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Njie H, Dale E, Gopinathan U. Procedural fairness in decision-making for financing a National Health Insurance Scheme: a case study from The Gambia. Health Policy Plan 2023; 38:i73-i82. [PMID: 37963076 PMCID: PMC10645046 DOI: 10.1093/heapol/czad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/29/2023] [Accepted: 07/27/2023] [Indexed: 11/16/2023] Open
Abstract
Achieving universal health coverage (UHC) involves difficult policy choices, and fair processes are critical for building legitimacy and trust. In 2021, The Gambia passed its National Health Insurance (NHI) Act. We explored decision-making processes shaping the financing of the NHI scheme (NHIS) with respect to procedural fairness criteria. We reviewed policy and strategic documents on The Gambia's UHC reforms to identify key policy choices and interviewed policymakers, technocrats, lawmakers, hospital chief executive officers, private sector representatives and civil society organizations (CSOs) including key CSOs left out of the NHIS discussions. Ministerial budget discussions and virtual proceedings of the National Assembly's debate on the NHI Bill were observed. To enhance public scrutiny, Gambians were encouraged to submit views to the National Assembly's committee; however, the procedures for doing so were unclear, and it was not possible to ascertain how these inputs were used. Despite available funds to undertake countrywide public engagement, the public consultations were mostly limited to government institutions, few trade unions and a handful of urban-based CSOs. While this represented an improved approach to public policy-making, several CSOs representing key constituents and advocating for the expansion of exemption criteria for insurance premiums to include more vulnerable groups felt excluded from the process. Overload of the National Assembly's legislative schedule and lack of National Assembly committee quorum were cited as reasons for not engaging in countrywide consultations. In conclusion, although there was an intent from the Executive and National Assembly to ensure transparent, participatory and inclusive decision-making, the process fell short in these aspects. These observations should be seen in the context of The Gambia's ongoing democratic transition where institutions for procedural fairness are expected to progressively improve. Learning from this experience to enhance the procedural fairness of decision-making can promote inclusiveness, ownership and sustainability of the NHIS in The Gambia.
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Affiliation(s)
- Hassan Njie
- Department of Community Medicine and Global Health, University of Oslo, Postboks 1130 Blindern, Oslo 0318, Norway
| | - Elina Dale
- Cluster for Global Health, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Unni Gopinathan
- Cluster for Global Health, Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
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Sumankuuro J, Griffiths F, Koon AD, Mapanga W, Maritim B, Mosam A, Goudge J. The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review. Int J Health Policy Manag 2023; 12:7352. [PMID: 38618795 PMCID: PMC10699827 DOI: 10.34172/ijhpm.2023.7352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/18/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals. METHODS We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively. RESULTS Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members. CONCLUSION We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.
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Affiliation(s)
- Joshua Sumankuuro
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Public Policy and Management, SD Dombo University of Business and Integrated Development Studies, Wa, Ghana
- School of Community Health, Charles Sturt University, Orange, NSW, Australia
| | - Frances Griffiths
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Adam D. Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Witness Mapanga
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Beryl Maritim
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Atiya Mosam
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Bust L, Whyle E, Olivier J. A discourse and content analysis of representation in the mainstream media of the South African National Health Insurance policy from 2011 to 2019. BMC Public Health 2023; 23:279. [PMID: 36750805 PMCID: PMC9904875 DOI: 10.1186/s12889-023-15144-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 01/27/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Media is a crucial factor in shaping public opinion and setting policy agendas. There is limited research on the role of media in health policy processes in low- and middle-income countries. This study profiles South Africa as a case example, currently in the process of implementing a major health policy reform, National Health Insurance (NHI). METHODS A descriptive, mixed methods study was conducted in five sequential phases. Evidence was gathered through a scoping review of secondary literature; discourse analysis of global policy documents on universal health coverage and South African NHI policy documents; and a content and discourse analysis of South African print and online media texts focused on NHI. Representations within media were analysed and dominant discourses that might influence the policy process were identified. RESULTS Discourses of 'health as a global public good' and 'neoliberalism' were identified in global and national policy documents. Similar neoliberal discourse was identified within SA media. Unique discourses were identified within SA media relating to biopolitics and corruption. Media representations revealed political and ideological contestation which was not as present in the global and national policy documents. Media representations did not mirror the lived reality of most of the South African population. The discourses identified influence the policy process and hinder public participation in these processes. They reinforce social hierarchy and power structures in South Africa, and might reinforce current inequalities in the health system, with negative repercussions for access to health care. CONCLUSIONS There is a need to understand mainstream media as part of a people-centred health system, particularly in the context of universal health coverage reforms such as NHI. Harmful media representations should be counter-acted. This requires the formation of collaborative and sustainable networks of policy actors to develop strategies on how to leverage media within health policy to support policy processes, build public trust and social cohesion, and ultimately decrease inequalities and increase access to health care. Research should be undertaken to explore media in other diverse formats and languages, and in other contexts, particularly low- and middle-income countries, to further understand media's role in health policy processes.
