Universal health coverage: breakthrough or great white elephant?

Buprenorphine deregulation as an opioid crisis policy response - A comparative analysis between France and the United States

BACKGROUND

In passing the Maintstreaming Addiction Treatment Act, the United States has abolished its federal X waiver, considered a major barrier to the wider buprenorphine prescribing needed to respond to opioid-related harms. Advocates for this policy have drawn on the French response of deregulating buprenorphine prescribing to address increasing overdose mortality around the turn of the millennium. So far, such policy advocacy has incompletely accounted for contextual and health system differences between the two countries.

METHODS

Using the health system dynamics framework, this analysis compares France from 1995 to 2003 (the relevant period of buprenorphine reform) to the US from 2018 until today (the comparison period to explore potential impacts of reform). We used it to guide examination of a) contextual issues relating to opioid use epidemiology and b) health system factors including prescriber supply, sector organization, and insurance coverage for primary care to draw relevant policy learning for the contemporary US.

RESULTS

We identified that the US had a 22.5-fold higher mortality rate and a 2.3-fold higher opioid use disorder (OUD) rate compared to France, despite having rates of prescribed buprenorphine per-capita higher than, and per-person with OUD comparable to, than that of France. These wide gulfs between the scales and nature of the problems between France and the US suggest that relaxing restrictions on buprenorphine prescribing through abolishing the X waiver will be insufficient for achieving hoped-for reductions in overdose mortality.

CONCLUSION

Health system strengthening with a focus on improvements in primary care prescriber supply, coverage, and coordination are likely higher yield policy complements to relaxing buprenorphine regulation. Such an approach would better prepare the US to adapt to ongoing dynamics and uncertainties in the opioid crisis and to optimize the already relatively high levels of buprenorphine prescribing.

The "No bed syndrome" in Ghana - what, how and why? A literature, electronic and print media review

Objectives

"No bed syndrome" has become a familiar phrase in Ghana. Yet, there is very little in medical texts or the peer reviewed literature about it. This review aimed to document what the phrase means in the Ghanaian context, how and why it occurs, and potential solutions.

Design

A qualitative desk review using a thematic synthesis of grey and published literature, print and electronic media content covering the period January 2014 to February 2021. Text was coded line by line to identify themes and sub-themes related to the research questions. Analysis was manual and with Microsoft Excel to sort themes.

Setting

Ghana.

Participants and Intervention

Not applicable.

Results

"No bed syndrome" describes the turning away by hospitals and clinics of people seeking walk in or referral emergency care with the stated reasons "no bed available" or "all beds are full". There are reported cases of people dying while going round multiple hospitals seeking help and being repeatedly turned away because there is "no bed". The situation appears to be most acute in the highly urbanized and densely populated Greater Accra region. It is driven by a complex of factors related to context, health system functions, values, and priorities. The solutions that have been tried are fragmented rather than well-coordinated whole system reform.

Discussions and recommendations

The "no bed syndrome" describes the challenge of a poorly functioning emergency health care system rather than just the absence of a bed on which to place an emergency case. Many low and middle income countries have similar challenges with their emergency health care systems and this analysis from Ghana is potentially valuable in attracting global attention and thinking about emergency health systems capacity and reform in low and middle income countries. The solution to the "no bed syndrome" in Ghana requires reform of Ghana's emergency healthcare system that takes a whole system and integrated approach. All the components of the health system such as human resource, information systems, financing, equipment tools and supplies, management and leadership need to be examined and addressed together alongside health system values such as accountability, equity or fairness in the formulation, implementation, continuous monitoring and evaluation of policies and programs for system reform to expand and strengthen emergency healthcare system capacity and responsiveness. Despite the temptation to fall back on them as low hanging fruit, piecemeal and ad-hoc solutions cannot solve the problem.

Health Coverage and Financial Protection in Uganda: A Political Economy Perspective

BACKGROUND

As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition.

METHODS

The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector.

RESULTS

We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship.

CONCLUSION

By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

Power analysis in health policy and systems research: a guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

How has sustainable development goals declaration influenced health financing reforms for universal health coverage at the country level? A scoping review of literature

BACKGROUND

Achieving universal health coverage (UHC) requires health financing reforms (HFR) in many of the countries. HFR are inherently political. The sustainable development goals (SDG) declaration provides a global political commitment context that can influence HFR for UHC at national level. However, how the declaration has influenced HFR discourse at the national level and how ministries of health and other stakeholders are using the declaration to influence reforms towards UHC have not been explored. This review was conducted to provide information and lessons on how SDG declaration can influence health financing reforms for UHC based on countries experiences.

