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

Mapping alcohol and tobacco tax policy interventions to inform health and economic impact analyses: A United Kingdom based qualitative framework analysis

BACKGROUND

Alcohol and tobacco have different policy regimes and there is little understanding of how changes to policy on each commodity might combine to affect the same outcomes or to affect people who both drink and smoke. The aim of this study was to deepen understanding of the policy objectives of UK alcohol and tobacco tax options being considered at the time of the interviews with a set of UK policy participants in 2018, and the factors affecting the implementation and outcomes of the policy options discussed.

METHODS

Ten tax policy experts were recruited from government arms-length organisations and advocacy groups in England and Scotland (4 alcohol, 4 tobacco, 2 alcohol and tobacco). Alcohol and tobacco experts were interviewed together in pairs and asked to discuss alcohol and tobacco tax policy objectives, options, and the mechanisms of effect. Interviews were semi-structured, supported by a briefing document and topic guide, audio-recorded, transcribed and then analysed deductively using framework analysis.

RESULTS

Alcohol and tobacco tax policy share objectives of health improvement and there is a common set of policy options: increasing duty rates, duty escalators, multi-rate tax structures, industry levies and the hypothecation of tax revenue for investment in societal benefits. However, participants agreed that the harms caused by alcohol and tobacco and their industries are viewed differently, and that this influences the impacts that are prioritised in tax policymaking. Working-out how alcohol and tobacco taxes could work synergistically to reduce health inequalities was seen as desirable. Participants also highlighted the importance of avoiding the combined effects of price increases on alcohol and tobacco widening economic inequalities.

CONCLUSIONS

Impact analyses should consider the combined effects of alcohol and tobacco tax policies on health and economic inequalities, and how the effects of changes to the tax on each commodity might trade-off.

Determinants of government spending on primary healthcare: a global data analysis

In 2018 global leaders renewed their political commitment to primary healthcare (PHC) ratifying the Declaration of Astana emphasising the importance of building a sustainable PHC system based on accessible and affordable delivery models strengthened by community empowerment. Yet, PHC often remains underfunded, of poor quality, unreliable and not accountable to users which further deprives PHC of funding. This paper analyses the determinants of PHC expenditure in 102 countries, and quantitatively tests the influence of a set of economic, social and political determinants of government expenditure on PHC. The analysis is focused on the determinants of PHC funding from government sources as the government is in a position to make decisions in relation to this expenditure as opposed to out-of-pocket spending which is not in their direct control. Multivariate regression analysis was done to determine statistically significant predictors.Our analysis found that some economic factors-namely Gross Domestic Product (GDP) per capita, government commitment to health and tax revenue raising capacity-were strongly associated with per capita government spending on PHC. We also found that control of corruption was strongly associated with the level of total spending on PHC, while voice and accountability were positively associated with greater government commitment to PHC as measured by government spending on PHC as a share of total government health spending.Our analysis takes a step towards understanding of the drivers of PHC expenditure beyond the level of national income. Some of these drivers may be beyond the remit of health policy decision makers and relate to broader governance arrangements and political forces in societies. Thus, efforts to prioritise PHC in the health agenda and increase PHC expenditure should recognise the constraints within the political landscapes and engage with a wide range of actors who influence decisions affecting the health sector.

Gearing health systems for universal health coverage

Universal health coverage requires adequate and sustainable resourcing, which includes human capital, finance and infrastructure for its realization and sustainability. Well-functioning health systems enable health service delivery and therefore need to be either adequately or optimally geared-prepared and equipped-for service delivery to advance universal health coverage. Adequately geared health systems have sufficient capacity and capability per resourcing levels whereas optimally geared health systems achieve the best possible capacity and capability per resourcing levels. Adequately or optimally geared health systems help to mitigate health system constraints, challenges and inefficiencies. Effective, efficient, equitable, robust, resilient and responsive health systems are elements for implementing and realizing universal health coverage and are embedded and aligned to a global people-centric health strategy. These elements build, enhance and sustain health systems to advance universal health coverage. Effective and efficient health systems encompass continuous improvement and high performance for providing quality healthcare. Robust and resilient health systems provide a supportive and enabling environment for health service delivery. Responsive and equitable health systems prioritize people and access to healthcare. Efforts should be made to design, construct, re-define, refine and optimize health systems that are effective, efficient, equitable, robust, resilient and responsive to deliver decent quality healthcare for all.

Prevalence of unmet health care need in older adults in 83 countries: measuring progressing towards universal health coverage in the context of global population ageing

Current measures for monitoring progress towards universal health coverage (UHC) do not adequately account for populations that do not have the same level of access to quality care services and/or financial protection to cover health expenses for when care is accessed. This gap in accounting for unmet health care needs may contribute to underutilization of needed services or widening inequalities. Asking people whether or not their needs for health care have been met, as part of a household survey, is a pragmatic way of capturing this information. This analysis examined responses to self-reported questions about unmet need asked as part of 17 health, social and economic surveys conducted between 2001 and 2019, representing 83 low-, middle- and high-income countries. Noting the large variation in questions and response categories, the results point to low levels (less than 2%) of unmet need reported in adults aged 60+ years in countries like Andorra, Qatar, Republic of Korea, Slovenia, Thailand and Viet Nam to rates of over 50% in Georgia, Haiti, Morocco, Rwanda, and Zimbabwe. While unique, these estimates are likely underestimates, and do not begin to address issues of poor quality of care as a barrier or contributing to unmet need in those who were able to access care. Monitoring progress towards UHC will need to incorporate estimates of unmet need if we are to reach universality and reduce health inequalities in older populations.

Financing health system elements in Africa: A scoping review

Countries that are reforming their health systems to progress towards Universal Health Coverage (UHC) need to consider total resource requirements over the long term to plan for the implementation and sustainable financing of UHC. However, there is a lack of detailed conceptualization as to how the current health financing mechanisms interplay across health system elements. Thus, we aimed to generate evidence on how to utilize resources from different sources of funds in Africa. We conducted a scoping review of empirical research following the six-stage methodological framework for Scoping Review by Arksey & O'Malley and Levac, Colquhoun & O'Brien. We searched for published and grey literature in Medline, Cochrane Library, PubMed, WHO database, World bank and Google Scholar search engines databases and summarized data using a narrative approach, involving thematic syntheses and descriptive statistics. We included 156 studies out of 1,168 studies among which 13% were conceptual studies while 87% were empirical studies. These selected studies focused on the financing of the 13 health system elements. About 45% focused on service delivery, 13% on human resources, 5% on medical products, and 3% on infrastructure and governance. Studies reporting multiple health system elements were 8%, while health financing assessment frameworks was 23%. The publication years ranged from 1975 to 2021. While public sources were the most dominant form of financing, global documentation of health expenditure does not track funding on all the health system dimensions that informed the conceptual framework of this scoping review. There is a need to advocate for expenditure tracking for health systems, including intangibles. Further analysis would inform the development of a framework for assessing financing sources for health system elements based on efficiency, feasibility, sustainability, equity, and displacement.

Burden of lower respiratory infections and associated risk factors across regions in Ethiopia: a subnational analysis of the Global Burden of Diseases 2019 study

OBJECTIVE

This analysis is to present the burden and trends of morbidity and mortality due to lower respiratory infections (LRIs), their contributing risk factors, and the disparity across administrative regions and cities from 1990 to 2019.

DESIGN

This analysis used Global Burden of Disease 2019 framework to estimate morbidity and mortality outcomes of LRI and its contributing risk factors. The Global Burden of Disease study uses all available data sources and Cause of Death Ensemble model to estimate deaths from LRI and a meta-regression disease modelling technique to estimate LRI non-fatal outcomes with 95% uncertainty intervals (UI).

STUDY SETTING

The study includes nine region states and two chartered cities of Ethiopia.

