Regulating India's health services: to what end? What future?

Out-of-pocket Health Spending and Its Impact on Household Well-being in Maharashtra

Health is one of the major determinants of the overall well-being of a society. The World Health Organization has emphasised the right to health for all, and the universal health coverage is a paradigm of this emphasis with an agenda of nobody to be left behind in the provision of health services without any financial burden by 2030.This article tries to analyse the extent of catastrophic expenditure being incurred by the people despite being sheltered under a financial protection (Health Insurance) in the state of Maharashtra. The impact caused by out-of-pocket (OOP) health expenditure on the economic status of the people in the state is assessed using the National Sample Survey Office’s 71st round conducted by the Ministry of Health and Family Welfare, Government of India. It was found that over 4.18% of the population endured the burden caused by OOP expenditure by falling below the poverty line post health payments. A higher proportion of rural population is observed to have experienced a fall in the economic status from above poverty line (APL) to below poverty line (BPL) due to high OOP expenditure than that of the urban population in Maharashtra.

A realist evaluation of the implementation of a large-scale school eye health programme in India: a qualitative study

PURPOSE

This study investigates how and in what circumstances a school-based eye health programme, the Refractive Errors Among CHildren (REACH) programme, achieved its desired outcomes: accessibility, standards of refractive care, fidelity and availability of comprehensive services, for over 2 million school children in six districts across India.

METHODS

We conducted a realist evaluation to identify programme aspects and their causal relationships with outcomes. Deductive and inductive thematic analysis of qualitative data included three phases: 1. theory gleaning, 2. eliciting programme theory, 3. revisiting programme theory. The Initial Programme Theories (IPTs) were developed and revised through review of the literature, programme documents and field notes. We reviewed informal and formal discussions from the participatory advisory workshops and conducted semi-structured interviews with key stakeholders for the development and refinement of the IPTs. We based our analysis on the programme designers' perspective; used contexts, mechanisms and outcomes configuration for the analysis and presentation of the findings and reported the revised IPTs for the REACH programme.

RESULTS

We identified four major programme aspects of the REACH programme for evaluation: programme governing unit, human resource, innovation and technology and funding. Based on the intended outcomes of the programme, themes and contexts were sorted and IPTs were defined. We revised the IPTs based on the analysis of the interviews (n = 19). The contexts and mechanisms that were reported to have potential influence on the attainment of favourable programme outcomes were identified. The revisions to the IPTs included: co-designing a collaborative model and involving local government officials to reinforce trust, community partnerships; local well-trained staff to encourage participation; use of the web-based data capturing system with built-in quality control measures and continued technical support; pre-determined costs and targets for the outputs promoted transparency and adherence with costs.

CONCLUSION

This process provided a comprehensive understanding of the opportunities and possibilities for a large-scale school eye health programme in diverse local contexts in India. This illustrated the importance of embracing principles of system thinking and considering contextual factors for School Eye Health programmes in low and middle-income countries.

Dissonances and disconnects: the life and times of community based accountability in the national rural health mission in Tamilnadu, India

Background

There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. However, implementation of these processes have shown mixed results over time and geography. The Community Action for Health (CAH) project was introduced as part of India’s National Rural Health Mission (now National Health Mission) to strengthen community-based accountability through community monitoring and planning. In this study we trace the implementation process of this project from its piloting, implementation and abrupt termination in the South Indian state of Tamil Nadu.

Methods

We framed CAH as an innovation introduced into the health system. We use the framework on integration of innovations in complex systems developed by Atun and others. We used qualitative approaches to study the implementation. We conducted interviews among a range of individuals who were directly involved in the implementation, focusing on the policy making organizational level.

Results

We uncover what we have termed “dissonances” and “disconnects” at the state level among individuals with key responsibility of implementation. By dissonances we refer to the diversity of perspective on the concept of community-based accountability and its perceived role. By disconnects we refer to the lack of spaces and processes for “sense-making” in a largely hierarchically functioning system. These constructs we believe contributes significantly to making sense of the initial uptake and the subsequent abrupt termination of the project.

Conclusions

This study contributes to the overall field of policy implementation, especially the phase between the emergence on the policy agenda and its incorporation into the day to day functioning of a system. It focuses on the implementation of contested interventions like community-based accountability, in Low- and Middle-income country settings undergoing transitions in governance. It highlights the importance of “problematization” a dimension not included in most currently popular frameworks to study the uptake and spread of innovations in the health system. It points not only to the importance of diverse perspectives present among individuals at different positions in the organization, but equally importantly the need for spaces and process of collective sense-making to ensure that a contested policy intervention is integrated into a complex system.

Factors governing the performance of Auxiliary Nurse Midwives in India: A study in Pune district

BACKGROUND

The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India.

METHODS

Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs' performance as a result of "mechanisms" (training, supervision, accountability mechanisms) within the given "context" (regulatory system, infrastructure and resources, ANMs' expanded scope of work, gender roles and norms).

RESULTS

Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving.

CONCLUSION

Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India.

Assessment of the public-private-partnerships model of a national health insurance scheme in India

A single hospital admission can deplete household resources so considerably as to induce impoverishment, especially in the Indian context of low government healthcare expenditure. Rashtriya Swasthya Bima Yojana (RSBY) was a national health insurance scheme for below-poverty-line Indian families, to provide improved access to hospitalization and greater financial protection via a public-private-partnership employing private sector implementation capacity. Study objectives were to understand governance (including regulatory) environment and contract arrangements; evaluate expansion of services to beneficiaries; and assess compliance of providers and user satisfaction. A case study approach in two districts met the need for in-depth information on scheme functioning, and RSBY implementation was examined between 2011 and 13 in Patiala (Punjab) and Yamunanagar (Haryana). Methods included 20 key stakeholder interviews, analysis of secondary datasets on beneficiaries and claims, primary data collection in 31 public and private hospitals and in greater depth in 12 hospitals, and an exit survey of 751 patients. Enrolled and non-enrolled hospitals were mapped in each district and service availability of enrolled hospitals assessed; enrollee characteristics were analysed; for the 12 hospitals, information was obtained on structural quality and process of care, and patient satisfaction and out-of-pocket payments. The Indian states and the government of India did not specify formal regulatory and implementation procedures in detail and states largely contracted out their functions to private insurance firms. Findings show regulatory weaknesses, and contractual breaches. Enrolment rates were low in both districts and more so for Patiala and there was limited access to services. There was little difference in process of care between public and private hospitals, though the structural capacity of private hospitals was better than public hospitals. RSBY helped improve accessibility and gave some degree of financial protection to patients. It also actively engaged with existing resources in the Indian health care and insurance markets.

