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Ifeagwu SC, Nakaboga Kikonyogo R, Nakkazi S, Beinomugisha J, Ojiambo Wandera S, Kiwanuka SN, King R, Van Bortel T, Brayne C, Parkes-Ratanshi R. "Sickness has no time": Awareness and perceptions of health care workers on universal health coverage in Uganda. PLoS One 2024; 19:e0306922. [PMID: 39024379 PMCID: PMC11257248 DOI: 10.1371/journal.pone.0306922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 06/25/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION Each person having access to needed health services, of sufficient quality, and without suffering financial hardship, defined as universal health coverage (UHC) by the World Health Organization, is critical to improve population health, particularly for vulnerable populations. UHC requires multisectoral collaboration and good governance, and this will require buy-in of key stakeholders; but their views are under-documented. The aim of this stakeholder analysis was to explore the awareness and perceptions of UHC by health care workers (HCWs) in Uganda. METHODS A mixed-methods study was conducted based on primary data from HCWs including an online QualtricsXM survey of 274 HCWs (from a database of persons who had received training at an academic institution), 23 key informant semi-structured interviews, and one eight-person focus group discussion. Data was collected from February to April 2022. Microsoft Excel and R Programme were used for quantitative analyses and NVivo version 12 for qualitative analyses. RESULTS HCWs attributed a high level of importance to UHC in Uganda. Participants discussed national communication and management practices, organisational roles, health financing and power dynamics, health care demand and the impact of and learnings from COVID-19. Four main themes-each with related sub-themes-emerged from the interview data providing insights into: (1) communication, (2) organisation, (3) power, and (4) trust. CONCLUSION There is a critical need for better communication of UHC targets by policymakers to improve understanding at a grassroots level. Results indicated that ensuring trust among the population through transparency in metrics and budgets, strong accountability measures, awareness of local cultural sensitivities, sensitisation of the UHC concept and community inclusion will be essential for a multisectoral roll out of UHC. Further provision of quality health services, a harmonisation of efforts, increased domestic health financing and investment of HCWs through fair remuneration will need to underpin the delivery of UHC.
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Affiliation(s)
- Susan C. Ifeagwu
- Cambridge Public Health, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Ruth Nakaboga Kikonyogo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzan Nakkazi
- The Academy for Health Innovation, Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joshua Beinomugisha
- The Academy for Health Innovation, Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Stephen Ojiambo Wandera
- Department of Population Studies, School of Statistics and Planning, College of Business and Management Sciences, Makerere University, Kampala, Uganda
| | - Suzanne N. Kiwanuka
- Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Rachel King
- Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Tine Van Bortel
- Cambridge Public Health, Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
- Leicester School of Applied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester, United Kingdom
| | - Carol Brayne
- Cambridge Public Health, Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Rosalind Parkes-Ratanshi
- Cambridge Public Health, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- The Academy for Health Innovation, Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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Bayked EM, Assfaw AK, Toleha HN, Zewdie S, Biset G, Ibirongbe DO, Kahissay MH. Willingness to pay for National Health Insurance Services and Associated Factors in Africa and Asia: a systematic review and meta-analysis. Front Public Health 2024; 12:1390937. [PMID: 38706546 PMCID: PMC11066245 DOI: 10.3389/fpubh.2024.1390937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 03/20/2024] [Indexed: 05/07/2024] Open
Abstract
Background Universal health coverage (UHC) is crucial for public health, poverty eradication, and economic growth. However, 97% of low- and middle-income countries (LMICs), particularly Africa and Asia, lack it, relying on out-of-pocket (OOP) expenditure. National Health Insurance (NHI) guarantees equity and priorities aligned with medical needs, for which we aimed to determine the pooled willingness to pay (WTP) and its influencing factors from the available literature in Africa and Asia. Methods Database searches were conducted on Scopus, HINARI, PubMed, Google Scholar, and Semantic Scholar from March 31 to April 4, 2023. The Joanna Briggs Institute's (JBI's) tools and the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement" were used to evaluate bias and frame the review, respectively. The data were analyzed using Stata 17. To assess heterogeneity, we conducted sensitivity and subgroup analyses, calculated the Luis Furuya-Kanamori (LFK) index, and used a random model to determine the effect estimates (proportions and odds ratios) with a p value less than 0.05 and a 95% CI. Results Nineteen studies were included in the review. The pooled WTP on the continents was 66.0% (95% CI, 54.0-77.0%) before outlier studies were not excluded, but increased to 71.0% (95% CI, 68-75%) after excluding them. The factors influencing the WTP were categorized as socio-demographic factors, income and economic issues, information level and sources, illness and illness expenditure, health service factors, factors related to financing schemes, as well as social capital and solidarity. Age has been found to be consistently and negatively related to the WTP for NHI, while income level was an almost consistent positive predictor of it. Conclusion The WTP for NHI was moderate, while it was slightly higher in Africa than Asia and was found to be affected by various factors, with age being reported to be consistently and negatively related to it, while an increase in income level was almost a positive determinant of it.
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Affiliation(s)
- Ewunetie Mekashaw Bayked
- Department of Pharmacy, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | - Abebe Kibret Assfaw
- Department of Psychology, Institute of Teachers’ Education and Behavioral Science, Wollo University, Dessie, Ethiopia
| | - Husien Nurahmed Toleha
- Department of Pharmacy, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | - Segenet Zewdie
- Department of Pharmacy, College of Medicine and Health Science, Injibara University, Injibara, Ethiopia
| | - Gebeyaw Biset
- Department of Pediatrics and Child Health Nursing, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | | | - Mesfin Haile Kahissay
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Parmar D, Mathauer I, Bloom D, Dkhimi F, Abuosi AA, Chen D, Chukwuma A, de Claro V, Comsa R, Domingo AF, Doroshenko O, Gong E, Goroshko A, Nketiah-Amponsah E, Lylozian H, Nkangu M, Onwujekwe O, Obikeze O, Pattnaik A, Rivillas JC, Tapkigen J, Vîlcu I, Wang H, Wee Co PA. Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries. Health Policy Plan 2024; 39:213-223. [PMID: 38261999 PMCID: PMC10883665 DOI: 10.1093/heapol/czad121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024] Open
Abstract
The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.
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Affiliation(s)
- Divya Parmar
- Department for Population Health, School for Life Course and Population Sciences, King’s College London, Guy’s Campus, London SE1 1UL, UK
| | - Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva 1211, Switzerland
| | - Danielle Bloom
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington D.C. 20433, USA
| | - Fahdi Dkhimi
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva 1211, Switzerland
| | - Aaron Asibi Abuosi
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra P.O. Box LG 78, Ghana
| | - Dorothee Chen
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Adanna Chukwuma
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Vergil de Claro
- RTI International Philippines, 16F Strata 2000, Ortigas Center, Pasig City 1600, Philippines
| | - Radu Comsa
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | | | - Olena Doroshenko
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Estelle Gong
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Alona Goroshko
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Edward Nketiah-Amponsah
- Department of Economics, University of Ghana, University of Ghana Kumasi City Campus, Legon Accra P. O. Box LG57, Ghana
| | - Hratchia Lylozian
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Miriam Nkangu
- Health Promotion Alliance Cameroon, Youandé, Cameroon
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu 400001, Nigeria
| | - Obioma Obikeze
- Department of Community Medicine, Federal Medical Centre, No. 1 Hospital Road, Ovom, Yenagoa, Bayelsa 560231, Nigeria
| | | | - Juan Carlos Rivillas
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Janet Tapkigen
- International Doctoral Programme in Epidemiology and Public Health, Tampere University, Kalevantie 4, Tampere 33100, Finland
| | - Ileana Vîlcu
- ThinkWell, Regus, Nations Business Centre, 6th floor Rue du Pré-de-la-Bichette 1, Geneva 1202, Switzerland
| | - Huihui Wang
- Health, Nutrition, and Population Global Practice, Europe and Central Asia Region, World Bank Group, 1818 H Street, N.W., Washington D.C. 20433, USA
| | - Pura Angela Wee Co
- ThinkWell, Regus Plaza Bldg., United Nations Avenue, Manila 1000, Philippines
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Mhazo AT, Maponga CC. Retracing loss of momentum for primary health care: can renewed political interest in the context of COVID-19 be a turning point? BMJ Glob Health 2023; 8:e012668. [PMID: 37474277 PMCID: PMC10360423 DOI: 10.1136/bmjgh-2023-012668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/25/2023] [Indexed: 07/22/2023] Open
Abstract
The COVID-19 pandemic has revealed major weaknesses in primary health care (PHC), and how such weaknesses pose a catastrophic threat to humanity. As a result, strengthening PHC has re-emerged as a global health priority and will take centre stage at the 2023 United Nations High Level Meeting (UNHLM) on Universal Health Coverage (UHC). In this analysis, we examine why, despite its fundamental importance and incredible promise, the momentum for PHC has been lost over the years. The portrayal of PHC itself (policy image) and the dominance of global interests has undermined the attractiveness of intended PHC reforms, leading to legacy historical policy choices (critical junctures) that have become extremely difficult to dismantle, even when it is clear that such choices were a mistake. PHC has been a subject of several political declarations, but post-declarative action has been weak. The COVID-19 provides a momentous opportunity under which the image of PHC has been reconstructed in the context of health security, breaking away from the dominant social justice paradigms. However, we posit that effective PHC investments are those that are done under calm conditions, particularly through political choices that prioritise the needs of the poor who continue to face a crisis even in non-pandemic situations. In the aftermath of the 2023 UNHLM on UHC, country commitment should be evaluated based on the technical and financial resources allocated to PHC and tangible deliverables as opposed to the formulation of documents or convening of a gathering that simply (re) endorses the concept.
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Affiliation(s)
- Alison T Mhazo
- Community Health Sciences Unit (CHSU), Ministry of Health, Lilongwe, Malawi
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Chikhradze T, Brainerd EL, Ishtiaq A, Alperson R. How to become a strategic purchaser of rehabilitation services. Bull World Health Organ 2022; 100:709-716. [PMID: 36324546 PMCID: PMC9589378 DOI: 10.2471/blt.21.287499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 06/16/2023] Open
Abstract
Rehabilitative care is often overlooked and underfunded despite being a key component of universal health coverage, and now faces further neglect due to indirect impacts of the coronavirus disease 2019 pandemic. Policy-makers can leverage strategic purchasing approaches to make the most of available funds and maximize health gains. To implement more strategic purchasing of rehabilitation, health planners must: (i) develop and prioritize evidence-based rehabilitation service packages; (ii) use fit-for-purpose contracting and provider payment mechanisms to incentivize quality and efficient service delivery; and (iii) strengthen stewardship. This paper examines these three policy priorities by analysing their associated processes, actors and resources based on country experiences. Policy-makers will likely face several obstacles in operationalizing these policy priorities, including: inadequate accountability and coordination among sectors; limited data and research; undefined and non-standardized rehabilitation services, costs and outcomes; and inadequate availability of rehabilitative care. To overcome challenges and institute optimal strategic purchasing practices for rehabilitation, we recommend that policy-makers strengthen health sector stewardship and establish a framework for multisectoral collaboration, invest in data and research and make use of available experience from high-income settings, while creating a body of evidence from low- and middle-income settings.
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Affiliation(s)
- Tamara Chikhradze
- Results for Development, Suite 700, 1111 19th Street, Washington, District of Columbia, 20036, United States of America
| | - Emma L Brainerd
- Results for Development, Suite 700, 1111 19th Street, Washington, District of Columbia, 20036, United States of America
| | - Adeel Ishtiaq
- Results for Development, Suite 700, 1111 19th Street, Washington, District of Columbia, 20036, United States of America
| | - Reva Alperson
- Results for Development, Suite 700, 1111 19th Street, Washington, District of Columbia, 20036, United States of America
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Cashin C, Kimathi G, Otoo N, Bloom D, Gatome-Munyua A. SPARC the Change: What the Strategic Purchasing Africa Resource Center Has Learned about Improving Strategic Health Purchasing in Africa. Health Syst Reform 2022; 8:2149380. [PMID: 36473127 DOI: 10.1080/23288604.2022.2149380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Embodied in the goals of universal health coverage (UHC) are societal norms about ethics, equity, solidarity, and social justice. As African countries work toward UHC, it is important for their governments to use all available resources, knowledge, and networks to continue to bring this goal closer to reality for their populations. The Strategic Purchasing Africa Resource Center (SPARC) was established in 2018 as a "go-to" source of Africa-based expertise in strategic health purchasing, which is a critical policy tool for making more effective use of limited funds for UHC. SPARC facilitates collaboration among governments and research partners across Africa to fill gaps in knowledge on how to make progress on strategic purchasing. The cornerstone of this work has been the development and use of the Strategic Health Purchasing Progress Tracking Framework to garner insights from each country's efforts to make health purchasing more strategic. Application of the framework and subsequent dialogue within and between countries generated lessons on effective purchasing approaches that other countries can apply as they chart their own course to use strategic purchasing more effectively. These lessons include the need to clarify the roles of purchasing agencies, define explicit benefit packages as a precondition for other strategic purchasing functions, use contracting to set expectations, start simple with provider payment and avoid open-ended payment mechanisms, and use collaborative rather than punitive provider performance monitoring. SPARC has also facilitated learning on the "how-to" and practical steps countries can take to make progress on strategic purchasing to advance UHC.
