaecologists in the context of maternal and new-born care in Ghana. Sensitivity analysis showed that if a constant level of health was assumed (as in previous works), the need for health professionals could have been underestimated in the long-term. Towards universal health coverage, the findings reveal a need to adopt the need-based approach for HWF planning and to adjust HWF supply in line with population health needs.

Vision 2030 and Sustainable Development: State Capacity to Revitalize the Healthcare System in Saudi Arabia

Vision 2030 is a social and economic strategic program by the Kingdom of Saudi Arabia (KSA) aimed at diversifying the nation's economy and stimulating numerous changes in its social and economic sectors, including in healthcare. Sustainable Development (SD) 2030 is a global consensual agreement among nation-states to build a sustainable, desirable and progressively interrelated world. The Saudi government highlighted Vision 2030 to improve population health and the world body reiterated that SD 2030 will contribute to "healthy lives and promote well-being for all at all ages." This article analyzes the state capacity in revitalizing the healthcare system in Saudi Arabia with the context of Vision 2030 and SD 2030. Scoping reviews and thematic data analysis techniques were used as a method of this study. The realization of Vision 2030 is essential for the fulfilment of the SD Goals 2030. The government has realigned its national programs, plans and strategies with global development targets, indicators, and goals to achieve the SD Goals. Achieving SD 2030 is seen as the main component of development for health. Prudent reforms should be taken to accommodate the goals and objectives of Vision 2030 and SD 2030. These measures will help strengthen governance and state capacity so as to ultimately revitalize the Saudi healthcare system and improve population health. Saudi Arabia's Vision 2030 encourages the state to play a renewed role in development in light of the UN's declaration of the "right to development." While pursuing SD Goals, the state must create the necessary environment for sustaining capacity, need to improve service delivery by building cooperation and coordination among providers and interactions among groups to realize constructive roles and functions in maintaining state affairs, which ultimately enhances state capacity to revitalize healthcare system of Saudi Arabia.

Monetary value of disability-adjusted life years lost from all causes in Mauritius in 2019

Background: The Republic of Mauritius had a total of 422,567 disability-adjusted life years (DALYs) from all causes in 2019. This study aimed to estimate the monetary value of DALYs lost in 2019 from all causes in Mauritius and those projected to be lost in 2030; and to estimate the monetary value of DALYs savings in 2030 if Mauritius were to attain the national targets related to five targets of the United Nations Sustainable Development Goal 3 on good health and well-being. Methods: The human capital approach was used to monetarily value DALYs lost from 157 causes in 2019. The monetary value of DALYs lost in 2019 from each cause was calculated from the product of net gross domestic product (GDP) per capita in Mauritius and the number of DALYs lost from a specific cause. The percentage reductions implied in the SDG3 targets were used to project the monetary values of DALYs expected in 2030. The potential savings equal the monetary value of DALYs lost in 2019 less the monetary value of DALYs expected in 2030. Results:  The DALYs lost in 2019 had a total monetary value of Int$ 9.46 billion and a mean value of Int$ 22,389 per DALY. Of this amount, 84.2% resulted from non-communicable diseases; 8.7% from communicable, maternal, neonatal, and nutritional diseases; and 7.1% from injuries. Full attainment of national targets related to the five SDG3 targets would avert DALYs losses to the value of Int$ 2.4 billion. Conclusions: Diseases and injuries cause a significant annual DALYs loss with substantive monetary value. Fully achieving the five SDG3 targets could save Mauritius nearly 8% of its total GDP in 2019. To achieve such savings, Mauritius needs to strengthen further the national health system, other systems that tackle the social determinants of health, and the national health research system.

Cognitive Telerehabilitation for Older Adults With Neurodegenerative Diseases in the COVID-19 Era: A Perspective Study

The COVID-19 pandemic is a global health problem that is radically transforming public and private healthcare organizations around the world, negatively affecting the rehabilitative treatments of non-COVID pathologies as well. In this situation, it becomes crucial to be able to guarantee the continuity of care also to all those patients with neurodegenerative diseases unable to reach healthcare services. Remote communication technologies are gaining momentum as potentially effective options to support health care interventions-including cognitive rehabilitation-while patients can stay safely at home. In this context, we are implementing HomeCoRe (i.e., Home Cognitive Rehabilitation software) in order to offer an innovative approach and a valid support for home-based cognitive rehabilitation in neurodegenerative diseases, such as mild cognitive impairment and early dementia. HomeCoRe has been developed within a research project between engineers and clinicians in order to obtain a usable and safe cognitive rehabilitation tool. This software has multiple advantages for patients and therapists over traditional approaches, as shown in its use in hospital settings. HomeCoRe could then represent an opportunity for accessing cognitive rehabilitation in all those situations where patients and therapists are not in the same location due to particular restrictions, such as COVID-19 pandemic.