A study of the status of provision of sterilisation services in India

Context:

India has the second-largest population in the world with a significant growth rate that adversely affects the quality of life (QoL). Sterilisation is one of the main methods of female contraception in the country. Meeting the sterilisation services’ numerical demand and quality requirements have remained a challenge.

Aims:

This study was done to assess the infrastructural component of the sterilisation services provided by the static centres.

Settings and Design:

This was a descriptive cross-sectional facility-based study conducted from September to December 2017. It involved 30 facilities (10 district hospitals and 20 community health centres [CHCs]) from 10 divisions of the state of Madhya Pradesh.

Methods and Materials:

The data were collected using a pre-tested and pre-structured questionnaire, which was uploaded on the Ona platform.

Statistical Analysis Used:

Data analysis was performed using SPSS version 21.

Results:

Only 11 of the 30 facilities had proper waiting areas for the patients. Approximately, only 63% of the facilities had proper toilets, 50% had display of the contraceptives, and 43% had a complaint/suggestion box. In terms of the availability of equipment, only 43% of the facilities had a table with the Trendelenburg facility.

Conclusions:

The main limitations in the infrastructure of the facilities were general cleanliness; availability of proper waiting and post-operative areas; and the lack of equipment, record keeping, and supervision. To accomplish the provision of quality sterilisation services, policy-makers and programme managers need to pay attention to and address these limitations.

Regulating recognition and training for new medical specialties in India: the case of emergency medicine

Regulation is essential to health systems and is central to advancing equity-oriented policy objectives in health. Regulating new medical specialties is an emerging, yet underexplored, aspect of health sector governance in low- and middle-income countries (LMICs), such as India. Limited research exists regarding how regulatory institutions in India decide what specialties should be formally recognized and how training programmes for these specialties should be organized. Understanding these regulatory functions provides a lens into how policymakers envision the role of these specialties in the broader health system and how they view the linkages between medical education, health system needs and equity. Drawing upon the recent development of emergency medicine in India, the goal of this study was to understand how recognition and training for new medical specialties are regulated in India. Building on previous frameworks, we examined the institutions, functions, enforcement, mechanisms and institutional relationships that make up the regulatory architecture, and situated our analysis in historical context. Two data sources were iteratively utilized: document review (n = 93) and in-depth interviews (n = 87). Our analysis reveals a plurality of institutions involved in regulating recognition and training for new medical specialties in India, characterized by a lack of coordination, limited collaboration and weak accountability. We also found an absence of clear responsibility for the systematic, planned development of specialties, particularly in terms of health system in strengthening and achieving health equity. As medical specialization continues to shape health systems in LMICs, further streamlining and coordination in the regulatory system will enable policymakers, researchers, practitioners and civil society to proactively plan for how these specialties can better integrate with health systems, and to advance their contribution to improving health outcomes.

'A smile is most important.' Why chains are not currently the answer to quality concerns in the Indian retail pharmacy sector

Chain pharmacies are expanding in many low and middle-income countries (LMICs). Historically practices of independent pharmacies in these settings have been poor, and there is a need to understand how these new organisational arrangements are affecting the functioning of pharmacies, and the implications for public health. Drawing on economics literature, we develop a set of hypotheses as to how chains could address the quality failures that typify LMIC retail pharmacy markets, and explore these hypotheses using a set of 38 in-depth interviews, conducted in Bengaluru, India between 2014 and 2015. We look specifically at how being organised in a chain affects several key behaviours: employment of qualified staff; the ability of government authorities to focus regulation on central management structures; the propensity for firms to self-regulate; and the impact of the potentially lower-powered incentives faced by chain employees compared to independent owners. In practice, few differences were identified between chain and independent organisations in these areas. Not all chains were operating with a qualified pharmacist (akin to independent shops). Drug control authorities did not take advantage of the existing chain architecture to enforce regulation. Chains did heavily self-regulate but their focus was on customer service, rather than aspects of quality relevant to health outcomes. Additionally, widespread bribery in the sector was a barrier to effective drug control. Finally, the incentives faced by chain employees were not low-powered due to rewarding sales targets and pressure to increase sales. We observed that chains exerted strong influence over their staff but the potential to exploit this to improve quality of care is not currently being realised. A shift in focus from customer satisfaction to outcomes of public health concern is unlikely without either financial incentives or strengthened external regulation.

Characteristics of private partners in Chiranjeevi Yojana, a public-private-partnership to promote institutional births in Gujarat, India - Lessons for universal health coverage

Background

The Chiranjeevi Yojana (CY) is a Public-Private-Partnership between the state and private obstetricians in Gujarat, India, since 2007. The state pays for institutional births of the most vulnerable households (below-poverty-line and tribal) in private hospitals. An innovative remuneration package has been designed to disincentivise unnecessary cesareans. This study examines characteristics of private facilities which participated in the program.

Methods

We conducted a cross-sectional survey of all facilities which had conducted any births between June 2012 and April 2013 in three districts. We identified 111 private and 47 public facilities. Ninety of the 111 private facilities did caesarean sections in the last three months and were eligible to participate in the CY program. Of these, 40 (44%) participated in the CY program. We conducted descriptive and bivariate analyses followed by a Poisson regression model to estimate prevalence ratios of facility characteristics that predicted participation.

Results

We found that facilities participating in the CY program had a significantly higher likelihood of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of cesarean births (PR 2.1, 95% CI 1.2–3.5) or having obstetricians new in private practice (PR 1.9, 95% CI 1.2–3.1) or being less expensive (PR 1.8, 95% CI 1.1–3.0). But none of these factors retained significance in a multi variable model.