OUTCOME MEASURES

We calculated incidence, death and years of life lost (YLLs) due to LRIs and contributing risk factors using all accessible data sources. We calculated 95% UIs for the point estimates.

RESULTS

In 2019, LRIs incidence, death and YLLs among all age groups were 8313.7 (95% UI 7757.6-8918), 59.4 (95% UI 49.8-71.4) and 2404.5 (95% UI 2059.4-2833.3) per 100 000 people, respectively. From 1990, the corresponding decline rates were 39%, 61% and 76%, respectively. Children under the age of 5 years account for 20% of episodes, 42% of mortalities and 70% of the YLL of the total burden of LRIs in 2019. The mortality rate was significantly higher in predominantly pastoralist regions-Benishangul-Gumuz 101.8 (95% UI 84.0-121.7) and Afar 103.7 (95% UI 86.6-122.6). The Somali region showed the least decline in mortality rates. More than three-fourths of under-5 child deaths due to LRIs were attributed to malnutrition. Household air pollution from solid fuel attributed to nearly half of the risk factors for all age mortalities due to LRIs in the country.

CONCLUSION

In Ethiopia, LRIs have reduced significantly across the regions over the years (except in elders), however, are still the third-leading cause of mortality, disproportionately affecting children younger than 5 years old and predominantly pastoralist regions. Interventions need to consider leading risk factors, targeted age groups and pastoralist and cross-border communities.

Evolving market-shaping strategies to boost access to essential medical products in developing countries with HIV self-testing as a case study

The COVID-9 pandemic has exacerbated health inequities among countries in the Global South with limited access to essential medical products, leading to a higher infection and mortality rate, especially among vulnerable populations. Despite tremendous progress in global health financing, the estimated annual financing gap in developing countries is projected to reach US$371 billion per year by 2030. Therefore, developing market-shaping strategies is of great importance in ensuring adequate supply, affordable prices, and equitable access to essential medical products in low-and middle-income countries. We propose a strategic and appropriate market-shaping intervention framework for governments, international organizations, and NGOs to maximize access to essential medical products in developing countries. In the health field, we believe that market shaping strategy could be defined as a set of purposeful activities that market forces may intervene with to advance the development, production, supply, and distribution of global goods for health, making essential medical products more affordable, accessible, innovative, sustainable and quality assured. We argue that when designing a market-shaping strategy, policy or decision-makers must take full advantage of the key drivers to keep the market dynamic, interactive, and constantly evolving to meet the unmet medical needs. In addition, different forms of market-shaping interventions are determined by objectives and specific issues to be addressed. More comprehensive market shaping strategies, including the strategic use of market expansion, market disruption, market maintenance, and market contraction alone or together, deserve to be explored and key stakeholders are also expected to join forces to make the intervention more efficient and productive.

An exploratory review of investments by development actors in health workforce programmes and job creation

The World Health Organization's Global Strategy on Human Resources for Health: Workforce 2030 identified a projected shortfall of 18 million health workers by 2030, primarily in low- and middle-income countries. The need for investment was re-enforced by the 2016 report and recommendations of the United Nations High-Level Commission on Health Employment and Economic Growth. This exploratory policy tracing study has as objective to map and analyse investments by bilateral, multilateral and other development actors in human resources for health actions, programmes and health jobs more broadly since 2016. This analysis will contribute to the accountability of global human resources for health actions and its commitment by the international community. It provides insights in gaps, priorities and future policies' needs. The study follows an exploratory rapid review methodology, mapping and analysing the actions of four categories of development actors in implementing the ten recommendations of the United Nations High-Level Commission on Health Employment and Economic Growth. These four categories of actors include (A) bilateral agencies, (B) multilateral initiatives, (C) international financial institutions and (D) non-state actors. Analysing the data generated via this review, three trends can be observed. Firstly, while a broad range of human resources for health actions and outputs have been identified, data on programme outcomes and especially on their impacts are limited. Secondly, many of the programmatic human resources for health actions, often funded via bilateral or philanthropic grants and implemented by non-governmental organisations, seemed to be rather short-term in nature, focusing on in-service training, health security, technical and service delivery needs. Despite the strategic guidance and norms developed by multilateral initiatives, such as the International Labour Organization-Organisation for Economic Co-operation and Development-World Health Organization Working for Health programme, has it been for several development projects difficult to assess how their activities actually contributed to national human resources for health strategic development and health system reforms. Lastly, governance, monitoring and accountability between development actors and across the policy recommendations from the United Nations High-Level Commission on Health Employment and Economic Growth could be improved. There has been limited actionable progress made for the enablers required to transform the workforce, including in the domain of generating fiscal space for health that would strengthen jobs in the health sector, the development of health workforce partnerships and its global agenda, and the governance of international health workforce migration. In conclusion, one can observe that global health workforce needs are much recognised, especially given the impact of the Covid-19 pandemic. However, 20 years after the Joint Learning Initiative on Human Resources for Health, there is still an urgent need to take shared responsibility for international cooperative action for overcoming and addressing persistent underinvestment in the health workforce. Specific policy recommendations are provided to this end.

Fair pathways to net-zero healthcare

Over the past decade, it has become clear that the health sector is not only at risk from climate change but also a major polluter of greenhouse gases. In November 2021, the World Health Organization and partners launched the COP26 Health Programme for sustainable, climate-resilient and low-carbon health systems, and have since established the Alliance for Transformative Action on Climate and Health to support its implementation. Given the wide variation in health financing, carbon emissions and unmet health needs across the world, fair sharing of the remaining carbon budget and health gains will be critical. In this Perspective, we explore the challenges and opportunities of healthcare decarbonization, outlining the principles of fair pathways to net-zero healthcare that are attentive to health and socioeconomic inequalities within and between countries.

Reliability and validity of an innovative high performing healthcare system assessment tool

BACKGROUND

Universal Health coverage (UHC) is the mantra of the twenty-first century yet knowing when it has been achieved or how to best influence its progression remains elusive. An innovative framework for High Performing Healthcare (HPHC) attempts to address these issues. It focuses on measuring four constructs of Accountable, Affordable, Accessible, and Reliable (AAAR) healthcare that contribute to better health outcomes and impact. The HPHC tool collects information on the perceived functionality of health system processes and provides real-time data analysis on the AAAR constructs, and on processes for health system resilience, responsiveness, and quality, that include roles of community, private sector, as well as both demand, and supply factors affecting health system performance. The tool attempts to capture the multidimensionality of UHC measurement and evidence that links health system strengthening activities to outcomes. This paper provides evidence on the reliability and validity of the tool.

METHODS

Internet survey with non-probability sampling was used for testing reliability and validity of the HPHC tool. The volunteers were recruited using international networks and listservs. Two hundred and thirteen people from public, private, civil society and international organizations volunteered from 35 low-and-middle-income countries. Analyses involved testing reliability and validity and validation from other international sources of information as well as applicability in different setting and contexts.

RESULTS

The HPHC tool's AAAR constructs, and their sub-domains showed high internal consistency (Cronbach alpha >.80) and construct validity. The tool scores normal distribution displayed variations among respondents. In addition, the tool demonstrated its precision and relevance in different contexts/countries. The triangulation of HPHC findings with other international data sources further confirmed the tool's validity.

CONCLUSIONS

Besides being reliable and valid, the HPHC tool adds value to the state of health system measurement by focusing on linkages between AAAR processes and health outcomes. It ensures that health system stakeholders take responsibility and are accountable for better system performance, and the community is empowered to participate in decision-making process. The HPHC tool collects and analyzes data in real time with minimum costs, supports monitoring, and promotes adaptive management, policy, and program development for better health outcomes.

Health and economic benefits of achieving contraceptive and maternal health targets in Small Island Developing States in the Pacific and Caribbean

INTRODUCTION

Reducing unmet need for modern contraception and expanding access to quality maternal health (MH) services are priorities for improving women's health and economic empowerment. To support investment decisions, we estimated the additional cost and expected health and economic benefits of achieving the United Nations targets of zero unmet need for modern contraceptive choices and 95% coverage of MH services by 2030 in select Small Island Developing States.