Cost-Effectiveness of Testing and Treatment for Hepatitis B Virus and Hepatitis C Virus Infections: An Analysis by Scenarios, Regions, and Income

OBJECTIVES

Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups.

METHODS

We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination).

RESULTS

Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and -$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results.

CONCLUSIONS

Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices.

Atrial fibrillation in low- and middle-income countries: a narrative review

Preventing premature non-communicable disease mortality necessitates a thorough review of one of the most important risk factors for stroke, which is atrial fibrillation (AF). The latter and AF-related stroke are still considered to be problems of high-income countries and are frequently overlooked in low- and middle-income countries (LMICs). In this narrative review, we provide an overview of studies that evaluated at least one of the following determinants of AF burden in LMICs: current epidemiology and trends, stroke prevention, health outcomes, and economic burden. Studies focusing on samples close to the general population (including community- and primary care-based samples) indicate sex-specific prevalence rates up to 7.4% in LMICs. Although AF prevalence is still higher in high-income countries than LMICs, the gap in AF burden between these two groups has been reducing in the past three decades. Oral anticoagulant (OAC) therapy for stroke prevention is underused in LMICs, and there are little data on OAC therapy in relation to stroke risk scores, such as CHA2DS2-VASc. Available data also points to higher morbidity and mortality for patient with AF in LMICs than their counterparts in high-income countries. Data on the consequent economic burden in LMICs is scarce, but it is reasonable to consider it will follow the same trend as that observed for health outcomes. Raising the visibility of AF as a public health problem in LMICs is necessary as a first step to providing adequate care for patients with this condition.

Sustainable Development Goals relevant to kidney health: an update on progress

Globally, more than 5 million people die annually from lack of access to critical treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because they are pathologically diverse and are often asymptomatic. As such, kidney disease is often diagnosed late, and the global burden of kidney disease continues to be underappreciated. When kidney disease is not detected and treated early, patient care requires specialized resources that drive up cost, place many people at risk of catastrophic health expenditure and pose high opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress is disjointed and uneven among and within countries. The six SDG Transformations framework can be used to examine SDGs with relevance to kidney health that require attention and reveal inter-linkages among the SDGs that should accelerate progress.

Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease.

Each Sustainable Development Goal (SDG) has the potential to improve kidney health and prevent kidney disease by improving the general health and well-being of individuals and societies, and by protecting the environment.

Achievement of each SDG is interrelated to the achievement of multiple other SDGs; therefore, a multisectoral approach is required.

The global burden of kidney disease has been relatively underestimated because of a lack of data.

Structural violence and the social determinants of health have an important impact on kidney disease risk.

Kidney disease is the leading global cause of catastrophic health expenditure, in part because of the high costs of kidney replacement therapy.

Achievement of universal health coverage is the minimum requirement to ensure sustainable and affordable access to early detection and quality treatment of kidney disease and/or its risk factors, which should translate to a reduction in the burden of kidney failure in the future.

Ending malnutrition in all its forms requires scaling up proven nutrition interventions and much more: a 129-country analysis

BACKGROUND

Sustainable Development Goal (SDG) 2.2 calls for an end to all forms of malnutrition, with 2025 targets of a 40% reduction in stunting (relative to 2012), for wasting to occur in less than 5% of children, and for a 50% reduction in anaemia in women (15-49 years). We assessed the likelihood of countries reaching these targets by scaling up proven interventions and identified priority interventions, based on cost-effectiveness.

METHODS

For 129 countries, the Optima Nutrition model was used to compare 2019-2030 nutrition outcomes between a status quo (maintained intervention coverage) scenario and a scenario where outcome-specific interventions were scaled up to 95% coverage over 5 years. The average cost-effectiveness of each intervention was calculated as it was added to an expanding package of interventions.