Conclusion

Private obstetricians who participate in the CY program tend to be new to private practice, provide general services, conduct fewer caesareans and are also less expensive. This is advantageous to the PPP and widens the target beneficiary groups that can be serviced by the PPP. The state should design remuneration packages with the aim of attracting relatively new obstetricians to set up practices in more remote areas. It is possible that the CY remuneration package design is effective in keeping caesarean rates in check, and needs to be studied further.

Do chain pharmacies perform better than independent pharmacies? Evidence from a standardised patient study of the management of childhood diarrhoea and suspected tuberculosis in urban India

Introduction

Pharmacies and drug stores are frequently patients’ first point of care in many low-income and middle-income countries, but their practice is often poor. Pharmacy retailing in India has traditionally been dominated by local, individually owned shops, but recent years have seen the growth of pharmacy chains. In theory, lower-powered profit incentives and self-regulation to preserve brand identity may lead to higher quality in chain stores. In practice, this has been little studied.

Methods

We randomly selected a stratified sample of chain and independent pharmacies in urban Bengaluru. Standardised patients (SPs) visited pharmacies and presented a scripted case of diarrhoea for a child and suspected tuberculosis (TB). SPs were debriefed immediately after the visit using a structured questionnaire. We measured the quality of history taking, therapeutic management and advice giving against national (Government of India) and international (WHO) guidelines. We used Pearson’s χ² tests to examine associations between pharmacy type and case management.

Findings

Management of childhood diarrhoea and suspected TB was woefully substandard. History taking of the SP was limited; unnecessary and harmful medicines, including antibiotics, were commonly sold; and advice giving was near non-existent. The performance of chains and independent shops was strikingly similar for most areas of assessment. We observed no significant differences between the management of suspected TB in chains and independents. 43% of chains and 45% of independents managed the TB case correctly; 17% and 16% of chains and independents, respectively, sold antibiotics. We found that chains sold significantly fewer harmful antibiotics and antidiarrhoeals (35% vs 48%, p=0.029) and prescription-only medicines (37% vs 49%, p=0.048) for the patient with diarrhoea compared with independent shops. Not a single shop managed the patient with diarrhoea correctly according to guidelines.

Conclusion

Our results from Bengaluru suggest that it is unlikely that chains alone can solve persisting quality challenges. However, they may offer a potential vehicle through which to deliver interventions. Future intervention research should consider recruiting chains to see whether effectiveness of interventions differ among chains compared with independents.

Regulating the for-profit private healthcare providers towards universal health coverage: A qualitative study of legal and organizational framework in Mongolia

BACKGROUND

Regulating the behavior of private providers in the context of mixed health systems has become increasingly important and challenging in many developing countries moving towards universal health coverage including Mongolia. This study examines the current regulatory architecture for private healthcare in Mongolia exploring its role for improving accessibility, affordability, and quality of private care and identifies gaps in policy design and implementation.

METHODS

Qualitative research methods were used including documentary review, analysis, and in-depth interviews with 45 representatives of key actors involved in and affected by regulations in Mongolia's mixed health system, along with long-term participant observation.

RESULTS

There has been extensive legal documentation developed regulating private healthcare, with specific organizations assigned to conduct health regulations and inspections. However, the regulatory architecture for healthcare in Mongolia is not optimally designed to improve affordability and quality of private care. This is not limited only to private care: important regulatory functions targeted to quality of care do not exist at the national level. The imprecise content and details of regulations in laws inviting increased political interference, governance issues, unclear roles, and responsibilities of different government regulatory bodies have contributed to failures in implementation of existing regulations.

Quality Health Care and Willingness to Pay for Health Insurance Retention: A Randomized Experiment in Kolkata Slums

The low quality of health care in developing countries reduces the poor's incentives to use quality health services and their demand for health insurance. Using data from a field experiment in India, I show that randomly offering insurance policyholders a free preventive checkup with a qualified doctor has a twofold effect: receiving this additional benefit raises willingness to pay to renew health insurance by 53%, doubling the likelihood of hypothetical renewal; exposed individuals are 10 percentage points more likely to consult a qualified practitioner when ill after the checkup. Both effects are concentrated on poorer households. There is no effect on health knowledge and healthcare spending. This suggests that exposing insured households to quality preventive care can be a cost-effective way of raising the demand for quality health care and retaining policyholders in the insurance scheme. Copyright © 2016 John Wiley & Sons, Ltd.

Examining the changing health care seeking behavior in the era of health sector reforms in India: evidences from the National Sample Surveys 2004 & 2014

Background

Health policy formulations in India have witnessed a shift from a reactive approach to a more proactive approach over the last decade. It is therefore important to understand the effectiveness of recent national health policies (such as the National Rural Health Mission and the National Urban Health Mission) in addressing the varied needs of the heterogeneous population of India.

Methods

We use datasets from the National Sample Surveys carried out in 2004 and 2014 to understand the change in the health seeking behavior as a result of these policies. The choice of health care facilities and the associated expenditures are compared through descriptive analyses. A multinomial logistic regression is used to identify the significant parameters which contribute towards the share of health care providers in India. The health status of two economically disparate Indian states (Bihar and Kerala) are also compared through specific metrics of performance.

Results

It is seen that due to increased availability of facilities in close proximity, both rural and urban residents prefer to avail of those facilities which will result in minimization of transportation cost. The effectiveness of national health policies is found to vary on a regional scale. Literacy and health status have a strong correlation, thereby reinforcing that Bihar still lags far behind Kerala in terms of access to equitable health care.

Conclusion

Therefore, a hierarchical system, incorporating medical pluralism and tailor-made policies targeted at diverse health care demands, needs to be put in place to achieve Goal 3 of the Sustainable Development Goals as decreed by the United Nations, i.e., "health for all".

Biopolitical Excess: Techno-Legal Assemblage of Stem Cell Research in India

Stem cell research on cardiac patients at the All India Institute of Medical Sciences (AIIMS), which was disclosed through the media in 2005, created a storm. On the one hand, it was celebrated as a ‘global first in pioneering stem cell medicine’. On the other hand, not only the AIIMS study, but, more broadly, stem cell research and therapy in India was criticised for ‘tall claims [and] questionable ethics’. The responses of the policymakers and regulators in India were equally divergent. How are we to understand the contingency and unpredictability of the regulatory regime in India? The answers to this and other related questions are often presented through a regulatory fix—countries such as India need to tighten their regulatory regime. The need for a legally binding regulatory regime is undeniable; nevertheless, a narrow focus on a regulatory fix fails to explain several issues. In this article, I analyse the stem cell research on cardiac patients at AIIMS. Through a focus on epistemic, ethical and juridical assemblage of stem cell research, I highlight the inescapable contingency in the translation between ‘governmental rationality’ and ‘the practice of government’ and show how this reflects biopolitical excess.