METHODS

Five Pacific (Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu) and four Caribbean (Barbados, Guyana, Jamaica and Saint Lucia) countries were considered based on population survey data availability. For each country, the Lives Saved Tool was used to model costs, health outcomes and economic benefits for two scenarios: business-as-usual (BAU) (coverage maintained) and coverage-targets-achieved, which scaled linearly from 2022 (following COVID-19 disruptions) coverage of evidence-based family planning and MH interventions to reach United Nations targets, including modern contraceptive methods and access to complete antenatal, delivery and emergency care. Unintended pregnancies, maternal deaths, stillbirths and newborn deaths averted by the coverage-targets-achieved scenario were converted to workforce, education and social economic benefits; and benefit-cost ratios were calculated.

RESULTS

The coverage-targets-achieved scenario required an additional US$12.6M (US$10.8M-US$15.9M) over 2020-2030 for the five Pacific countries (15% more than US$82.4M to maintain BAU). This additional investment was estimated to avert 126 000 (40%) unintended pregnancies, 2200 (28%) stillbirths and 121 (29%) maternal deaths and lead to a 15-fold economic benefit of US$190.6M (US$67.0M-US$304.5M) by 2050. For the four Caribbean countries, an additional US$17.8M (US$15.3M-US$22.4M) was needed to reach the targets (4% more than US$405.4M to maintain BAU). This was estimated to avert 127 000 (23%) unintended pregnancies, 3600 (23%) stillbirths and 221 (25%) maternal deaths and lead to a 24-fold economic benefit of US$426.2M (US$138.6M-US$745.7M) by 2050.

CONCLUSION

Achieving full coverage of contraceptive and MH services in the Pacific and Caribbean is likely to have a high return on investment.

Understanding integrated service delivery: a scoping review of models for noncommunicable disease and mental health interventions in low-and-middle income countries

BACKGROUND

Noncommunicable diseases (NCDs) and mental health conditions represent a growing proportion of disease burden in low- and middle-income countries (LMICs). While past efforts have identified interventions to be delivered across health system levels to address this burden, the challenge remains of how to deliver heterogenous interventions in resource-constrained settings. One possible solution is the Integration of interventions within existing care delivery models. This study reviews and summarizes published literature on models of integrated NCD and mental health care in LMICs.

METHODS

We searched Pubmed, African Index Medicus and reference lists to conduct a scoping review of studies describing an integrated model of NCD or neuropsychiatric conditions (NPs) implemented in a LMIC. Conditions of interest were grouped into common and severe NCDs and NPs. We identified domains of interest and types of service integration, conducting a narrative synthesis of study types. Studies were screened and characteristics were extracted for all relevant studies. Results are reported using PRISMA-ScR.

RESULTS

Our search yielded 5004 studies, we included 219 models of integration from 188 studies. Most studies were conducted in middle-income countries, with the majority in sub-Saharan Africa. Health services were offered across all health system levels, with most models implemented at health centers. Common NCDs (including type 2 diabetes and hypertension) were most frequently addressed by these models, followed by common NPs (including depression and anxiety). Conditions and/or services were often integrated into existing primary healthcare, HIV, maternal and child health programs. Services provided for conditions of interest varied and frequency of these services differed across health system levels. Many models demonstrated decentralization of services to lower health system levels, and task shifting to lower cadre providers.

CONCLUSIONS

While integrated service design is a promising method to achieve ambitious global goals, little is known about what works, when, and why. This review characterizing care integration programs is an initial step toward developing a structured study of care integration.

Trade-offs between Sustainable Development Goals in carbon capture and utilisation

Carbon capture and utilisation (CCU) provides an appealing framework to turn carbon emissions into valuable fuels and chemicals. However, given the vast energy required to activate the CO₂ molecule, CCU may have implications on sustainable development that are still poorly understood due to the narrow scope of current carbon footprint-oriented assessments lacking absolute sustainability thresholds. To bridge this gap, we developed a power-chemicals nexus model to look into the future and understand how we could produce 22 net-zero bulk chemicals of crucial importance in a sustainable manner by integrating fossil, CCU routes and power technologies, often assessed separately. We evaluated the environmental performance of these technologies in terms of their contribution to 5 Sustainable Development Goals (SDGs), using 16 life cycle assessment metrics and 9 planetary boundaries (PB) to quantify and interpret the impact values. We found that fossil chemicals could hamper the attainment of SDG 3 on good health and well-being and SDG 13 on climate change. CCU could help meet SDG 13 but would damage other SDGs due to burden-shifting to human health, water scarcity, and minerals and metals depletion impacts. The collateral damage could be mitigated by judiciously combining fossil and CCU routes with carbon-negative power sources guided by optimisation models incorporating SDGs-based performance criteria explicitly. Our work highlights the importance of embracing the SDGs in technology development to sensibly support the low-carbon energy and chemicals transition.

Using costing to facilitate policy making towards Universal Health Coverage: findings and recommendations from country-level experiences

As countries progress towards universal health coverage (UHC), they frequently develop explicit packages of health services compatible with UHC goals. As part of the Disease Control Initiative 3 Country Translation project, a systematic survey instrument was developed and used to review the experience of five low-income and lower-middle-income countries-Afghanistan, Ethiopia, Pakistan, Somalia and Sudan-in estimating the cost of their proposed packages. The paper highlights the main results of the survey, providing information about how costing exercises were conducted and used and what country teams perceived to be the main challenges. Key messages are identified to facilitate similar exercises and improve their usefulness. Critical challenges to be addressed include inconsistent application of costing methods, measurement errors and data reliability issues, the lack of adequate capacity building, and the lack of integration between costing and budgeting. The paper formulates four recommendations to address these challenges: (1) developing more systematic guidance and standard ways to implement costing methodologies, particularly regarding the treatment of health systems-related common costs, (2) acknowledging ranges of uncertainty of costing results and integrating sensitivity analysis, (3) building long-term capacity at the local level and institutionalising the costing process in order to improve both reliability and policy relevance, and (4) closely linking costing exercises to public budgeting.

Strengthening integrated sexual reproductive health and rights and HIV services programs to achieve sustainable development goals 3 and 5 in Africa

Each year, over 200 million women globally cannot prevent pregnancy through modern contraceptive methods, with 70-80% of these women residing in sub-Saharan Africa. Consequently, almost 50% of pregnancies are unintended and 35 million unsafe abortions occur annually in the region. Further, sub-Saharan Africa has the highest burden globally of Human Immune-Deficiency Virus (HIV) infection, and over 57% of those affected are women. Women with a positive HIV status in sub-Saharan Africa experience higher rates of unintended pregnancy and unsafe abortion practices. In this commentary, we propose strategies to strengthen integrated sexual and reproductive health and rights (SRHR) and HIV services programs to improve the sexual and reproductive health of girls and women and to work towards achieving SDGs 3 and 5 in sub-Saharan Africa. We suggest a focus on capacity building, strengthening intersectoral collaborations, and improving governance and financial investment.

Health sector funding in Ghana: The effect of IMF conditionalities

Purpose

This paper examines the factors influencing government health spending in Ghana with a particular focus on IMF conditionalities.

Design/methodology/approach

We estimate four simultaneous equations using three-stage least squares (3SLS) estimator. The data used cover the period 1980-2014.

Findings

After controlling for some other factors affecting government health spending, the results show that democracy and foreign aid significantly increase public sector health funding. IMF programs with its associated conditionalities insignificantly reduce public health spending Ghana.

Originality/value

This study provides important evidence on the impact of IMF conditionalities on health sector funding in Ghana. The results will serve as guide to policymakers when negotiating for IMF credit so that such arrangements do not obstruct health sector funding.