RESULTS

Of the 129 countries modelled, 46 (36%), 66 (51%) and 0 (0%) were on track to achieve the stunting, wasting and anaemia targets respectively. Scaling up 18 nutrition interventions increased the number of countries reaching the SDG 2.2 targets to 50 (39%), 83 (64%) and 7 (5%) respectively. Intermittent preventative treatment of malaria during pregnancy (IPTp), infant and young child feeding education, vitamin A supplementation and lipid-based nutrition supplements for children produced 88% of the total impact on stunting, with average costs per case averted of US$103, US$267, US$556 and US$1795 when interventions were consecutively scaled up, respectively. Vitamin A supplementation and cash transfers produced 100% of the total global impact on prevention of wasting, with average costs per case averted of US$1989 and US$19,427, respectively. IPTp, iron and folic acid supplementation for non-pregnant women, and multiple micronutrient supplementation for pregnant women produced 85% of the total impact on anaemia prevalence, with average costs per case averted of US$9, US$35 and US$47, respectively.

CONCLUSIONS

Prioritising nutrition investment to the most cost-effective interventions within the country context can maximise the impact of funding. A greater focus on complementing nutrition-specific interventions with nutrition-sensitive ones that address the social determinants of health is critical to reach the SDG targets.

Guaranteeing the Health Rights of People with Disabilities in the COVID-19 Pandemic: Perspectives from China

The question of how to guarantee the health rights of people with disabilities, and their health equity in particular, is frequently neglected in infectious disease pandemics. The international response to the ongoing COVID-19 pandemic is no exception in this regard. This neglect is related to other forms of marginalization and exclusion, as people with disabilities are generally poorer and more vulnerable than their non-disabled counterparts. Sustainable Development Goal 3 lacks an appropriate human rights language that enshrines equality and inclusivity in pandemic prevention work and related policies and legislation; and, as a result, it does not sufficiently guarantee the health rights of people with disabilities. This paper draws on China's pandemic prevention work to extract relevant lessons, and seeks to explain how decision-making systems and resource allocation mechanisms impact on the health rights of people with disabilities. It discusses the unique roles of justice and legislation in helping to guarantee the health rights of people with disabilities in an infectious disease pandemic, and concludes that future research should more closely consider how Sustainable Development Goal 16 can support Sustainable Development Goal 3.

Action-Based Costing for National Action Plans for Health Security: Accelerating Progress Toward the International Health Regulations (2005)

Multiple costing tools have been developed to understand the resources required to build and sustain implementation of the International Health Regulations (IHR), including a detailed costing tool developed by WHO ("WHO Costing Tool") and 2 action-based costing tools, Georgetown University's IHR Costing Tool and CDC's Priority Actions Costing Tool (PACT). The relative performance of these tools is unknown. Nigeria costed its National Action Plan for Health Security (NAPHS) using the WHO Costing Tool. We conducted a desktop review, using the other tools to compare the cost estimates generated using different costing approaches. Technical working groups developed activity plans and estimated component costs using the WHO Costing Tool during a weeklong workshop with approximately 60 participants from various ministries, departments, and federal agencies. We retrospectively applied the IHR Costing Tool and PACT to generate rapid cost estimates required to achieve a Joint External Evaluation (JEE) score of "demonstrated capacity" (level 4). The tools generated similar activities for implementation. Cost estimates varied based on the anticipated procurement and human resources requirements and by the level of implementation (eg, health facility-level versus local government area-level procurement). The desktop IHR Costing Tool and PACT tools required approximately 2 and 8 person-hours to complete, respectively. A strategic costing approach, wherein governments select from a menu of recommended and costed actions following the JEE to develop a NAPHS, could accelerate implementation of plans. Major cost drivers, including procurement and human resources, should be prioritized based on anticipated resource availability and countries' priorities.

Global hepatitis C elimination: an investment framework

WHO has set global targets for the elimination of hepatitis B and hepatitis C as a public health threat by 2030. However, investment in elimination programmes remains low. To help drive political commitment and catalyse domestic and international financing, we have developed a global investment framework for the elimination of hepatitis B and hepatitis C. The global investment framework presented in this Health Policy paper outlines national and international activities that will enable reductions in hepatitis C incidence and mortality, and identifies potential sources of funding and tools to help countries build the economic case for investing in national elimination activities. The goal of this framework is to provide a way for countries, particularly those with minimal resources, to gain the substantial economic benefit and cost savings that come from investing in hepatitis C elimination.