Psychometric properties of the Trust in Physician Scale in Tamil Nadu, India

CONTEXT

Trust in health care is of high intrinsic value. It also leads to positive outcomes such as better treatment adherence and disclosure of sensitive information. Therefore, there is a need to measure trust in health care objectively.

AIMS

To assess the psychometric properties of the Trust in Physician Scale in Tamil Nadu, India.

SETTINGS AND DESIGN

The study was conducted in a private tertiary hospital setting in Tamil Nadu by a cross-sectional survey design.

METHODS

The Trust in Physician Scale and General Trust Scale were administered to 288 participants in the waiting area of a tertiary care hospital in Tamil Nadu.

STATISTICAL ANALYSIS

Descriptive statistics, exploratory factor analysis, and Cronbach's alpha statistics were used to assess the validity and reliability of the scale.

RESULTS

The respondents were predominantly men from rural areas, older than 35 years of age, and with lesser than 8 years of schooling. The questionnaire had acceptable internal consistency with Cronbach's alpha of 0.707 (95% confidence interval 0.654-0.755). Exploratory factor analysis divided the questionnaire into four domains. Seven items loaded into factor 1 which explained dependability and competence of the physician, two items loaded on factor 2, and one each in factors 3 and 4. The latter four items had very low item to total correlations and hence did not contribute much to the questionnaire.

CONCLUSIONS

The Trust in Physician questionnaire needs to be modified to accurately measure the domains of trust in the context of the study area. More qualitative studies are required to understand the domains of trust in this cultural and social context.

Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector?

The private for-profit sector's prominence in health-care delivery, and concern about its failures to deliver social benefit, has driven a search for interventions to improve the sector's functioning. We review evidence for the effectiveness and limitations of such private sector interventions in low-income and middle-income countries. Few robust assessments are available, but some conclusions are possible. Prohibiting the private sector is very unlikely to succeed, and regulatory approaches face persistent challenges in many low-income and middle-income countries. Attention is therefore turning to interventions that encourage private providers to improve quality and coverage (while advancing their financial interests) such as social marketing, social franchising, vouchers, and contracting. However, evidence about the effect on clinical quality, coverage, equity, and cost-effectiveness is inadequate. Other challenges concern scalability and scope, indicating the limitations of such interventions as a basis for universal health coverage, though interventions can address focused problems on a restricted scale.

Point-of-care testing in India: missed opportunities to realize the true potential of point-of-care testing programs

BACKGROUND

The core objective of any point-of-care (POC) testing program is to ensure that testing will result in an actionable management decision (e.g. referral, confirmatory test, treatment), within the same clinical encounter (e.g. POC continuum). This can but does not have to involve rapid tests. Most studies on POC testing focus on one specific test and disease in a particular healthcare setting. This paper describes the actors, technologies and practices involved in diagnosing major diseases in five Indian settings - the home, community, clinics, peripheral laboratories and hospitals. The aim was to understand how tests are used and fit into the health system and with what implications for the POC continuum.

METHODS

The paper reports on a qualitative study including 78 semi-structured interviews and 13 focus group discussions with doctors, nurses, patients, lab technicians, program officers and informal providers, conducted between January and June 2013 in rural and urban Karnataka, South India. Actors, diseases, tests and diagnostic processes were mapped for each of the five settings and analyzed with regard to whether and how POC continuums are being ensured.

RESULTS

Successful POC testing hardly occurs in any of the five settings. In hospitals and public clinics, most of the rapid tests are used in laboratories where either the single patient encounter advantage is not realized or the rapidity is compromised. Lab-based testing in a context of manpower and equipment shortages leads to delays. In smaller peripheral laboratories and private clinics with shorter turn-around-times, rapid tests are unavailable or too costly. Here providers find alternative measures to ensure the POC continuum. In the home setting, patients who can afford a test are not/do not feel empowered to use those devices.

CONCLUSION

These results show that there is much diagnostic delay that deters the POC continuum. Existing rapid tests are currently not translated into treatment decisions rapidly or are not available where they could ensure shorter turn-around times, thus undermining their full potential. To ensure the success of POC testing programs, test developers, decision-makers and funders need to account for such ground realities and overcome barriers to POC testing programs.

The case for stronger regulation of private practitioners to control tuberculosis in low- and middle-income countries

Tuberculosis case management practices of private practitioners in low- and middle-income countries are commonly not in compliance with treatment guidelines, thus increasing the risk of drug resistance. National Tuberculosis control programs have long been encouraged to collaborate with private providers to improve compliance, but there is no example yet of a sustained, large scale collaborations with private practitioners in these settings. Regulations have long been realized as a potential response to poor quality care, however there has been a lack of interest from the international actors to invest in stronger regulation of private providers in these countries due to limited evidence and many implementation challenges. Regulatory strategies have now evolved beyond the costly conventional form of command and control. These new strategies need to be tested for addressing the challenge of poor quality care among private providers. Multilateral and bilateral funding agencies committed to tuberculosis control need to invest in facilitating strengthening government’s capacity to effectively regulate private providers.

Developing hospital accreditation standards in Uganda

BACKGROUND

Whereas accreditation is widely used as a tool to improve quality of healthcare in the developed world, it is a concept not well adapted in most developing countries for a host of reasons, including insufficient incentives, insufficient training and a shortage of human and material resources. The purpose of this paper is to describe refining use and outcomes of a self-assessment hospital accreditation tool developed for a resource-limited context.

METHODS

We invited 60 stakeholders to review a set of standards (from which a self-assessment tool was developed), and subsequently refined them to include 485 standards in 7 domains. We then invited 60 hospitals to test them. A study team traveled to each of the 40 hospitals that agreed to participate providing training and debrief the self-assessment. The study was completed in 8 weeks.