Equality and social determinants of spatial accessibility, availability, and affordability to primary health care in Hong Kong, a descriptive study from the perspective of spatial analysis

Objective

Primary health care (PHC) is widely perceived to be the backbone of health care systems. Since the outbreak of COVID-19, PHC has not only provided primary medical services, but also served as a grassroots network for public health. Our research explored the accessibility, availability, and affordability of primary health care from a spatial perspective, to understand the social determinants affecting access to it in Hong Kong.

Method

This constitutes a descriptive study from the perspective of spatial analysis. The nearest neighbor method was used to measure the geographic accessibility of PHC based on the road network. The 2SFCA method was used to measure spatial availability and affordability to primary health care, while the SARAR model, Spatial Error model, and Spatial Lag model were then constructed to explain potential factors influencing accessibility and availability of PHC.

Results

In terms of accessibility, 95% of residents in Hong Kong can reach a PHC institution within 15 minutes; in terms of availability, 83% of residents can receive PHC service within a month; while in terms of affordability, only 32% of residents can afford PHC services with the support of medical insurance and medical voucher. In Hong Kong, education status and household income show a significant impact on accessibility and availability of PHC. Regions with higher concentrations of residents with post-secondary education receive more PHC resources, while regions with higher concentrations of high-income households show poorer accessibility and poorer availability to PHC.

Conclusion

The good accessibility and availability of primary health care reflects that the network layout of existing PHC systems in Hong Kong is reasonable and can meet the needs of most residents. No serious gap between social groups further shows equality in resource allocation of PHC in Hong Kong. However, affordability of PHC is not ideal. Indeed, narrowing the gap between availability and affordability is key to fully utilizing the capacity of the PHC system in Hong Kong. The private sector plays an important role in this, but the low coverage of medical insurance in outpatient services exacerbates the crowding of public PHC and underutilization of private PHC. We suggest diverting patients from public to private institutions through medical insurance, medical vouchers, or other ways, to relieve the pressure on the public health system and make full use of existing primary health care in Hong Kong.

Willingness to pay for a National Health Insurance Scheme in The Gambia: a contingent valuation study

In pursuit of universal health coverage, many low- and middle-income countries are reforming their health financing systems and introducing health insurance schemes. As part of these reforms, lawmakers in The Gambia enacted 'The National Health Insurance Bill, 2021'. The Act will establish a National Health Insurance Scheme (NHIS) that pays for the cost of healthcare services for its members. This study assessed Gambians' willingness to pay (WTP) for a NHIS. Using multistage sampling design with no replacement, head/co-head of households were presented with a hypothetical health insurance scheme from July to August 2020. Their WTP and factors influencing WTP were elicited using a contingent valuation method. Descriptive statistics were used to describe sample characteristics. Lopez-Feldman's modified ordered probit model and linear regression were applied to estimate respondents' WTP as well as identify factors that influence their WTP. More than 90% of the respondents-677 (94.4%) were willing to join and pay for the scheme. Half of these respondents-398 (58.8%) agreed to pay the first bid of US dollars (US$) 20.78 or Gambian dalasi (GMD) 1000. The average WTP was estimated at US$23.27 (GMD1119.82), whereas average maximum amount to pay was US$26.01 (GMD1251.16). Results of the two models together showed that gender, level of education and household income were statistically significant, with the latter showing negative influence on WTP. The study found that Gambians were largely receptive to the scheme and have stated their willingness to contribute. Our findings can inform policymakers in The Gambia and other sub-Saharan countries when establishing contribution rates and exemption criteria during social health insurance scheme implementation.

Identifying and Predicting Healthcare Waste Management Costs for an Optimal Sustainable Management System: Evidence from the Greek Public Sector

The healthcare sector is an ever-growing industry which produces a vast amount of waste each year, and it is crucial for healthcare systems to have an effective and sustainable medical waste management system in order to protect public health. Greek public hospitals in 2018 produced 9500 tons of hazardous healthcare wastes, and it is expected to reach 18,200 tons in 2025 and exceed 18,800 tons in 2030. In this paper, we investigated the factors that affect healthcare wastes. We obtained data from all Greek public hospitals and conducted a regression analysis, with the management cost of waste and the kilos of waste as the dependent variables, and a number of variables reflecting the characteristics of each hospital and its output as the independent variables. We applied and compared several models. Our study shows that healthcare wastes are affected by several individual-hospital characteristics, such as the number of beds, the type of the hospital, the services the hospital provides, the number of annual inpatients, the days of stay, the total number of surgeries, the existence of special units, and the total number of employees. Finally, our study presents two prediction models concerning the management costs and quantities of infectious waste for Greece's public hospitals and proposes specific actions to reduce healthcare wastes and the respective costs, as well as to implement and adopt certain tools, in terms of sustainability.

Contribution of the Technical Efficiency of Public Health Programs to National Trends and Regional Disparities in Unintentional Childhood Injury in Japan

To achieve the Sustainable Development Goals, strengthening investments in health service inputs has been widely emphasized, but less attention has been paid to tackling variation in the technical efficiency of services. In this study, we estimated the technical efficiency of local public health programs for the prevention of unintentional childhood injury and explored its contribution to national trend changes and regional health disparities in Japan. Efficiency scores were estimated based on the Cobb-Douglas and translog production functions using a true fixed effects model in a stochastic frontier analysis to account for unobserved time-invariant heterogeneity across prefectures. Using public data sources, we compiled panel data from 2001 to 2017 for all 47 prefectures in Japan. We treated disability-adjusted life years (DALYs) as the output, coverage rates of public health programs as inputs, and caregivers' capacity and environmental factors as constraints. To investigate the contribution of efficiency to trend changes and disparities in output, we calculated the predicted DALYs with several measures of inefficiency scores (2001 average, yearly average, and prefecture-year-specific estimates). In the translog model, mean efficiency increased from 0.62 in 2001 to 0.85 in 2017. The efficiency gaps among prefectures narrowed until 2007 and then remained constant until 2017. Holding inefficiency score constant, inputs and constraints contributed to improvements in average DALYs and widened regional gaps. Improved efficiency over the years further contributed to improvements in average DALYs. Efficiency improvement in low-output regions and stagnated improvement in high-output regions offset the trend of widening regional health disparities. Similar results were obtained with the Cobb-Douglas model. Our results demonstrated that assessing the inputs, constraints, output, and technical efficiency of public health programs could provide policy leverage relevant to region-specific conditions and performance to achieve health promotion and equity.

A pandemic triad: HIV, COVID-19 and debt in low- and middle-income countries

This article assesses the impact of the HIV and COVID-19 pandemics and debt dynamics on health, HIV and pandemic preparedness and response-related financing in developing countries. Using a novel dataset, we did a cross-national systematic analysis of all data sources available for government expenditures on health, HIV, COVID-19 and debt servicing in selected developing countries. We found an inadequate multilateral response with the ensuing gaps allowing both pandemics to thrive. The G20 Debt Service Suspension Initiative and the Common Framework only covered countries with a third of the global population of people living with HIV. Rising and unsustainable debt levels are limiting the capacity of governments to protect the health of their populations. Government spending is already falling in response to high debt payments. Specifically, debt servicing is crowding out lifesaving investments. In 2020, for every USD 5 available, USD 4 was spent on debt servicing. Only USD 1 was invested in health. This is a binding constraint on countries' efforts to control COVID-19. Even with a gargantuan effort to increase health expenditure, the outlook for health financing remains negative. Fiscal consolidation, with a heavy emphasis on expenditure cuts, is expected to take place across 139 countries in the coming years. These findings suggest that fiscal policymakers should be concerned about the crowding-out and constraining effects of public debt. To this end, pragmatic recommendations are made to treat and cancel debt as a critical policy lever to accelerate the end of the HIV and COVID-19 pandemics in developing countries as a key condition to addressing the growing inequalities and to ensure debt can be a benefit, not a burden.