METHODS

We conducted a rapid review of literature and followed the preferred reporting items for systematic review and meta-analysis (PRISMA) guideline. We conducted a comprehensive electronic search on Ovid Medline, PubMed, EBSCO, Scopus, Web of Science. In searching the electronic databases, we combined various conceptual terms for "sustainable development goals" and "health financing" using Boolean operators. In addition, we conducted manual searched using google scholar.

RESULTS

Twelve articles satisfied our eligibility criteria. The included articles were analyzed thematically, and the results presented narratively. The SDG declaration has provided an enabling environment for putting in place necessary legislations, reforming health financing organization, and revisions of national health polices to align to the country's commitment on UHC. However, there is limited information on the process; how health ministries and other stakeholders have used SDG declaration to advocate, lobby, and engage various constituencies to support HFR for UHC.

CONCLUSION

The SDG declaration can be a catalyst for health financing reform, providing reference for necessary legislations and policies for financing UHC. However, to facilitate better cross-country learning on how SDG declaration catalyzes HFR for UHC there, is need to examine the processes of how stakeholders have used the declaration as window of opportunity to accelerate reforms.

Variation in financial protection and it association with health expenditure indicators: an analysis of low- and middle-income countries

BACKGROUND

An insight into variation in financial protection among countries and the underpinning factors associated with the variations observed will help to inform public health policy and practice.

METHOD

Secondary datasets from Global Health Expenditure Database and World Bank Development Indicators collected between 2000 and 2016 were used. Financial protection was measured in 75 low- and middle-income countries (LMICs) using the sustainable development goals framework. Funnel plot charts were used to explore the variation, and regression models were used to measure associations.

RESULT

Fifty-three (67%) countries were within the 99% control limits indicating common-cause variation; 11 countries were above the upper control limit and 15 countries were below the lower control limit. In the fully adjusted model, country, spending on health relative to their economy had the strongest association with the variation in catastrophic spending. Every 1% increase in health spending relative to gross domestic product (GDP) was found to be associated with a reduction of 0.13% in the number of people that incurred catastrophic health spending.

CONCLUSION

There is substantial variation in financial protection, as measured by the number of people that incurred catastrophic health spending, in LMICs; a proportion of this could be explained by the difference in GDP and external health expenditure.

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

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

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

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

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

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

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

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

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

Universal health coverage as a global public health goal: the work of the International Labour Organisation, c.1925-2018

We examine the efforts of the International Labour Organisation (ILO) to extend medical care under social security, through international conventions, advocacy and technical assistance. We consider the challenges faced by the ILO in advancing global health coverage through its labourist, social security model. The narrative begins in the interwar period, with the early conventions on sickness insurance, then discusses the rights-based universalistic vision expressed in the Philadelphia Declaration (1944). We characterize the ILO's postwar research and technical assistance as "progressive gradualism" then show how from the late-1970s the ILO became increasingly marginalized, though it retained an advisory role within the now dominant "co-operative pluralistic" model.

Eliminating Deaths From Cervical Cancer-Report of a Panel at the 7th Annual Symposium on Global Cancer Research, a Satellite Meeting at the Consortium of Universities for Global Health 10th Annual Meeting

This is a summary of the presentations addressing approaches and achievements to reach the goal of eliminating cervical cancer as a global public health problem that were delivered at the 7th Annual Symposium on Global Cancer Research at the 10th Annual Consortium of Universities for Global Health Meeting in March 2019. Dr Princess Nothemba Simelela, Assistant Director-General for Family, Women, Children and Adolescents, World Health Organization, gave an introduction to the World Health Organization-led Cervical Cancer Elimination Initiative and the emerging conceptual framework and targets that will shape the global 2020 to 2030 strategy. Subsequent presentations shared experiences from national programs in Rwanda (Agnes Binagwaho), Latin America (Patricia J. Garcia), and Senegal (Babacar Gueye and J. Andrew Dykens. Successes in intensified human papillomavirus vaccination and screening with follow-up treatment of early and advanced lesions detected are highlighted as well as the challenges and obstacles in achieving and maintaining high coverage in Africa and Latin America. With strong political leadership, commitment of national stakeholders, and the use of proven and cost-effective approaches to human papillomavirus vaccination, screening, and treatment, the vision of a world free of cervical cancer and saving women's lives every year by preventing deaths from cervical cancer will be achievable in the next generation in all countries.