RESULTS

Hospital self-assessments revealed hospitals were remarkably open to frank rating of their performance and willing to rank all 485 measures. Good performance was measured in outreach programs, availability of some types of equipment and running water, 24-h staff calls systems, clinical guidelines and waste segregation. Poor performance was measured in care for the vulnerable, staff living quarters, physician performance reviews, patient satisfaction surveys and sterilizing equipment.

CONCLUSION

We have demonstrated the feasibility of a self-assessment approach to hospital standards in low-income country setting. This low-cost approach may be used as a good precursor to establishing a national accreditation body, as indicated by the Ministry's efforts to take the next steps. Copyright © 2015 John Wiley & Sons, Ltd.

Impact of patients' healthcare payment methods on hospital discharge process: evidence from India

This study investigates the impact of patients' payment methods on hospitals' discharge process. Patients' payment methods, particularly the use of third-party payers, are documented to impact hospitals' behavior. However, evidence is still missing on how differences across payment categories affect hospital discharge, a complicated and poorly standardized process. Data are derived from a single case study carried out in 2014 at the Mazumdar Shaw Medical Center at the Narayana Health City Campus in Bangalore, India. A mixed-method approach has been adopted. First, process mapping for different payment categories was conducted using unstructured interviews with staff and on-the-floor observations. Second, linear regression analysis was applied on a sample of 1000 discharges that occurred in January 2014 to investigate the impact of patients' payment categories on discharge turnaround time. The qualitative evidence highlights substantial variation in the discharge process across payment categories. Regression analyses reveal that the sequential process used to discharge community health insurance patients results in a significantly shorter discharge turnaround time and that cash-paying patients do not experience any significantly shorter discharge duration. For hospital managers, this study provides important evidence that patient utilization of a third-party payer does not hamper hospital efficiency. This finding should also encourage policy makers and third-party payers to work towards expanding the medical insurance system, particularly in India and particularly community-based schemes. At the same time, our findings document a strong fragmentation of discharge processes, which should spur hospitals and third-party payers to cooperate in order to set standards and minimize disruptions to patient flows. Copyright © 2015 John Wiley & Sons, Ltd.

Steering healthcare service delivery: a regulatory perspective

PURPOSE

The purpose of this paper is to explore regulation in India's healthcare sector and makes recommendations needed for enhancing the healthcare service.

DESIGN/METHODOLOGY/APPROACH

The literature was reviewed to understand healthcare's regulatory context. To understand the current healthcare system, qualitative data were collected from state-level officials, public and private hospital staff. A patient survey was performed to assess service quality (QoS).

FINDINGS

Regulation plays a central role in driving healthcare QoS. India needs to strengthen market and institutional co-production based approaches for steering its healthcare in which delivery processes are complex and pose different challenges.

RESEARCH LIMITATIONS/IMPLICATIONS

This study assesses current healthcare regulation in an Indian state and presents a framework for studying and strengthening regulation. Agile regulation should be based on service delivery issues (pull approach) rather than monitoring and sanctions based regulatory environment (push approach).

PRACTICAL IMPLICATIONS

Healthcare pitfalls across the world seem to follow similar follies. India's complexity and experience is useful for emerging and developed economies.

ORIGINALITY/VALUE

The author reviewed around 70 publications and synthesised them in healthcare regulatory contexts. Patient's perception of private providers could be a key input towards steering regulation. Identifying gaps across QoS dimensions would be useful in taking corrective measures.

Development and validation of a socioculturally competent trust in physician scale for a developing country setting

Trust in physicians is the unwritten covenant between the patient and the physician that the physician will do what is in the best interest of the patient. This forms the undercurrent of all healthcare relationships. Several scales exist for assessment of trust in physicians in developed healthcare settings, but to our knowledge none of these have been developed in a developing country context.

OBJECTIVES

To develop and validate a new trust in physician scale for a developing country setting.

METHODS

Dimensions of trust in physicians, which were identified in a previous qualitative study in the same setting, were used to develop a scale. This scale was administered among 616 adults selected from urban and rural areas of Tamil Nadu, south India, using a multistage sampling cross sectional survey method. The individual items were analysed using a classical test approach as well as item response theory. Cronbach's α was calculated and the item to total correlation of each item was assessed. After testing for unidimensionality and absence of local dependence, a 2 parameter logistic Semajima's graded response model was fit and item characteristics assessed.

RESULTS

Competence, assurance of treatment, respect for the physician and loyalty to the physician were important dimensions of trust. A total of 31 items were developed using these dimensions. Of these, 22 were selected for final analysis. The Cronbach's α was 0.928. The item to total correlations were acceptable for all the 22 items. The item response analysis revealed good item characteristic curves and item information for all the items. Based on the item parameters and item information, a final 12 item scale was developed. The scale performs optimally in the low to moderate trust range.

CONCLUSIONS

The final 12 item trust in physician scale has a good construct validity and internal consistency.

What do they do? Interactions between village doctors and medical representatives in Chakaria, Bangladesh

BACKGROUND

Informally trained village doctors supply the majority of healthcare services to the rural poor in many developing countries. This study describes the demographic and socio-economic differences between medical representatives (MRs) and village doctors in rural Bangladesh, and explores the nature of their interactions.

METHODS

This study was conducted in Chakaria, a rural sub-district of Bangladesh. Focus group discussions and in-depth interviews were conducted, along with a quantitative survey to understand practice perceptions. Data analysis was performed using grounded theory and bivariate statistical tests.

RESULTS

We surveyed 43 MRs and 83 village doctors through 22 focus group discussions and 33 in-depth interviews. MRs have a higher average per capita monthly expenditure compared to village doctors. MRs are better educated with 98% having bachelor's degrees whereas 84% of village doctors have twelfth grade education or less (p<0.001). MRs are the principal information source about new medications for the village doctors. Furthermore, incentives offered by MRs and credit availability influence the prescription practices of village doctors.

CONCLUSIONS

MRs being the key player in providing information about drugs to village doctors might influence their prescription practices. Improvements in the quality of healthcare delivered to the rural poor in informal provider-based health markets require stricter regulations and educational initiatives for providers and MRs.

Governing stem cell therapy in India: regulatory vacuum or jurisdictional ambiguity?