Arms sales and child health

The adverse effects of armed conflict on child health are well recognised. The relationships among the arms trade, armed conflict and child health are less clearly defined. The arms trade is one of the largest industries in the world (total expenditure US$1917 billion in 2019), generating colossal profits to private companies and individuals at the expense of taxpayers throughout the world. The money wasted on weapons designed to kill and maim should be used for more socially useful products, such as clean water, food, health and education. The sustainable development goals can be funded by diverting money from the arms companies. Health professionals and their organisations have a responsibility to children to try and curb the ever-expanding arms industry.

Primary health care and sustainable development goals

We examine the potential and limitations of primary health care in contributing to the achievement of the health-related sustainable development goals (SDGs), and recommend policies to enable a functioning primary health-care system. Governments have recently reaffirmed their commitment to the SDGs through the 2018 Declaration of Astana, which redefines the three functions of primary health care as: service provision, multisectoral actions and the empowerment of citizens. In other words, the health-related SDGs cannot be achieved by the provision of health-care services alone. Some health issues are related to environment, necessitating joint efforts between local, national and international partners; other issues require public awareness (health literacy) of preventable illnesses. However, the provision of primary health care, and hence achievement of the SDGs, is hampered by several issues. First, inadequate government spending on health is exacerbated by the small proportions allocated to primary health care. Second, the shortage and maldistribution of the health workforce, and chronic absenteeism in some countries, has led to a situation in which staffing levels are inversely related to poverty and need. Third, the health workforce is not trained in multisectoral actions, and already experiences workloads of an overwhelming nature. Finally, health illiteracy is common among the population, even in developed countries. We recommend that governments increase spending on health and primary health care, implement interventions to retain the rural health workforce, and update the pre-service training curricula of personnel to include skills in multisectoral collaboration and enhanced community engagement.

Allocating resources to support universal health coverage: development of a geographical funding formula in Malawi

BACKGROUND

Universal health coverage (UHC) requires that local health sector institutions-such as local authorities-are properly funded to fulfil their service delivery commitments. In this study, we examine how formula funding can align sub-national resource allocations with national priorities. This is illustrated by outlining alternative options for using mathematical formula to guide the allocation of national drug and service delivery budgets to district councils in Malawi in 2018/2019.

METHODS

We use demographic, epidemiological and health sector budget data with information on implementation constraints to construct three variant allocation formulae. The first gives an equal per capita allocation to each district, and is included as a baseline to compare alternatives. The second allocates funds to districts using estimates of the resources required to provide Malawi's essential health package of priority cost-effective interventions to the full population in need of each intervention. The third adjusts these estimates to reflect a practicable level of attainable coverage for each intervention, based on the current configurations of health services and demand for interventions.

FINDINGS

Compared with current district allocations, not underpinned by an explicit formula, the formulae presented in this study suggest sizeable shifts in the allocations received by many districts. In some cases, the magnitude of these shifts exceed 50% reductions or doubling of district budgets. The large shifts illustrate inequities in the current system of budget allocation and the potential improvements possible.

CONCLUSION

The use of mathematical formulae can guide the efficient and equitable allocation of healthcare funds to local health authorities. The formulae developed were facilitated by the existence of an explicit package of priority interventions. The approach can be replicated in wide range of countries seeking to achieve UHC.

Road to family planning and RMNCHN related SDGs: Tracing the role of public health spending in India

Globally, public health expenditure (PHE) is closely associated with Reproductive, Maternal, Newborn, Child Health, and Nutrition (RMNCHN) and Family Planning (FP) outcomes. In India, the role of PHE in shaping the progress towards the attainment of RMNCHN and FP-related Sustainable Development Goals (SDGs) is not widely documented. Using the four consecutive rounds of National Family Health Survey (NFHS), we have investigated the progress in RMNCHN and FP indicators and their association with PHE by applying robust econometric modelling. The findings suggest that although there is noticeable progress in the RMNCHN indicators from 1992-93-2015-16, India has failed to achieve RMNCHN targets related to Millennium Development Goals (MDGs). Lack of noteworthy correlation between FP indicators and PHE supports the argument that post National Rural Health Mission (2005), the core family welfare expenditure suffered a setback despite the absolute rise in PHE. However, correlation plots and the multivariate panel data regression analyses affirm that even with a moderate rise, PHE emerges as an important predictor of RMNCHN outcomes in the country. Thus, the road to achieving RMNCHN and FP-related SDGs demands to avoid austerity on PHE and strengthen the integration of RMNCHN and FP programmes at the operational level.