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Affiliation(s)
- Lynn Bust
- Health Policy and Systems Division, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Eleanor Whyle
- grid.7836.a0000 0004 1937 1151Health Policy and Systems Division, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jill Olivier
- grid.7836.a0000 0004 1937 1151Health Policy and Systems Division, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions? Health Res Policy Syst 2023; 21:7. [PMID: 36670433 PMCID: PMC9862822 DOI: 10.1186/s12961-022-00952-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 12/17/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Despite political promise to reduce out-of-pocket (OOP) expenditure on healthcare through the National Health Insurance Program (NHIP) of Nepal, its implementation is challenging with low enrolment and high drop-out rates. Program performance can often be linked with political economy considerations and interests of stakeholders. This study aimed to develop an in-depth understanding of organizational and systemic challenges in implementing NHIP. METHODS We conducted a structured narrative review of available literature on the NHIP in Nepal. We analysed data using a political economy analysis for health financing reform framework. The findings were explained under six broad categories: interest groups, bureaucracy, budgets, leadership, beneficiary and external actors. In addition, we triangulated and further presented the literature review findings using expert opinions (views expressed in public forums). RESULTS Nepal has formulated acts, rules, regulations, and policies to implement NHIP. Under this program, the Health Insurance Board (HIB) is the purchaser of health services, and health facilities under the Ministry of Health and Population (MoHP) are the providers. The NHIP has been rolled out in all 77 districts. Several challenges have hindered the performance of NHIP at the policy and implementation levels. Challenges under interest groups included inadequate or delayed reimbursement and drop-out of hospitals in implementing the programme. Bureaucracy-related challenges were hegemony of provider over the purchaser, and inadequate staff (delay in the approval of organogram of HIB). There was inadequate monitoring of premium collection, and claim reimbursement was higher than collected premium. Challenges under leadership included high political commitments but weak translation into action, consideration of health insurance as poor return on investment, and intention of leaders to privatize the NHIP. Beneficiaries experienced compromised quality of care or lack of services when needed, high drop-out rates and low interest in renewal of premiums. External actors provided technical assistance in policy design but limited support in implementation. CONCLUSIONS Despite enabling a policy environment, the NHIP faced many challenges in implementation. There is an urgent need for institutional arrangements (e.g. digitalization of claims and reimbursement, endorsement of organogram of HIB and recruitment of staff), increased coverage of financial protection and service (increased benefit package and introduction of cost-sharing/co-payment model), legislative reforms (e.g. legal provision for cost-sharing mechanism, integration of fragmented schemes, tripartite agreement to reimburse claims and accreditation of health facilities to ensure quality healthcare), and leveraging technical support from the external actors. High levels of commitment and accountability among political leaders and bureaucrats are required to strengthen financial sustainability and implementation.