Stem cell treatments are being offered in Indian clinics although preclinical evidence of their efficacy and safety is lacking. This is attributed to a governance vacuum created by the lack of legally binding research guidelines. By contrast, this paper highlights jurisdictional ambiguities arising from trying to regulate stem cell therapy under the auspices of research guidelines when treatments are offered in a private market disconnected from clinical trials. While statutory laws have been strengthened in 2014, prospects for their implementation remain weak, given embedded challenges of putting healthcare laws and professional codes into practice. Finally, attending to the capacities of consumer law and civil society activism to remedy the problem of unregulated treatments, the paper finds that the very definition of a governance vacuum needs to be reframed to clarify whose rights to health care are threatened by the proliferation of commercial treatments and individualized negligence-based remedies for grievances.

Regulating healthcare complaints: a literature review

Purpose

– The purpose of this paper is to explore approaches to the regulation of healthcare complaints and disciplinary processes.

Design/methodology/approach

– A literature review was conducted across Medline, Sociological Abstracts, Web of Science, Google Scholar and the health, law and social sciences collections of Informit, using terms tapping both the complaints process and regulation generally.

Findings

– A total of 118 papers dealing with regulation of health complaints or disciplinary proceedings were located. The review reveals a shift away from self-regulation towards greater external oversight, including innovative regulatory approaches including “networked governance” and flexible or “responsive” regulation. It reports growing interest in adoption of strategic and responsive approaches to health complaints governance, by rejecting traditional legal forms in favor of more strategic and responsive forms, taking account of the complexity of adverse health events by tailoring responses to individual circumstances of complainants and their local environments.

Originality/value

– The challenge of how to collect and harness complaints data to improve the quality of healthcare at a systemic level warrants further research. Scope also exists for researching health complaints commissions and other “meta-regulatory” bodies to explore how to make these processes fairer and better able to meet the complex needs of complainants, health professionals, health services and society.

Rethinking eye health systems to achieve universal coverage: the role of research

Achieving universal coverage in eye care remains a tremendous challenge as 226 million people in the world remain visually impaired, the majority from avoidable causes. The impact of eye care interventions has been constrained by the limited capacities of health systems in low-income and middle-income countries to deliver effective eye care services. Services for eye health are still not adequately integrated into the health systems of low-income and middle-income countries. We contend that radical rethinking and deeper development of eye health systems are necessary to achieve VISION 2020 goals. Responding to the challenges of chronic eye diseases will require systems thinking, analysis and action, based on evidence from health systems research.

Innovation in regulation of rapidly changing health markets

The rapid evolution and spread of health markets across low and middle-income countries (LMICs) has contributed to a significant increase in the availability of health-related goods and services around the world. The support institutions needed to regulate these markets have lagged behind, with regulatory systems that are weak and under-resourced. This paper explores the key issues associated with regulation of health markets in LMICs, and the different goals of regulation, namely quality and safety of care, value for money, social agreement over fair access and financing, and accountability. Licensing, price controls, and other traditional approaches to the regulation of markets for health products and services have played an important role, but they have been of questionable effectiveness in ensuring safety and efficacy at the point of the user in LMICs. The paper proposes a health market systems conceptual framework, using the value chain for the production, distribution and retail of health goods and services, to examine regulation of health markets in the LMIC context. We conclude by exploring the changing context going forwards, laying out implications for future heath market regulation. We argue that the case for new approaches to the regulation of markets for health products and services in LMICs is compelling. Although traditional "command and control" approaches will have a place in the toolkit of regulators, a broader bundle of approaches is needed that is adapted to the national and market-level context of particular LMICs. The implication is that it is not possible to apply standard or single interventions across countries, as approaches proven to work well in one context will not necessarily work well elsewhere.

What explains regulatory failure? Analysing the architecture of health care regulation in two Indian states

Regulating health care is a pre-eminent policy challenge in many low- and middle-income countries (LMIC), particularly those with a strong private health sector. Yet, the regulatory approaches instituted in these countries have often been reported to be ineffective-India being exemplary. There is limited empirical research on the architecture and processes of health care regulation in LMIC that would explain these regulatory failures. We undertook a research study in two Indian states, with the aims of (1) mapping the organizations engaged with, and the written policies focused on health care regulation, (2) identifying gaps in the design and implementation of policies for health care regulation and (3) investigating underlying reasons for the identified gaps. We adopted a stepped research approach and applied a framework of basic regulatory functions for health care, to assess prevailing gaps in policy design and implementation. Qualitative research methods were employed including in-depth interviews with 32 representatives of regulatory organizations and document review. Several gaps in policy design were observed across both states, with a number of basic regulatory functions not underwritten in law, nor assigned to a regulatory organization to enact. In some instances the contents of regulatory policies had been weakened or diluted, rendering them less effective. Implementation gaps were also extensively reported in both states. Regulatory gaps were underpinned by human resource constraints, ambivalence in the roles of regulatory organizations, ineffective co-ordination between regulatory groups and extensive contestation of regulatory policies by private stakeholders. The findings are instructive that prevailing arrangements for health care regulation are ill equipped to enact several basic functions, and further that the performance of regulatory organizations is subject to pressures and distortions similar to those characterizing the wider health system. This suggests that attempts to strengthen health care regulation will be ineffectual unless underlying governance failures are addressed.

Maternal Health and Care in India: Why a Major Public Health Strategy Is Essential

India has large inequalities in maternal health and high maternal mortality and morbidity rates. A social model of maternal health was used as a framework for a broad review of online published literature to appraise the approaches used by India to address these issues and to examine the potential for reducing the country’s maternal health inequalities.

The review found the following:

• An apparent lack of coordinated economic, social, and health strategy and policies focused on improving maternal health

• No acknowledgment in national health policy of the limitations of the medical model of maternal health and little apparent mention of the social model

• No evident national frameworks for quality assurance in maternity care

• Lack of recognition of the importance of woman-centered care

• No evident comprehensive maternal health needs assessment to underpin coordinated multisector working

• An apparent lack of reliable national data collection for setting inequality targets and monitoring progress

• No apparent performance-focused management system for improving maternity care nationally.