How viable is social health insurance for financing health in Zambia? Results from a national willingness to pay survey

In an era of considerable uncertainty about future prospects for development assistance to fund major health programmes in Sub-Saharan Africa, social health insurance is increasingly being considered as an alternative mechanism for increasing financing health. However, empirical support for social health insurance in sub-Saharan Africa remains sparse. The main aim of this study was to examine the viability of increasing health financing through social health insurance in Zambia. The paper uses a large nationally representative household survey to estimate the expected mean and total willingness to pay for social health insurance. The revenue potential of social health insurance for health sector funding is assessed. The results show that despite a high level of public support for social health insurance, with 80% willing to join a social insurance scheme, the estimated mean monthly willingness-to-pay is relatively low at Zambian Kwacha 55 (US$8.8 in 2014 dollars) per household. The evidence presented in this paper suggests that the revenue potential of social health insurance would not be sufficient to fund major improvements in quality of care for insured members, let alone cross-subsidize benefits to non-members.

Facilitators and barriers to point-of-care testing for sexually transmitted infections in low- and middle-income countries: a scoping review

Background

Sexually transmitted infections (STIs) in low- and middle-income countries (LMICs) are predominantly managed by syndromic management. However, most STIs are asymptomatic. These untreated STIs cause individual morbidity, and lead to high STI prevalences.

There is increasing interest in the use of point-of-care tests (POCTs) for STIs in LMICs, which could facilitate same day testing and treatment. To best utilise these tests, we must understand the facilitators and barriers to their implementation. The aim of this review is to explore how point-of-care testing for STIs has been implemented into healthcare systems in LMIC and the facilitators and barriers to doing so.

Methods

A scoping review was conducted by searching MEDLINE, Embase, Emcare, CINAHL, Scopus, LILACS, the Cochrane Library, and ProQuest Dissertations and Theses for studies published between 1st January 1998 and 5th June 2020. Abstracts and full articles were screened independently by two reviewers. Studies were considered for inclusion if they assessed the acceptability, feasibility, facilitators, or barriers to implementation of point-of-care testing for chlamydia, gonorrhoea, trichomoniasis or syphilis in LMICs. Thematic analysis was used to analyse and present the facilitators and barriers to point-of-care STI testing.

Results

The literature search revealed 82 articles suitable for inclusion; 44 (53.7%) from sub-Saharan Africa; 21 (25.6%) from Latin American and the Caribbean; 10 (12.2%) from East Asia and the Pacific; 6 (7.3%) from South Asia; and one (1.2%) multi-regional study. Thematic analysis revealed seven overarching themes related to the implementation of POCTs in LMICs, namely (i) Ideal test characteristics, (ii) Client factors, (iii) Healthcare provision factors, (iv) Policy, infrastructure and health system factors, (v) Training, audit, and feedback, (vi) Reaching new testing environments, and (vii) Dual testing.

Conclusion

Implementation of POCTs in LMICs is complex, with many of the barriers due to wider health system weakness. In addition to pressing for broader structural change to facilitate basic healthcare delivery, these themes may also be used as a basis on which to develop future interventions. The literature was heavily skewed towards syphilis testing, and so more research needs to be conducted assessing chlamydia, gonorrhoea, and trichomoniasis testing, as well as home or self-testing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07534-9.

The economics of the UN Sustainable Development Goals: does sustainability make financial sense?

The implementation of the UN Sustainable Development Goals is a global priority, but one whose full implementation is vulnerable to the high costs associated with it. This raises the question: does the implementation of the SDGs make financial sense? This article addresses this question and outlines the need to raise awareness of the economic benefits of implementing the global goals. Further, it presents and discusses the main financial gaps to achieve the Sustainable Development Goals by 2030.

Development assistance for human resources for health, 1990-2020

BACKGROUND

Investing in the health workforce is key to achieving the health-related Sustainable Development Goals. However, achieving these Goals requires addressing a projected global shortage of 18 million health workers (mostly in low- and middle-income countries). Within that context, in 2016, the World Health Assembly adopted the WHO Global Strategy on Human Resources for Health: Workforce 2030. In the Strategy, the role of official development assistance to support the health workforce is an area of interest. The objective of this study is to examine progress on implementing the Global Strategy by updating previous analyses that estimated and examined official development assistance targeted towards human resources for health.

METHODS

We leveraged data from IHME's Development Assistance for Health database, COVID development assistance database and the OECD's Creditor Reporting System online database. We utilized an updated keyword list to identify the relevant human resources for health-related activities from the project databases. When possible, we also estimated the fraction of human resources for health projects that considered and/or focused on gender as a key factor. We described trends, examined changes in the availability of human resources for health-related development assistance since the adoption of the Global Strategy and compared disease burden and availability of donor resources.

RESULTS

Since 2016, development assistance for human resources for health has increased with a slight dip in 2019. In 2020, fueled by the onset of the COVID-19 pandemic, it reached an all-time high of $4.1 billion, more than double its value in 2016 and a 116.5% increase over 2019. The highest share (42.4%) of support for human resources for health-related activities has been directed towards training. Since the adoption of the Global Strategy, donor resources for health workforce-related activities have on average increased by 13.3% compared to 16.0% from 2000 through 2015. For 47 countries identified by the WHO as having severe workforce shortages, the availability of donor resources remains modest.

CONCLUSIONS

Since 2016, donor support for health workforce-related activities has increased. However, there are lingering concerns related to the short-term nature of activities that donor funding supports and its viability for creating sustainable health systems.

Investing in the health workforce: fiscal space analysis of 20 countries in East and Southern Africa, 2021-2026

Background and objectives

The health workforce (HWF) is at the core of ensuring an efficient, effective and functional health system, but it faces chronic underinvestment. This paper presents a fiscal space analysis of 20 countries in East and Southern Africa to generate sustained evidence-based advocacy for significant and smarter investment in the HWF.

Methods

We adapted an established empirical framework for fiscal space analysis and applied it to the HWF. Country-specific data were curated and triangulated from publicly available datasets and government reports to model the fiscal space for the HWF for each country. Based on the current knowledge, three scenarios (business as-usual, optimistic and very optimistic) were modelled and compared.

Findings

A business-as-usual scenario shows that the cumulative fiscal space across the 20 countries is US$12.179 billion, which would likely increase by 28% to US$15.612 billion by 2026 but varies across countries—the highest proportional increases expected in Seychelles (117%) and Mozambique (69%) but lowest in Zambia (15%). Under optimistic assumptions, allocating an additional 1.5% of gross domestic product (GDP) to health even without further prioritising the proportional allocation to the wage bill could boost the cumulative fiscal space for HWF by US$4.639 billion. In a very optimistic scenario of a 1.5% increase in health expenditure as a proportion of GDP and further prioritisation of HWF within the health expenditure, the cumulative fiscal space for HWF could improve by some 105%—ranging from 24% in Zambia to 330% in Lesotho.

Conclusion

Small increments in government health expenditure and increased prioritisation of HWF in funding in tandem with the 57% global average could potentially increase the fiscal space for HWF by at least 32% in 11 countries. Unless the HWF is sufficiently prioritised within the health expenditures, only increasing the overall health expenditure to even recommended levels would still portend severe underinvestment in HWF amid unabating shortages to deliver health services. Thus, HWF strategies and investment plans should include fiscal space analysis to deepen advocacy for sustainable investment in the HWF.

Health workforce supply, needs and financial feasibility in Lesotho: a labour market analysis

BACKGROUND

The Government of Lesotho has prioritised health investment that aims to improve the health and socioeconomic development of the country, including the scaling up of the health workforce (HWF) training and improving their working conditions. Following a health labour market analysis, the paper highlights the available stock of health workers in Lesotho's health labour market, 10-year projected supply versus needs and the financial implications.

METHODS

Multiple complementary approaches were used to collect data and analyse the HWF situation and labour market dynamics. These included a scooping assessment, desk review, triangulation of different data sources for descriptive analysis and modelling of the HWF supply, need and financial space.