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Affiliation(s)
- Cheryl Cashin
- Results for Development, Health Portfolio, Washington, DC, USA
| | - George Kimathi
- Amref Health Africa, Institute of Capacity Development (ICD), Nairobi, Kenya
| | | | - Danielle Bloom
- Results for Development, Health Portfolio, Toronto, Canada
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Umuhoza SM, Musange SF, Nyandwi A, Gatome-Munyua A, Mumararungu A, Hitimana R, Rulisa A, Uwaliraye P. Strengths and Weaknesses of Strategic Health Purchasing for Universal Health Coverage in Rwanda. Health Syst Reform 2022; 8:e2061891. [PMID: 35696425 DOI: 10.1080/23288604.2022.2061891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
In the context of scarce resources and increasing health care costs, strategic purchasing is viewed as a key mechanism to spur countries' progress toward universal health coverage (UHC), by using limited resources more effectively. We applied the Strategic Health Purchasing Progress Tracking Framework to examine the health purchasing arrangements in three health financing schemes in Rwanda-the Community Based Health Insurance (CBHI) scheme, the Rwanda Social Security Board (RSSB) medical scheme, and performance-based financing (PBF). Data were collected from secondary and primary sources between September 2020 and March 2021.The objective of the study was to identify areas of progress in strategic purchasing that can be built on, and to identify areas of overlap, duplication, or conflict that limit progress in strategic purchasing to advance UHC goals. This study found that Rwanda has made progress in many areas of strategic purchasing and has a strong foundation for building further. However, some overlaps and duplication of functions weaken the power of purchasers to improve resource allocation, incentives for providers, and accountability. In addition, some of the policies within the purchasing functions could be made more strategic. In particular, open-ended fee-for-service payment in the CBHI scheme not only threatens the scheme's financial sustainability but also imposes a high administrative burden. Better alignment and integration of contracting, incentives, and information system design to provide timely and relevant information for purchasing decisions would contribute to more strategic health purchasing and ensure that Rwanda's health sector achievements are sustained and expanded.
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Affiliation(s)
- Stella M Umuhoza
- School of Public Health, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Sabine F Musange
- School of Public Health, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Alypio Nyandwi
- Department of Planning, Monitoring and Evaluation and Health Financing, Rwanda Ministry of Health, Kigali, Rwanda
| | | | - Angeline Mumararungu
- Department of Planning, Monitoring and Evaluation and Health Financing, Rwanda Ministry of Health, Kigali, Rwanda
| | - Regis Hitimana
- Health Benefits Department Rwanda Social Security Board, Kigali, Rwanda
| | - Alexis Rulisa
- Community Based Health Insurance Department, Rwanda Social Security Board, Kigali, Rwanda
| | - Parfait Uwaliraye
- Department of Planning, Monitoring and Evaluation and Health Financing, Rwanda Ministry of Health, Kigali, Rwanda
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Gatome-Munyua A, Cashin C. Introduction to the Special Issue on Making Progress on Strategic Health Purchasing in Africa. Health Syst Reform 2022; 8:2129026. [PMID: 36174651 DOI: 10.1080/23288604.2022.2129026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
| | - Cheryl Cashin
- Health Portfolio, Results for Development, Washington, DC, USA
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