Although India has made large increases in maternal health care provision over recent decades, a pragmatic review of government policies, the reports of international agencies, and the findings of published research studies indicate that major barriers exist to reducing maternal health inequalities and to achieving good quality care for disadvantaged women. The main barrier appears to be the widespread use at all levels, including government, of the medical model of maternal health, which focuses mostly on obstetric interventions and fails to address the wider economic and social determinants of maternal health or to use a woman-centered approach to maternity care.

We recommend that Indian governments adopt instead a “social model” approach to maternal health improvement and urgently employ a public health strategy led by a national multisector task force to reduce inequalities in maternal health.

By 'default or design'? The expansion of the private health care sector in Madhya Pradesh, India

OBJECTIVE

Despite an extensive tiered public healthcare system, India has one of the most privatized healthcare systems in world. There is no evidence suggesting that this privatization at anytime has been deliberate. So what has contributed to the private healthcare sector becoming so dominant in the setting?

METHODS

We explore possible reasons for the rapid expansion of the private sector through in depth interviews with policy makers in the public and private sectors in Madhya Pradesh province, Central India. Interviews were analyzed using qualitative content analysis.

RESULTS AND CONCLUSIONS

Public and private sector respondents concurred that the expansion of private sector had occurred by default; a passive privatization resulting from an underfunded and underperforming public health sector. Regulation by the public sector has lagged behind the development of a popular private healthcare market. Professional self-regulation functioned poorly, with professional bodies reported as being opportunistic. The private sector is fractured and heterogeneous making it more difficult to regulate. Further, the state has focused on regulating its own public sector, little attention has been paid to the expanding private sector. Income and career opportunities for qualified healthcare professionals are attractive in the private sector. India needs to invest more in the public health system, develop ways of reducing out of pocket expenses through integration of, regulation of and partnerships with segments of the private health sector.

Building institutions for an effective health system: lessons from China's experience with rural health reform

This paper is concerned with the management of health system changes aimed at substantially increasing the access to safe and effective health services. It argues that an effective health sector relies on trust-based relationships between users, providers and funders of health services, and that one of the major challenges governments face is to construct institutional arrangements within which these relationships can be embedded. It presents the case of China, which is implementing an ambitious health reform, drawing on a series of visits to rural counties by the author over a 10-year period. It illustrates how the development of reform strategies has been a response both to the challenges arising from the transition to a market economy and the result of actions by different actors, which have led to the gradual creation of increasingly complex institutions. The overall direction of change has been strongly influenced by the efforts made by the political leadership to manage a transition to a modern economy which provides at least some basic benefits to all. The paper concludes that the key lessons for other countries from China's experience with health system reform are less about the detailed design of specific interventions than about its approach to the management of institution-building in a context of complexity and rapid change.

Financing health care for all: challenges and opportunities

India's health financing system is a cause of and an exacerbating factor in the challenges of health inequity, inadequate availability and reach, unequal access, and poor-quality and costly health-care services. Low per person spending on health and insufficient public expenditure result in one of the highest proportions of private out-of-pocket expenses in the world. Citizens receive low value for money in the public and the private sectors. Financial protection against medical expenditures is far from universal with only 10% of the population having medical insurance. The Government of India has made a commitment to increase public spending on health from less than 1% to 3% of the gross domestic product during the next few years. Increased public funding combined with flexibility of financial transfers from centre to state can greatly improve the performance of state-operated public systems. Enhanced public spending can be used to introduce universal medical insurance that can help to substantially reduce the burden of private out-of-pocket expenditures on health. Increased public spending can also contribute to quality assurance in the public and private sectors through effective regulation and oversight. In addition to an increase in public expenditures on health, the Government of India will, however, need to introduce specific methods to contain costs, improve the efficiency of spending, increase accountability, and monitor the effect of expenditures on health.

Health care and equity in India

In India, despite improvements in access to health care, inequalities are related to socioeconomic status, geography, and gender, and are compounded by high out-of-pocket expenditures, with more than three-quarters of the increasing financial burden of health care being met by households. Health-care expenditures exacerbate poverty, with about 39 million additional people falling into poverty every year as a result of such expenditures. We identify key challenges for the achievement of equity in service provision, and equity in financing and financial risk protection in India. These challenges include an imbalance in resource allocation, inadequate physical access to high-quality health services and human resources for health, high out-of-pocket health expenditures, inflation in health spending, and behavioural factors that affect the demand for appropriate health care. Use of equity metrics in monitoring, assessment, and strategic planning; investment in development of a rigorous knowledge base of health-systems research; development of a refined equity-focused process of deliberative decision making in health reform; and redefinition of the specific responsibilities and accountabilities of key actors are needed to try to achieve equity in health care in India. The implementation of these principles with strengthened public health and primary-care services will help to ensure a more equitable health care for India's population.

Good governance and corruption in the health sector: lessons from the Karnataka experience

Strengthening good governance and preventing corruption in health care are universal challenges. The Karnataka Lokayukta (KLA), a public complaints agency in Karnataka state (India), was created in 1986 but played a prominent role controlling systemic corruption only after a change of leadership in 2001 with a new Lokayukta (ombudsman) and Vigilance Director for Health (VDH). This case study of the KLA (2001-06) analysed the:Scope and level of poor governance in the health sector; KLA objectives and its strategy; Factors which affected public health sector governance and the operation of the KLA. We used a participatory and opportunistic evaluation design, examined documents about KLA activities, conducted three site visits, two key informant and 44 semi-structured interviews and used a force field model to analyse the governance findings. The Lokayukta and his VDH were both proactive and economically independent with an extended social network, technical expertise in both jurisdiction and health care, and were widely perceived to be acting for the common good. They mobilized media and the public about governance issues which were affected by factors at the individual, organizational and societal levels. Their investigations revealed systemic corruption within the public health sector at all levels as well as in public/private collaborations and the political and justice systems. However, wider contextual issues limited their effectiveness in intervening. The departure of the Lokayukta, upon completing his term, was due to a lack of continued political support for controlling corruption. Governance in the health sector is affected by positive and negative forces. A key positive factor was the combined social, cultural and symbolic capital of the two leaders which empowered them to challenge corrupt behaviour and promote good governance. Although change was possible, it was precarious and requires continuous political support to be sustained.