FINDINGS

Lesotho had about 20 942 active health workers across 18 health occupations in 2020, mostly community health workers (69%), nurses and midwives (17.9%), while medical practitioners were 2%. Almost one out of three professional nurses and midwives (28.43%) were unemployed, and nearly 20% of associate nurse professionals, 13.26% of pharmacy technicians and 24.91% of laboratory technicians were also unemployed. There were 20.73 doctors, nurses and midwives per 10 000 population in Lesotho, and this could potentially increase to a density of 31.49 doctors, nurses and midwives per 10 000 population by 2030 compared with a need of 46.72 per 10 000 population by 2030 based on projected health service needs using disease burden and evolving population size and demographics. The existing stock of health workers covered only 47% of the needs and could improve to 55% in 2030. The financial space for the HWF employment was roughly US$40.94 million in 2020, increasing to about US$66.69 million by 2030. In comparison, the cost of employing all health workers already in the supply pipeline (in addition to the currently employed ones) was estimated to be US$61.48 million but could reach US$104.24 million by 2030. Thus, a 33% gap is apparent between the financial space and what is required to guarantee employment for all health workers in the supply pipeline.

CONCLUSION

Lesotho's HWF stock falls short of its population health need by 53%. The unemployment of some cadres is, however, apparent. Addressing the need requires increasing the HWF budget by at least 12.3% annually up to 2030 or prioritising at least 33% of its recurrent health expenditure to the HWF.

The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages

BACKGROUND

Practical links between health systems and health security are historically prevalent, but the conceptual links between these fields remain under explored, with little on health system strengthening. The need to address this gap gains relevance in light of the COVID-19 pandemic as it demonstrated a crucial relationship between health system capacities and effective health security response. Acknowledging the importance of developing stronger and more resilient health systems globally for health emergency preparedness, the WHO developed a Health Systems for Health Security framework that aims to promote a common understanding of what health systems for health security entails whilst identifying key capacities required.

METHODS/ RESULTS

To further explore and analyse the conceptual and practical links between health systems and health security within the peer reviewed literature, a rapid scoping review was carried out to provide an overview of the type, extent and quantity of research available. Studies were included if they had been peer-reviewed and were published in English (seven databases 2000 to 2020). 343 articles were identified, of those 204 discussed health systems and health security (high and medium relevance), 101 discussed just health systems and 47 discussed only health security (low relevance). Within the high and medium relevance articles, several concepts emerged, including the prioritization of health security over health systems, the tendency to treat health security as exceptionalism focusing on acute health emergencies, and a conceptualisation of security as 'state security' not 'human security' or population health.

CONCLUSION

Examples of literature exploring links between health systems and health security are provided. We also present recommendations for further research, offering several investments and/or programmes that could reliably lead to maximal gains from both a health system and a health security perspective, and why these should be explored further. This paper could help researchers and funders when deciding upon the scope, nature and design of future research in this area. Additionally, the paper legitimises the necessity of the Health Systems for Health Security framework, with the findings of this paper providing useful insights and evidentiary examples for effective implementation of the framework.

The impact of retirement on inpatient healthcare utilization in Guangzhou, China: a regression discontinuity analysis of 189,031 health insurance claims

Background

Previous studies suggest that retirement, a major life event, affects overall healthcare utilization. We examine, the effects of retirement on inpatient healthcare utilization, including effect heterogeneity by gender, disease category, and type of health service.

Methods

We used routine health insurance claims data (N = 87,087) spanning the period 2021 - September 2013 from the Urban Employee Basic Medical Insurance (UEBMI), a mandatory social health insurance for working and retired employees in urban China. We applied a non-parametric fuzzy regression discontinuity design using the statutory retirement age in urban China as an exogenous instrument to measure the causal effect of retirement on six measures of inpatient healthcare utilization.

Results

Retirement reduced total hospital costs (-84.71 Chinese Yuan (CNY), 95% confidence interval (CI) -172.03 – 2.61), shortened length of hospital stays (-44.59, 95% CI -70.50 – -18.68), and increased hospital readmissions (0.06, 95% CI 0.00 – 0.12) and primary hospital visits (0.06, 95% CI 0.02 – 0.09) among women. Retirement did not significantly change inpatient healthcare utilization among men. The retirement effects among women varied by disease category. Specifically, retirement substantially increased hospitalizations for non-communicable diseases (NCDs), yet had only modest or no effect on hospitalizations for communicable diseases or injuries. Retirement effects among women also varied by the type of services. For relatively inexpensive services, such as nonoperative treatment, there were surges in the extensive margin (hospital readmission). For relatively expensive and invasive services, such as surgeries, retirement reduced the intensive margin (out-of-pocket expenditures and length of stay).

Conclusions

Retirement decreases overall use of inpatient healthcare for women. The examination on the disease-related heterogeneous effects helps with the introduction and implementation of integrated healthcare delivery and appropriate incentive schemes to encourage better use of healthcare resources among older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02664-2.

Estimating the cost of achieving basic water, sanitation, hygiene, and waste management services in public health-care facilities in the 46 UN designated least-developed countries: a modelling study

Background

An alarming number of public health-care facilities in low-income and middle-income countries lack basic water, sanitation, hygiene (WASH), and waste management services. This study estimates the costs of achieving full coverage of basic WASH and waste services in existing public health facilities in the 46 UN designated least-developed countries (LDCs).

Methods

In this modelling study, in-need facilities were quantified by combining published counts of public facilities with estimated basic WASH and waste service coverage. Country-specific per-facility capital and recurrent costs to deliver basic services were collected via survey of country WASH experts and officials between Sept 24 and Dec 24, 2020. Baseline cost estimates were modelled and discounted by 5% per year. Key assumptions were adjusted to produce lower and upper estimates, including adjusting the discount rate to 8% and 3% per year, respectively.

Findings

An estimated US$6·5 billion to $9·6 billion from 2021 to 2030 is needed to achieve full coverage of basic WASH and waste services in public health facilities in LDCs. Capital costs are $2·9 billion to $4·8 billion and recurrent costs are $3·6 billion to $4·8 billion over this time period. A mean of $0·24–0·40 per capita in capital investment is needed each year, and annual operations and maintenance costs are expected to increase from $0·10 in 2021 to $0·39–0·60 in 2030. Waste management accounts for the greatest share of costs, requiring $3·7 billion (46·6% of the total) in the baseline estimates, followed by $1·8 billion (23·1%) for sanitation, $1·5 billion (19·5%) for water, and $845 million (10·7%) for hygiene. Needs are greatest for non-hospital facilities ($7·4 billion [94%] of $7·9 billion) and for facilities in rural areas ($5·3 billion [68%]).

Interpretation

Investment will need to increase to reach full coverage of basic WASH and waste services in public health facilities. Financial needs are modest compared with current overall health and WASH spending, and better service coverage will yield substantial health benefits. To sustain services and prevent degradation and early replacement, countries will need to routinely budget for operations and maintenance of WASH and waste management assets.

Funding

WHO (including underlying grants from the governments of Japan, the Netherlands, and the UK), World Bank (including an underlying grant from the Global Water Security and Sanitation Partnership), and UNICEF.

Translations

For the Arabic, French and Portuguese translations of the abstract see Supplementary Materials section.