What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments

BACKGROUND

Monitoring progress towards Universal Health Coverage (UHC) requires an assessment of progress in coverage of health services and protection of households from the impact of direct out-of-pocket payments (i.e. financial risk protection). Although Uganda has expressed aspirations for attaining UHC, out-of-pocket payments remain a major contributor to total health expenditure. The aim of this study is to monitor progress in financial risk protection in Uganda.

METHODS

This study uses data from the Uganda National Household Surveys for 2005/06, 2009/10, 2012/13 and 2016/17. We measure financial risk protection using catastrophic health care payments and impoverishment indicators. Health care payments are catastrophic if they exceed a set threshold (i.e. 10 and 25%) of the total household consumption expenditure. Health payments are impoverishing if they push the household below the poverty line (the US$1.90/day and Uganda's national poverty lines). A logistic regression model is used to assess the factors associated with household financial risk.

RESULTS

The results show that while progress has been made in reducing financial risk, this progress remains minimal, and there is still a risk of a reversal of this trend. We find that although catastrophic health payments at the 10% threshold decreased from 22.4% in 2005/06 to 13.8% in 2012/13, it increased to 14.2% in 2016/17. The percentage of Ugandans pushed below the national poverty line (US$1.90/day) has decreased from 5.2% in 2005/06 to 2.7% in 2016/17. The distribution of both catastrophic health payments and impoverishment varies across socio-economic status, location and residence. In addition, certain household characteristics (poverty, having a child below 5 years and an adult above 60 years) are more associated with the lack of financial risk protection.

CONCLUSION

There is need for targeted interventions to reduce OOP, especially among those affected so as to increase financial risk protection. In the short-term, it is important to ensure that public health services are funded adequately to enable effective coverage with quality health care. In the medium-term, increased reliance on mandatory prepayment will reduce the burden of OOP health spending further.

A model of the economic benefits of global hepatitis C elimination: an investment case

Major gains in reducing the burden of hepatitis C are now possible because of the discovery of a cure. The prevention of premature deaths and increased workforce participation among people who are cured are likely to provide substantial indirect economic benefits. We developed an investment case for hepatitis C for the six WHO world regions, which, to our knowledge, is the first to consider both indirect and direct economic benefits in this context. Scaling up of testing and treatment to reach the 2030 WHO hepatitis C elimination targets was estimated to prevent 2·1 million (95% credible interval 1·3-3·2 million) hepatitis C-related deaths and 10 million (4-14 million) new hepatitis C virus infections globally between 2018 and 2030. This elimination strategy was estimated to cost US$41·5 billion (33·1-48·7 billion) in testing, treatment, and health care between 2018 and 2030 ($23·4 billion more than the status quo scenario of no testing or treatment scale up), with a global average of $885 (654-1189) per disability-adjusted life-year averted at 2030. Compared with the status quo scenario, the elimination scenario generated $46·1 billion (35·9-53·8 billion) in cumulative productivity gains by 2030. These indirect costs made elimination cost-saving by 2027, with a net economic benefit of $22·7 billion (17·1-27·9 billion) by 2030. This model shows that countries might be underestimating the true burden of hepatitis C and will benefit from investing in elimination.

Assessment of Progress towards Achieving Sustainable Development Goals of the “Agenda 2030” by Using the CoCoSo and the Shannon Entropy Methods: The Case of the EU Countries

The United Nations Member States adopted the “Agenda 2030” which contains 17 sustainable development goals (SDG) that involve a certain number of targets and indicators. Although the indicators are helpful in defining the position of the current country relative to the goals’ achievement, it is very complex to determine its position relative to other countries, because this requires an extensive analysis. Therefore, in this paper, the application of the multiple-criteria decision-making approach (MCDM) in defining the position of the EU (Europe Union) countries relative to the SDGs is proposed. The MCDM model is based on the Combined Compromise Solution (CoCoSo) and the Shannon Entropy methods. The final results highlight Sweden as the country that best implemented the set SD goals and has the best outputs relative to them, while Romania is in last place. The main reason for these kinds of results could be that the countries on the bottom of the list are relatively new EU members and have not been made to properly implement SDGs yet. The conclusion is that the obtained results are fully objective and rational, and that the applied model is applicable for performing this kind of analysis.

Community Engagement in Support of Moving Toward Universal Health Coverage

Community engagement describes a complex political process with dynamic negotiation and renegotiation of power and authority between providers and recipients of health care in order to achieve a shared goal of universal health care coverage. Though examples exist of community engagement projects, there is very little guidance on how to implement and embed community engagement as a concerted, integrated, strategic, and sustained component of health systems. Through a series of case studies, this article explores the factors that enable community engagement particularly with a direct impact on health systems.

Does health insurance impact health service utilization among older adults in urban China? A nationwide cross-sectional study

Background

China’s rapidly aging population has led to many challenges related to the health care delivery and financing. Since 2007, the Urban Residents Basic Medical Insurance (URBMI) program has provided financial protection for older adults living in urban areas not already covered by other health insurance schemes. We conducted a national level assessment on this population’s health needs and health service utilization.

Methods

Records for 9646 individuals over the age of 60 were extracted for analysis from two National Health Service Surveys conducted in 2008 and 2013. Multiple regression models were used to examine associations between socioeconomic factors, health needs and health service utilization while controlling for demographic characteristics and survey year.

Results

Self-reported illness, especially non-communicable diseases (NCDs) increased significantly between 2008 and 2013 regardless of insurance enrollment, age group or income level. In 2013, over 75% of individuals reported at least one NCD. Outpatient services decreased for the uninsured but increased for those with insurance. Middle- and high-income groups with insurance experienced a higher increase in outpatient visits and hospital admissions than the low-income group. Forgone hospital admissions (defined as an admission indicated by a doctor but which was declined or not followed through by the patient) decreased. However, over 20% of individuals had to forgo necessary hospital admissions, and 40% of these cases were due to financial barriers. Outpatient visits and hospital admissions increased between 2008 and 2013, and insured individuals utilized more services than those without insurance.

Conclusion

After the implementation of URBMI, health service utilization increased and forgone hospital admissions decreased, indicating the program helped to improve access to health services. However, there was still a marked difference in utilization among different income groups, with the high-income group experiencing the greatest increase. This factor calls for further attention to be given to issues related to equity. Prevalence of self-reported NCDs greatly increased among the study population between 2008 and 2013, suggesting that health insurance programs need to ensure they cover sufficient support for the treatment and prevention of NCDs.

Improving geographical accessibility modeling for operational use by local health actors

BACKGROUND

Geographical accessibility to health facilities remains one of the main barriers to access care in rural areas of the developing world. Although methods and tools exist to model geographic accessibility, the lack of basic geographic information prevents their widespread use at the local level for targeted program implementation. The aim of this study was to develop very precise, context-specific estimates of geographic accessibility to care in a rural district of Madagascar to help with the design and implementation of interventions that improve access for remote populations.

METHODS

We used a participatory approach to map all the paths, residential areas, buildings and rice fields on OpenStreetMap (OSM). We estimated shortest routes from every household in the District to the nearest primary health care center (PHC) and community health site (CHS) with the Open Source Routing Machine (OSMR) tool. Then, we used remote sensing methods to obtain a high resolution land cover map, a digital elevation model and rainfall data to model travel speed. Travel speed models were calibrated with field data obtained by GPS tracking in a sample of 168 walking routes. Model results were used to predict travel time to seek care at PHCs and CHSs for all the shortest routes estimated earlier. Finally, we integrated geographical accessibility results into an e-health platform developed with R Shiny.

RESULTS

We mapped over 100,000 buildings, 23,000 km of footpaths, and 4925 residential areas throughout Ifanadiana district; these data are freely available on OSM. We found that over three quarters of the population lived more than one hour away from a PHC, and 10-15% lived more than 1 h away from a CHS. Moreover, we identified areas in the North and East of the district where the nearest PHC was further than 5 h away, and vulnerable populations across the district with poor geographical access (> 1 h) to both PHCs and CHSs.

CONCLUSION

Our study demonstrates how to improve geographical accessibility modeling so that results can be context-specific and operationally actionable by local health actors. The importance of such approaches is paramount for achieving universal health coverage (UHC) in rural areas throughout the world.

Universal health coverage and key populations

PURPOSE OF REVIEW

There is renewed focus at global and national level to adopt commitments to ensure universal access to health services. The present study highlights key considerations to ensure that the commitment to 'leave no one behind' includes key populations, recognizing the specific impact of marginalization, stigma, discrimination, and criminalization on their access to health.

RECENT FINDINGS

Universal health coverage (UHC) means that all people can use the promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. Countries commit to UHC through Sustainable Development Goals (SDG Target 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to well tolerated, effective, quality, and affordable essential medicines).

SUMMARY

UHC cannot be achieved without addressing the needs of key populations. At the same time, the goal of UHC provides new opportunities to improve health equity and the health of key populations. Political commitment, defining and including essential high-impact, evidence-based interventions for key populations, and their full integration into national health benefit packages; integrated, decentralized, and differentiated health services with involvement, ownership, and acceptance of communities to ensure equity and quality; ensuring financing for UHC provides coverage for key populations, including those who may be undocumented, are needed. Developing more effective interventions and service delivery approaches, providing a supportive policy and legal environment; and measuring progress against clear targets for accountability and programme adjustment will also be required for key populations to benefit fully from UHC.

Monitoring Sustainable Development Goals 3: Assessing the Readiness of Low- and Middle-Income Countries

Background: The Millennium Development Goals (MDGs) availed opportunities for scaling up service coverage but called for stringent monitoring and evaluation (M&E) focusing mainly on MDG related programs. The Sustainable Development Goals 3 (SDGs) and the universal health coverage (UHC) agenda present a broader scope and require more sophisticated M&E systems. We assessed the readiness of low- and middle-income countries to monitor SDG 3.

Methods: Employing mixed methods, we reviewed health sector M&E plans of 6 countries in the World Health Organization (WHO) Africa Region to assess the challenges to M&E, the indicator selection pattern and the extent of multisectoral collaboration. Qualitative data were analysed using content thematic analysis while quantitative data were analysed using Excel.

Results: Challenges to monitoring SDG 3 include weak institutional capacity; fragmentation of M&E functions; inadequate domestic financing; inadequate data availability, dissemination and utilization of M&E products. The total number of indictors in the reviewed plans varied from 38 for Zimbabwe to 235 for Zanzibar. Sixty-nine percent of indicators for the Gambia and 89% for Zanzibar were not classified in any domain in the M&E results chain. Countries lay greater M&E emphasis on service delivery, health systems, maternal and child health as well as communicable diseases with a seeming neglect of the non-communicable diseases (NCDs). Inclusion of SDG 3 indicators only ranged from 48% for Zanzibar to 67% for Kenya. Although monitoring SDG 3 calls for multisectoral collaboration, consideration of the role of other sectors in the M&E plans was either absent or limited to the statistical departments.

Conclusion: There are common challenges confronting M&E at county-level. Countries have omitted key indicators for monitoring components of the SDG 3 targets especially those on NCDs and injuries. The role of other sectors in monitoring SDG 3 targets is not adequately reflected. These could be bottlenecks to tracking progress towards SDG 3 if not addressed. Beyond providing compendium of indicators to guide countries, we advocate for a more binding minimum set of indicators for all countries to which they may add depending on their context. Ministries of Health (MoHs) should prioritise M&E as an important pillar for health service planning and implementation and not as an add-on activity.

Breaking Specialty Silos: Improving Global Child Health Through Essential Surgical Care

Children’s health care providers and children’s surgery providers can partner to improve children’s health by developing the surgical workforce, focusing on “best buy” surgeries, integrating children’s surgery into national plans, streamlining data collection and research, and leveraging financing.

Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal

Data from a retrospective costing analysis offers insights and practical considerations for policy makers and locally elected officials for designing and implementing a new community health work cadre as a mechanism to achieve SDG targets in Nepal.

Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal’s commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.