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Kachapila M, Kigozi J, Oppong R. Exploring the roles of players in strategic purchasing for healthcare in Africa-a scoping review. Health Policy Plan 2022; 38:97-108. [PMID: 36318330 PMCID: PMC9849715 DOI: 10.1093/heapol/czac093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2022] Open
Abstract
Following the World Health Organization (WHO) guidance on strategic purchasing in 2000, low- and middle-income countries (LMICs) are trying to shift from passive purchasing (using fixed budgets) to strategic purchasing of healthcare which ties reimbursement to outcomes. However, there is limited evidence on strategic purchasing in Africa. We conducted a scoping literature review aimed at summarizing the roles played by governments, purchasers and providers in relation to citizens/population in strategic purchasing in Africa. The review searched for scientific journal articles that contained data on strategic purchasing collected from Africa. The literature search identified 957 articles of which 80 matched the inclusion criteria and were included in the review. The study revealed that in some countries strategic purchasing has been used as a tool for healthcare reforms or for strengthening systems that were not functional under fixed budgets. However, there was some evidence of a lack of government commitment in taking leading roles and funding strategic purchasing. Further, in some countries the laws need to be revised to accommodate new arrangements that were not part of fixed budgets. The review also established that there were some obstacles within the public health systems that deterred purchasers from promoting efficiency among providers and that prevented providers from having full autonomy in decision making. As African countries strive to shift from passive to strategic purchasing of healthcare, there is need for full government commitment on strategic purchasing. There is need to further revise appropriate legal frameworks to support strategic purchasing, conduct assessments of the healthcare systems before designing strategic purchasing schemes and to sensitize the providers and citizens on their roles and entitlements respectively.
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Affiliation(s)
- Mwayi Kachapila
- *Corresponding author. Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail:
| | - Jesse Kigozi
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Raymond Oppong
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Paluku J, Kitambala E, Furaha CM, Bulu Bobina R, Habamungu P, Camara BS, Sidibe S, Banze Kyongolwa DF, Tripathi V, Delamou A. Integrating Client Tracker Tool Into Fistula Management: Experience From the Fistula Care Plus Project in the Democratic Republic of Congo, 2017 to 2019. Front Public Health 2022; 10:902107. [PMID: 35757601 PMCID: PMC9218534 DOI: 10.3389/fpubh.2022.902107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/16/2022] [Indexed: 11/20/2022] Open
Abstract
This study aimed to document the experience of integration and the contribution of the Client Tracker (CT) to female genital fistula (FGF) management and data quality in sites supported by the Fistula Care+ Project in the Democratic Republic of Congo (DRC), from 2017 to 2019. It was a parallel mixed methods study using routine quantitative data and qualitative data from in-depth interviews with the project staff. Quantitative findings indicated that CT forms were present in the medical records of 63% of patients; of these, 38% were completely filled out, and 29% were correctly filled out. Qualitative findings suggested that the level of use of CT in the management of FGF was associated with staff familiarity with the CT, staff understanding of concepts in the CT forms, and the CT-related additional workload. The CT has mainly contributed to improving data quality and reporting, quality of care, follow-up of fistula patients, and self-supervision of management activities. A possible simplification of the CT and/or harmonization of its content with existing routine forms, coupled with adequate continuous training of staff on record-keeping, would further contribute to maximizing CT effectiveness and sustainability.