NCD Countdown 2030: efficient pathways and strategic investments to accelerate progress towards the Sustainable Development Goal target 3.4 in low-income and middle-income countries

Most countries have made little progress in achieving the Sustainable Development Goal (SDG) target 3.4, which calls for a reduction in premature mortality from non-communicable diseases (NCDs) by a third from 2015 to 2030. In this Health Policy paper, we synthesise the evidence related to interventions that can reduce premature mortality from the major NCDs over the next decade and that are feasible to implement in countries at all levels of income. Our recommendations are intended as generic guidance to help 123 low-income and middle-income countries meet SDG target 3.4; country-level applications require additional analyses and consideration of the local implementation and utilisation context. Protecting current investments and scaling up these interventions is especially crucial in the context of COVID-19-related health system disruptions. We show how cost-effectiveness data and other information can be used to define locally tailored packages of interventions to accelerate rates of decline in NCD mortality. Under realistic implementation constraints, most countries could achieve (or almost achieve) the NCD target using a combination of these interventions; the greatest gains would be for cardiovascular disease mortality. Implementing the most efficient package of interventions in each world region would require, on average, an additional US$18 billion annually over 2023-30; this investment could avert 39 million deaths and generate an average net economic benefit of $2·7 trillion, or $390 per capita. Although specific clinical intervention pathways would vary across countries and regions, policies to reduce behavioural risks, such as tobacco smoking, harmful use of alcohol, and excess sodium intake, would be relevant in nearly every country, accounting for nearly two-thirds of the health gains of any locally tailored NCD package. By 2030, ministries of health would need to contribute about 20% of their budgets to high-priority NCD interventions. Our report concludes with a discussion of financing and health system implementation considerations and reflections on the NCD agenda beyond the SDG target 3.4 and beyond the SDG period.

Healthcare system resilience in Bangladesh and Haiti in times of global changes (climate-related events, migration and Covid-19): an interdisciplinary mixed method research protocol

Background

Since climate change, pandemics and population mobility are challenging healthcare systems, an empirical and integrative research to studying and help improving the health systems resilience is needed. We present an interdisciplinary and mixed-methods research protocol, ClimHB, focusing on vulnerable localities in Bangladesh and Haiti, two countries highly sensitive to global changes. We develop a protocol studying the resilience of the healthcare system at multiple levels in the context of climate change and variability, population mobility and the Covid-19 pandemic, both from an institutional and community perspective.

Methods

The conceptual framework designed is based on a combination of Levesque’s Health Access Framework and the Foreign, Commonwealth and Development Office’s Resilience Framework to address both outputs and the processes of resilience of healthcare systems. It uses a mixed-method sequential exploratory research design combining multi-sites and longitudinal approaches. Forty clusters spread over four sites will be studied to understand the importance of context, involving more than 40 healthcare service providers and 2000 households to be surveyed. We will collect primary data through questionnaires, in-depth and semi-structured interviews, focus groups and participatory filming. We will also use secondary data on environmental events sensitive to climate change and potential health risks, healthcare providers’ functioning and organisation. Statistical analyses will include event-history analyses, development of composite indices, multilevel modelling and spatial analyses.

Discussion

This research will generate inter-disciplinary evidence and thus, through knowledge transfer activities, contribute to research on low and middle-income countries (LMIC) health systems and global changes and will better inform decision-makers and populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07294-3.

The Association between Health Workforce and Health Outcomes: A Cross-Country Econometric Study

This study investigates the strength and significance of the associations of health workforce with multiple health outcomes and COVID-19 excess deaths across countries, using the latest WHO dataset. Multiple log-linear regression analyses, counterfactual scenarios analyses, and Pearson correlation analyses were performed. The average density of health workforce and the average levels of health outcomes were strongly associated with country income level. A higher density of the health workforce, especially the aggregate density of skilled health workers and density of nursing and midwifery personnel, was significantly associated with better levels of several health outcomes, including maternal mortality ratio, under-five mortality rate, infant mortality rate, and neonatal mortality rate, and was significantly correlated with a lower level of COVID-19 excess deaths per 100 K people, though not robust to weighting by population. The low density of the health workforce, especially in relatively low-income countries, can be a major barrier to improving these health outcomes and achieving health-related SDGs; however, improving the density of the health workforce alone is far from enough to achieve these goals. Our study suggests that investment in health workforce should be an integral part of strategies to achieve health-related SDGs, and achieving non-health SDGs related to poverty alleviation and expansion of female education are complementary to achieving both sets of goals, especially for those low- and middle-income countries. In light of the strains on the health workforce during the current COVID-19 pandemic, more attention should be paid to health workforce to strengthen health system resilience and long-term improvement in health outcomes.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11205-022-02910-z.

Hospital unit costs in Jordan: insights from a country facing competing health demands and striving for universal health coverage

BACKGROUND

Public providers in Jordan are facing increasing health demands due to human crises. This study aimed to benchmark the unit costs of hospital services in public providers in Jordan to provide insights into the outlook for public health care costs.

METHODS

The unit costs of hospital services per admission, inpatient days, outpatient visits, emergency visits and surgical operations were estimated using the standard average costing method (top-down) for the fiscal year 2018-2019. The unit costs per inpatient day were estimated for nine specialities and staff in Jordanian dinars (exchange rate JOD 1 = USD 1.41).

RESULTS

The average unit cost per admission in Jordan was JOD 782.300 (USD 1101.80), the per inpatient day cost was JOD 236.600 (USD 333.20), the per bed day cost was JOD 172.900 (USD 244.90), the per outpatient visit cost was JOD 58.400 (USD 82.30), the per operation cost was JOD 449.600 (USD 633.20) and the per emergency room visit cost was JOD 31.800 (USD 44.80). The specialities of ICU/CCU and OB/GYN presented the highest unit costs per inpatient day across providers: JOD 377.800 (USD 532.90) and JOD 362.600 (USD 510.70), respectively. The average salaried unit cost of staff depended mainly on year of employment. Nonetheless, the unit costs varied depending on the service utilization, type of service and organizational outlet.

CONCLUSIONS

Knowledge of how unit costs vary across public providers in Jordan is essential to outline cost control strategies and inform future research. Institutionalization of the cost information system and high-level governmental support are necessary to generate a routine practice of collecting and sharing cost information.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

Global return on investment and cost-effectiveness of WHO's HEAR interventions for hearing loss: a modelling study

Background

To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries’ universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium.

Methods

We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario.

Findings

Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested.

Interpretation

This is the first-ever global investment case for integrating ear and hearing care interventions in countries’ universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services.

Funding

None.

Cost-Effectiveness Threshold for Healthcare: Justification and Quantification

Every public health expenditure, including the one that saves lives or extends life expectancy of particular persons (target population), bears a cost. Although cost-effectiveness analysis (CEA) is routinely performed in health policy, ethical justification of CEA is rarely discussed. Also, there is neither consensus value nor even consensus method for determining cost-effectiveness threshold (CET) for life-extending measures. In this study, we performed ethical analysis of CEA by policy impact assessment based on connection of health and wealth (poorer people have statistically shorter life expectancies) and concluded that CEA is not only a practical but also an ethical necessity. To quantify CET, we used three independent methods: (1) literature survey of analyzing salaries in risky occupations, (2) utilizing Prospect Theory suggesting that people value their lives in monetary terms twice more than their lifetime earnings, and (3) literature survey of the U.S. current legal practice. To the best of our knowledge, nobody applied method (2) to determine CET. The three methods yielded rather similar results with CET about 1.0 ± 0.4 gross domestic product per capita (GDPpc) per quality-adjusted life-year. Therefore, a sum of not higher than 140% GDPpc is statistically sufficient to “purchase” an additional year of life—or, alternatively, to “rob” one year of life if taken away. Therefore, 140% GDP per capita per quality-adjusted life-year should be considered as the upper limit of prudent and ethically justified expenditure on life extension programs.