Job satisfaction and motivation of health workers in public and private sectors: cross-sectional analysis from two Indian states

BACKGROUND

Ensuring health worker job satisfaction and motivation are important if health workers are to be retained and effectively deliver health services in many developing countries, whether they work in the public or private sector. The objectives of the paper are to identify important aspects of health worker satisfaction and motivation in two Indian states working in public and private sectors.

METHODS

Cross-sectional surveys of 1916 public and private sector health workers in Andhra Pradesh and Uttar Pradesh, India, were conducted using a standardized instrument to identify health workers' satisfaction with key work factors related to motivation. Ratings were compared with how important health workers consider these factors.

RESULTS

There was high variability in the ratings for areas of satisfaction and motivation across the different practice settings, but there were also commonalities. Four groups of factors were identified, with those relating to job content and work environment viewed as the most important characteristics of the ideal job, and rated higher than a good income. In both states, public sector health workers rated "good employment benefits" as significantly more important than private sector workers, as well as a "superior who recognizes work". There were large differences in whether these factors were considered present on the job, particularly between public and private sector health workers in Uttar Pradesh, where the public sector fared consistently lower (P < 0.01). Discordance between what motivational factors health workers considered important and their perceptions of actual presence of these factors were also highest in Uttar Pradesh in the public sector, where all 17 items had greater discordance for public sector workers than for workers in the private sector (P < 0.001).

CONCLUSION

There are common areas of health worker motivation that should be considered by managers and policy makers, particularly the importance of non-financial motivators such as working environment and skill development opportunities. But managers also need to focus on the importance of locally assessing conditions and managing incentives to ensure health workers are motivated in their work.

'By papers and pens, you can only do so much': views about accountability and human resource management from Indian government health administrators and workers

Although accountability drives in the Indian health sector sporadically highlight egregious behaviour of individual health providers, accountability needs to be understood more broadly. From a managerial perspective, while accountability functions as a control mechanism that involves reviews and sanctions, it also has a constructive side that encourages learning from errors and discretion to support innovation. This points to social relationships: how formal rules and hierarchies combine with informal norms and processes and more fundamentally how power relations are negotiated. Drawing from this conceptual background and based on qualitative research, this article analyses the views of government primary health care administrators and workers from Koppal district, northern Karnataka, India. In particular, the article details how these actors view two management functions concerned with internal accountability: supervision and disciplinary action. A number of disjunctures are revealed. Although extensive information systems exist, they do not guide responsiveness or planning. While supportive supervision efforts are acknowledged and practiced, implicit quid-pro-quo bargains that justify poor service delivery performance are more prevalent. Despite the enactment of numerous disciplinary measures, little discipline is observed. These disjunctures reflect nuanced and layered relationships between health administrators and workers, as well as how power is negotiated through corruption and elected representatives within the broader political economy context of health systems in northern Karnataka, India. These various dimensions of accountability need to be addressed if it is to be used more equitably and effectively.

Knowledge, legitimacy and economic practice in informal markets for medicine: a critical review of research

Current debates and market based interventions in international public health seek to bring about explicit improvements in the quality of care offered by informal providers. In this paper we examine how informal providers are framed as problematic and question assumptions about what constitutes appropriate knowledge and expectations of how economic actors in the medical marketplace will behave. We argue that existing portraits of informal providers tend to establish clear cut distinctions between different kinds of practitioner; 'dis-embed' biomedical transactions from the broader relationships within which they take place; freeze or anatomise what are dynamic economic relationships between stakeholders, and obscure or ignore the position of informal providers in a global pharmaceutical supply chain.

Regulating health care markets in China and India

Health care markets in China and India have expanded rapidly. The regulatory response has lagged behind in both countries and has followed a different pathway in each. Using the examples of front-line health providers and health insurance, this paper discusses how their different approaches have emerged from their own historical and political contexts and have led to different ways to address the main regulatory questions concerning quality of care, value for money, social agreement, and accountability. In both countries, the challenge is to build trust-based institutions that rely less on state-dominated approaches to regulation and involve other key actors.

Framework for assessing governance of the health system in developing countries: gateway to good governance

Governance is thought to be a key determinant of economic growth, social advancement and overall development, as well as for the attainment of the MDGs in low- and middle-income countries. Governance of the health system is the least well-understood aspect of health systems. A framework for assessing health system governance (HSG) at national and sub-national levels is presented, which has been applied in countries of the Eastern Mediterranean. In developing the HSG framework key issues considered included the role of the state vs. the market; role of the ministries of health vs. other state ministries; role of actors in governance; static vs. dynamic health systems; and health reform vs. human rights-based approach to health. Four existing frameworks were considered: World Health Organization's (WHO) domains of stewardship; Pan American Health Organization's (PAHO) essential public health functions; World Bank's six basic aspects of governance; and United Nations Development Programme (UNDP) principles of good governance. The proposed HSG assessment framework includes the following 10 principles-strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness, equity and inclusiveness, effectiveness and efficiency, accountability, intelligence and information, and ethics. The framework permits 'diagnoses of the ills' in HSG at the policy and operational levels and points to interventions for its improvement. In the case of Pakistan, where the framework was applied, a positive aspect was the growing participation and consensus orientation among stakeholders, while weaknesses were identified in relation to strategic vision, accountability, transparency, effectiveness and efficiency and rule of law. In using the HSG framework it needs to be recognized that the principles are value driven and not normative and are to be seen in the social and political context; and the framework relies on a qualitative approach and does not follow a scoring or ranking system. It does not directly address aid effectiveness but provides insight on the ability to utilize external resources and has the ability to include the effect of global health governance on national HSG as the subject itself gets better crystallized. The improved performance of the ministries of health and state health departments is at the heart of this framework. The framework helps raise the level of awareness among policymakers of the importance of HSG. The road to good governance in health is long and uneven. Assessing HSG is only the first step; the challenge that remains is to carry out effective governance in vastly different institutional contexts.

Poverty and access to health care in developing countries

People in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services. This article documents disparities in access to health services in low- and middle-income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Whereas the poor in LMICs are consistently at a disadvantage in each of the dimensions of access and their determinants, this need not be the case. Many different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation, and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor.