Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: A study of policy barriers and opportunities in Cambodia

Classification and focus comparison of health financing frameworks: A scoping review

OBJECTIVE

The purpose of this study is to review the current frameworks for understanding and assessing health financing and draw out the dimensions of conceptual frameworks.

METHODS

This scoping review was conducted using the five stages of Arksey and O'Malley's framework. We reviewed all published peer-reviewed literature indexed in PubMed, SCOPUS, and Embase from 2000 up to 2021 for inclusion.

RESULTS

We identified 21 frameworks developed to assess financing in the health system. We classified frameworks by grouping them into: frameworks focusing on health financing as a constituent of health system and frameworks focusing on health financing only. We classified health financing frameworks further into three main groups according to the general commonalities among them. These three groups are as follows: (1) frameworks providing general recommendations for improving health financing system regardless of sources of financing, (2) frameworks focusing on improving the performance of health insurance schemes, and (3) frameworks focusing on managing public health financing.

CONCLUSION

Despite being diverse, various health financing frameworks offer synergistic views to the health financing system and provide a comprehensive picture of the health financing system. These frameworks can help policy makers decide which framework is more appropriate to start with based on their local contextual features and the changes they are going to bring about in their health financing system.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

The sustainability of premium payment of national health insurance's self-enrolled members in Jakarta Greater Area

Background: The sustainability of the National Health Insurance (NHI) program heavily relies on the premium of its member. The negligence of a large number of members at pay the premium lead to the failure of the Social Security Agency for Health (SSAH) to deliver its services. This study aims at analyzing important factors that influence the sustainability of premium payment of NHI’s self-enrolled members in the Jakarta Greater Area.

Design and methods: This study performed an econometric analysis from the panel and the same respondent’s data in 2015 and 2017. The population of the study was NHI’s self-enrolled members who lived in the City of Jakarta, Bogor, Depok, Tangerang, Bekasi, (Jakarta Greater Area) and it represents the urban area of Indonesia. The ordinal logistic regression model was used to determine the type of sustainability NHI premium payment.

Results: The survey shows that around 28.3% of self-enrolled members do not pay the NHI insurance premium regularly. Applying ordered logit this study statistically confirms that age of household head, income per month, never experience economic hardship, 1^st/2^nd class registration, and benefits of SSAH are positively correlated with compliance rate to pay NHI insurance premium. Whereas tobacco consumption, health-seeking behavior, and the 2016 increase of premium are negatively correlated with regular premium payment.

Conclusions: This study calls for policy intervention to improve compliance of premium payment such as i) massive promotion of insurance literacy and benefits of insurance through a health professional, internet, and government officer; ii) expanding auto-debit and installment premium payment; iii) incentive for paying premium regularly and not smoking; and iv) improving access and quality of health services.

Health equity funds as the pathway to universal coverage in Cambodia: care seeking and financial risk protection

Cambodia has developed the health equity fund (HEF) system to improve access to health services for the poor, and this strengthens the health system towards the universal health coverage goal. Given rising healthcare costs, Cambodia has introduced several innovations and accomplished considerable progress in improving access to health services and catastrophic health expenditures for the targeted population groups. Though this is improving in recent years, HEF households remain at the higher risk of catastrophic spending as measured by the higher share of HEF households with catastrophic health expenses being at 6.9% compared to the non-HEF households of 5.5% in 2017. Poverty targeting poses another challenge for the health system. Nevertheless, HEF appeared to be more significantly associated with decreased out-of-pocket expenditure per illness among those who sought care from public providers. Increasing population and cost coverages of the HEF and effectively attracting beneficiaries to the public sector will further enhance the financial protection and pave the pathway towards universal coverage. Our recommendations focus on leveraging the HEF experience for expanding coverage and increasing equitable access, as well as strengthening the quality of healthcare services.

The implementation of pharmaceutical services in public hospitals in Mexico: an analysis of the legal framework and organizational practice

BACKGROUND

The implementation of pharmaceutical services in hospitals contributes to the appropriate use of medicines and patient safety. However, the relationship of implementation with the legal framework and organizational practice has not been studied in depth. The objective of this research is to determine the role of these two factors (the legal framework and organizational practice) in the implementation of pharmaceutical services in public hospitals of the Ministry of Health of Mexico.

METHODS

Semi-structured interviews were conducted with four groups of actors involved. The analysis focused on the legal framework, defined as the rules, laws and regulations, and on organizational practice, defined as the implementation of the legal framework by related individuals, that is, how they put it into practice.