Universal Health Coverage Policy and Progress towards the Attainment of Universal Sexual and Reproductive Health and Rights Services in Ethiopia

Critical interpretive analysis of literature review was applied to shed light on the status of universal access to Sexual and Reproductive Health and Rights (SRHR) and the progress towards Universal Health Coverage (UHC) in Ethiopia. Special emphasis was given to the determinations of the Ethiopian health policy frameworks to include comprehensive SRHR services in the UHC benefit package. Clinical services for pregnant women and newborn, abortion care, family planning, Female Genital Mutilation (FGM) complication treatment, Comprehensive Sexuality Education (CSE), and sexual health services are included in the national cost exempted services, but the latter three are not yet included in the health programs with defined objective and work plan. Capital intensive Sexual and Reproductive Health (SRH) services (such as infertility and reproductive cancers diagnosis and treatment) are not included in the UHC benefit package. Over the last two decades, a substantive progress is made in family planning service and maternal and child health, probably because they were taken as Millennium Development Goals (MDGs) indicators and have got better financial protection and political commitment. In order to include other SRHR services in the benefit package in due course and attain universal SRHR services without financial hardship in the Primary Health Care (PHC) setting, the domestic financing should be endorsed as a driving force. To make the multi-sectoral efforts towards achieving UHC and sustainable development goals (SDGs) complete, building resilient health systems through the humanitarian-development nexus for health systems strengthening in fragile setting should be equally prioritized, thereby leaving no one behind underserved.

NATIONAL HEALTH EXPENDITURE TRENDS, 2000 TO 2019

OBJECTIVE

The aim: To assess the long-term dynamics of health spending in Ukraine from the standpoint of readiness to make progress in the universal health coverage (UHC).

PATIENTS AND METHODS

Materials and methods: Data from the Global Health Expenditure Database, European Health for All database, World Bank Open Data, collected during 2000-2019 were used. The research was conducted using bibliosemantic, historical methods and benchmarking.

RESULTS

Results: All indicators of health spending in Ukraine showed some growth: total and government health spending of % Gross Domestic Product (GDP) by 34% (95% CI 13-55) and 28% (95% CI 8-48), total and government health spending per capita in US $ by 7.1 and 6.5 times and in Purchasing power parity (PPP) - by 4 and 3.8 times. Growth was interrupted during the global (2008) and national (2017-2019) financial crises. Out-of-pocket spending in Ukraine grew and amounted to 51.1% in 2019, which is by 2.1 times more than in the European region - 24.0% (15.5; 36.6). In 2019 Ukraine ranked among 10% of the countries with the worst combination of government health spending per share of GDP and share of OOPS in total health spending.

CONCLUSION

Conclusions: The study found an unsustainable upward dynamic in health spending. In the last decade, there has been a clear trend towards an increase % OOPS in total health spending against low, aimed at reducing government health spending as % of GDP, which could negatively affect UHC.

Addressing the Impact of Noncommunicable Diseases and Injuries (NCDIs) in Ethiopia: Findings and Recommendations from the Ethiopia NCDI Commission

BACKGROUND

Noncommunicable diseases and injuries (NCDIs) are the leading causes of premature mortality globally. Ethiopia is experiencing a rapid increase in NCDI burden. The Ethiopia NCDI Commission aimed to determine the burden of NCDIs, prioritize health sector interventions for NCDIs and estimate the cost and available fiscal-space for NCDI interventions.

METHODS

We retrieved data on NCDI disease burden and concomitant risk factors from the Global Burden of Disease (GBD) Study, complemented by systematic review of published literature from Ethiopia. Cost-effective interventions were identified through a structured priority-setting process and costed using the One Health tool. We conducted fiscal-space analysis to identify an affordable package of NCDI services in Ethiopia.

RESULTS

We find that there is a large and diverse NCDI disease burden and their risk factors such as hypertension and diabetes (these conditions are NCDIs themselves and could be risk factors to other NCDIs), including less common but more severe NCDIs such as rheumatic heart disease and cancers in women. Mental, neurological, chronic respiratory and surgical conditions also contribute to a substantial proportion of NCDI disease burden in Ethiopia. Among an initial list of 235 interventions, the commission recommended 90 top-priority NCDI interventions (including essential surgery) for implementation. The additional annual cost for scaling up of these interventions was estimated at US$550m (about US$4.7 per capita).

CONCLUSIONS

A targeted investment in cost-effective interventions could result in substantial reduction in premature mortality and may be within the projected fiscal space of Ethiopia. Innovative financing mechanisms, multi-sectoral governance, regional implementation, and an integrated service delivery approach mainly using primary health care are required to achieve these goals.

Economic consequences of caesarean section delivery: evidence from a household survey in Tanzania

BACKGROUND

Caesarean section (C-section) delivery is an important indicator of access to life-saving essential obstetric care. Yet, there is limited understanding of the costs of utilising C-section delivery care in sub-Saharan Africa. Thus, we estimated the direct and indirect patient cost of accessing C-section in Tanzania.

METHODS

Cross-sectional survey data of 2012 was used, which covered 3000 households from 11 districts in three regions. We interviewed women who had given births in the last 12 months before the survey to capture their experience of care. We used a regression model to estimate the effect of C-section on costs, while the degree of inequality on C-section coverage was assessed with a concentration index.

RESULTS

C-section increased the likelihood of paying for health care by 16% compared to normal delivery. The additional cost of C-section compared to normal delivery was 20 USD, but reduced to about 11 USD when restricted to public facilities. Women with C-section delivery spent an extra 2 days at the health facility compared to normal delivery, but this was reduced slightly to 1.9 days in public facilities. The distribution of C-section coverage was significantly in favour of wealthier than poorest women (CI = 0.2052, p < 0.01), and this pro-rich pattern was consistent in rural districts but with unclear pattern in urban districts.

CONCLUSIONS

C-section is a life-saving intervention but is associated with significant economic burden especially among the poor families. More health resources are needed for provision of free maternal care, reduce inequality in access and improve birth outcomes in Tanzania.

Review of the inclusion of SRHR interventions in essential packages of health services in low- and lower-middle income countries

Sexual and reproductive health and rights (SRHR) and universal health coverage (UHC) are fundamental to health as a human right. One way that countries operationalise UHC is through the development of an essential package of health services (EPHS), which describes a list of clinical and public health services that a government aspires to provide for their population. This study reviews the contents of 46 countries' EPHS against the standard of the Guttmacher-Lancet Report's (GLR) nine essential SRHR interventions. The analysis is conducted in two steps; EPHS are first categorised according to the level of specificity of their contents using a case classification scheme, then the most detailed EPHS are mapped onto the GLR's nine essential SRHR interventions. The results highlight the variations of EPHS and provide information on the inclusion of the GLR nine essential SRHR interventions in low- and lower-middle income countries' EPHS. This study also proposes a case classification scheme as an analytical tool to conceptualise how EPHS fall along a spectrum of specificity and defines a set of keywords for evaluating the contents of policies against the standard of the GLR. These analytical tools and findings can be relevant for policymakers, researchers, and organisations involved in SRHR advocacy to better understand the variations in detail among countries' EPHS and compare governments' commitment to SRHR as a human right.

The cost-effectiveness of sexual and reproductive health and rights interventions in low- and middle-income countries: a scoping review

Sexual and reproductive health and rights (SRHR) are an essential component of universal health coverage (UHC). In determining which SRHR interventions to include in their UHC benefits package, countries are advised to evaluate each service based on robust and reliable data, including cost-effectiveness data. We conducted a scoping review of full economic evaluations of the essential SRHR interventions included in the comprehensive package presented by the Guttmacher-Lancet Commission on SRHR. Of the 462 economic evaluations that met the inclusion criteria, the quantity of publications varied across regions, countries, and the components of the SRHR package, with the majority of publications reporting on HIV/AIDS, reproductive cancer, as well as antenatal care, childbirth, and postnatal care. Systematic reviews are needed for these components in support of more conclusive findings and actionable recommendations for programmes and policy. Further evaluations for interventions included in the remaining components are needed to provide a stronger evidence base for decision-making. The economic evaluations reviewed for this article were inherently varied in their applied methodologies, SRHR interventions and comparators, cost and effectiveness data, and cost-effectiveness thresholds, among others. Despite these differences, the vast majority of publications reported the evaluated SRHR interventions to be cost-effective.