RESULTS

The main problems identified were the lack of alignment between the rules and the incentives for compliance. Decision-makers identified the lack of managerial capacity in hospitals as the main implementation barrier, while hospital pharmacists pointed to poor regulation and the lack of clarity of the legal framework as the problems to consider.

CONCLUSIONS

Although the legal framework related to hospital pharmaceutical services in Mexico is inadequate, organizational factors (such as adequate skills of professional pharmacists and the support of the hospital director) have facilitated gradual implementation. To improve implementation, priority should be given to evaluation and modification of the current legislation along with the development of an official minimum standard for activities and services in hospital pharmacies.

Why Do Informal Sector Workers Not Pay the Premium Regularly? Evidence from the National Health Insurance System in Indonesia

BACKGROUND

The challenges of universal health coverage (UHC) in developing countries with a significant proportion of the labor force that works in the informal sector include administrative difficulties in recruiting, registering and collecting regular contributions in a cost-effective way. As most developing countries have a limited fiscal space to support the program in the long run, the fiscal sustainability of UHC, such as that in Indonesia, relies heavily on the contributions of its members. The failure of a large proportion of voluntary enrollees/self-enrolled members/informal sector workers (Peserta Mandiri/Pekerja Bukan Penerima Upah [PBPU] members) to pay their premiums may lead to the National Health Insurance System (NHIS) in Indonesia being unable to effectively deliver its services.

OBJECTIVE

This study aims at exploring the important factors that affect the compliance behavior of informal sector workers (PBPU members) in regularly paying their insurance premium. This analysis may be a basis for designing effective measures to encourage payment sustainability in informal sector workers in the NHIS.

METHOD

This study utilizes the survey data collected from three regional offices of the Indonesian Social Security Agency for Health (SSAH), which cover approximately 1210 PBPU members, to understand the relationship between members' characteristics and their compliance behavior regarding the premium payment. We applied an econometric analysis of a logit regression to statistically estimate which factors most affect their compliance behavior in paying the insurance premium.

RESULTS

This study reveals that almost 28% of PBPU members do not pay their insurance premiums in a sustainable way. Our logistic regression statistically confirms that the number of household members, financial hardship, membership in other social protection arrangements, and the utilization of health services are negatively correlated with the compliance rate of informal sector workers in paying their insurance premium. For instance, people who experience financial hardship tend to have a 7.7 percentage point lower probability of routinely paying the premium. In contrast, households that work in agricultural sectors and have income stability, the cost of inpatient care incurred before joining the NHIS, a comprehensive knowledge of the SSAH's services, and the availability of health professionals are all positively correlated with regular premium payment.

CONCLUSION

Although there is no single policy that can ensure that informal sector workers (PBPU members) regularly pay their premiums, this study recommends some policy interventions, including (1) flexibility in applying for a government subsidy for premiums (Penerima Bantuan Iuran [PBI]), especially for people who have financial hardship; (2) an intensive promotion of insurance literacy; (3) expanding the quantity and quality of healthcare services; and (4) tailor-made policies for ensuring the sustainability of premium payments for each regional division.

Patient narratives of illnesses requiring abdominal surgery in Cambodia: Heroic/stoic, and dealing with 'the ball of meat'

This study describes the illness narratives that inform treatment-seeking behaviours for acute abdominal conditions in Cambodia, and thereby explores factors impeding the timely delivery of surgical intervention. Semi-structured qualitative interviews were undertaken with patients who had undergone abdominal surgery at Siem Reap Provincial Hospital between 2011 and 2014. Interviews collected basic demographic information and also patient narratives based on Groleau's McGill Illness Narrative Interview (MINI). Interviews were contemporaneously translated from Khmer to English and recorded for transcription. A content analysis of interview transcripts based on narrative enquiry was undertaken. Ninety-seven patients participated in the study and five themes emerged from the data. These were: Explanatory models about the causes of abdominal pain and effects of surgery; Pre-surgery stoicism and illness management; Fear of poor outcomes and death; Burden of treatment costs and anticipated recovery time; and, Enhancing community trust in surgery. Our findings add the patient voice to the limited evidence about access to surgery, and socio-cultural and financial barriers affecting treatment-seeking behaviours in Cambodia. By understanding the collective narratives surrounding experiences of abdominal surgery, efforts to improve surgical services in Cambodia may be better informed of the reasons patients delay treatment.

The making of evidence-informed health policy in Cambodia: knowledge, institutions and processes

Introduction

In global health discussions, there have been widespread calls for health policy and programme implementation to be informed by the best available evidence. However, recommendations in the literature on knowledge translation are often decontextualised, with little attention to the local systems of institutions, structures and practices which can direct the production of evidence and shape whether or how it informs health decisions. This article explores these issues in the country setting of Cambodia, where the Ministry of Health has explicitly championed the language of evidence-based approaches to policy and planning.

Methods

Research for this paper combined multiple sources and material, including in-depth interviews with key informants in Phnom Penh and the analysis of documentary material and publications. Data collection and analysis focused on two key domains in evidence advisory systems: domestic capacities to generate health policy-relevant evidence and institutional mechanisms to monitor, evaluate and incorporate evidence in the policy process.

Results

We identified a number of structural arrangements that may increasingly work to facilitate the supply of health-related data and information, and their use to inform policy and planning. However, other trends and features appear to be more problematic, including gaps between research and public health priorities in the country, the fragmented nature of research activities and information systems, the lack of a national policy to support and guide the production and use of evidence for health policy, and challenges to the use of evidence for intersectoral policy-making.

Conclusions

In Cambodia, as in other low/middle-income countries, continued investments to increase the supply and quality of health data and information are needed, but greater attention should be paid to the enabling institutional environment to ensure relevance of health research products and effective knowledge management.

Factors determining the use of social support services among elderly people living in a city environment in Poland

Ageing populations entail important social issues. The population of Lodz is characterised by the highest ageing ratio in Poland (17.2% people aged 65 or above). The aim of our study was to present factors determining the use of social support services in the subpopulation of elderly people in a city environment. The study, conducted between 2011 and 2012 with the use of a survey questionnaire, included 466 respondents aged 65 or older, who were looked after by the Municipal Social Welfare Centre, Lodz-Polesie. The response rate was 93.2%. Most beneficiaries were women (77.9%). The respondents were mostly widows (73.9% of women) or widowers (43.7% of men). Most respondents applied for nursing services (79.7%), while 28.3% asked for financial help. In Lodz as a whole, these percentages were 81.0% and 19.0%. A chronic disease was the most common cause of the application for help (73.4%). In 4.1% of applicants, the cause was a low income per capita. Multivariate logistic regression analysis indicated that the variables which contributed to receiving financial support included being a man, aged 65-69 years, being single and receiving a monthly salary per capita below 500.0 PLN (Polish New Zlotys). The variables which contributed to receiving social care service in the form of nursing services included being a woman, aged 85 years or older, receiving a monthly salary per capita between 1001.0 and 1500.0 PLN, suffering from a chronic disease, which was a reason for applying for social support service, a result on the Activities of Daily Living scale confirming disability and a very negative self-evaluation of health. The results of the study have shown that the poor health condition of elderly people is the most frequent reason for applying for social services. Identifying reasons for applying for social care by elderly people might facilitate the introduction of workable solutions in the social and healthcare policy.

Subsidized health insurance coverage of people in the informal sector and vulnerable population groups: trends in institutional design in Asia

BACKGROUND

Many low- and middle-income countries with a social health insurance system face challenges on their road towards universal health coverage (UHC), especially for people in the informal sector and vulnerable population groups or the informally employed. One way to address this is to subsidize their contributions through general government revenue transfers to the health insurance fund. This paper provides an overview of such health financing arrangements in Asian low- and middle-income countries. The purpose is to assess the institutional design features of government subsidized health insurance type arrangements for vulnerable and informally employed population groups and to explore how these features contribute to UHC progress.

METHODS

This regional study is based on a literature search to collect country information on the specific institutional design features of such subsidization arrangements and data related to UHC progress indicators, i.e. population coverage, financial protection and access to care. The institutional design analysis focuses on eligibility rules, targeting and enrolment procedures; financing arrangements; the pooling architecture; and benefit entitlements.

RESULTS

Such financing arrangements currently exist in 8 countries with a total of 14 subsidization schemes. The most frequent groups covered are the poor, older persons and children. Membership in these arrangements is mostly mandatory as is full subsidization. An integrated pool for both the subsidized and the contributors exists in half of the countries, which is one of the most decisive features for equitable access and financial protection. Nonetheless, in most schemes, utilization rates of the subsidized are higher compared to the uninsured, but still lower compared to insured formal sector employees. Total population coverage rates, as well as a higher share of the subsidized in the total insured population are related with broader eligibility criteria.

CONCLUSIONS

Overall, government subsidized health insurance type arrangements can be effective mechanism to help countries progress towards UHC, yet there is potential to improve on institutional design features as well as implementation.