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Affiliation(s)
| | | | | | | | | | - Bienvenu Salim Camara
- Africa Center of Excellence for Communicable Diseases Prevention and Control (CEA-PCMT), University Gamal Abdel Nasser, Conakry, Guinea.,Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Sidikiba Sidibe
- Africa Center of Excellence for Communicable Diseases Prevention and Control (CEA-PCMT), University Gamal Abdel Nasser, Conakry, Guinea
| | | | | | - Alexandre Delamou
- Africa Center of Excellence for Communicable Diseases Prevention and Control (CEA-PCMT), University Gamal Abdel Nasser, Conakry, Guinea.,Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
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Abiiro GA, Alatinga KA, Yamey G. Why did Ghana's national health insurance capitation payment model fall off the policy agenda? A regional level policy analysis. Health Policy Plan 2021; 36:869-880. [PMID: 33956959 PMCID: PMC8227458 DOI: 10.1093/heapol/czab016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 11/29/2022] Open
Abstract
Provider payment reforms, such as capitation, are very contentious. Such reforms can drop off the policy agenda due to political and contextual resistance. Using the Shiffman and Smith (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007; 370 1370–9) framework, this study explains why Ghana’s National Health Insurance capitation payment policy that rose onto the policy agenda in 2012, dropped off the agenda in 2017 during its pilot implementation in the Ashanti region. We conducted a retrospective qualitative policy analysis by collecting field data in December 2019 in the Ashanti region through 18 interviews with regional and district level policy actors and four focus group discussions with community-level policy beneficiaries. The thematically analysed field data were triangulated with media reports on the policy. We discovered that technically framing capitation as a cost-containment strategy with less attention on portraying its health benefits resulted in a politically negative reframing of the policy as a strategy to punish fraudulent providers and opposition party electorates. At the level of policy actors, pilot implementation was constrained by a regional level anti-policy community, weak civil society mobilization and low trust in the then political leadership. Anti-policy campaigners drew on highly contentious and poorly implemented characteristics of the policy to demand cancellation of the policy. A change in government in 2017 created the needed political window for the suspension of the policy. While it was technically justified to pilot the policy in the stronghold of the main opposition party, this decision carried political risks. Other low- and middle-income countries considering capitation reforms should note that piloting potentially controversial policies such as capitation within a politically sensitive location can attract unanticipated partisan political interest in the policy. Such partisan interest can potentially lead to a decline in political attention for the policy in the event of a change in government.
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Affiliation(s)
- Gilbert Abotisem Abiiro
- Department of Planning, Faculty of Planning and Land Management, Simon Diedong Dombo University of Business and Integrated Development Studies, P. O. Box UPW 3, Wa, Ghana.,University for Development Studies, P. O. Box TL 1350, Tamale, Ghana
| | - Kennedy A Alatinga
- University for Development Studies, P. O. Box TL 1350, Tamale, Ghana.,Department of Community Development, Faculty of Planning and Land Management, Simon Diedong Dombo University of Business and Integrated Development Studies, P. O. Box UPW 3, Wa, Ghana
| | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC 27701, USA
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Jones CM, Gautier L, Ridde V. A scoping review of theories and conceptual frameworks used to analyse health financing policy processes in sub-Saharan Africa. Health Policy Plan 2021; 36:1197-1214. [PMID: 34027987 DOI: 10.1093/heapol/czaa173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2020] [Indexed: 11/15/2022] Open
Abstract
Health financing policies are critical policy instruments to achieve Universal Health Coverage, and they constitute a key area in policy analysis literature for the health policy and systems research (HPSR) field. Previous reviews have shown that analyses of policy change in low- and middle-income countries are under-theorised. This study aims to explore which theories and conceptual frameworks have been used in research on policy processes of health financing policy in sub-Saharan Africa and to identify challenges and lessons learned from their use. We conducted a scoping review of literature published in English and French between 2000 and 2017. We analysed 23 papers selected as studies of health financing policies in sub-Saharan African countries using policy process or health policy-related theory or conceptual framework ex ante. Theories and frameworks used alone were from political science (35%), economics (9%) and HPSR field (17%). Thirty-five per cent of authors adopted a 'do-it-yourself' (bricolage) approach combining theories and frameworks from within political science or between political science and HPSR. Kingdon's multiple streams theory (22%), Grindle and Thomas' arenas of conflict (26%) and Walt and Gilson's policy triangle (30%) were the most used. Authors select theories for their empirical relevance, methodological rational (e.g. comparison), availability of examples in literature, accessibility and consensus. Authors cite few operational and analytical challenges in using theory. The hybridisation, diversification and expansion of mid-range policy theories and conceptual frameworks used deductively in health financing policy reform research are issues for HPSR to consider. We make three recommendations for researchers in the HPSR field. Future research on health financing policy change processes in sub-Saharan Africa should include reflection on learning and challenges for using policy theories and frameworks in the context of HPSR.
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Affiliation(s)
- Catherine M Jones
- London School of Economics and Political Science, LSE Health, Houghton Street, London WC2A 2AE, UK
| | - Lara Gautier
- Département de Gestion, d'Évaluation et de Politique de Santé, École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, QC H3N 1X9, Canada.,Centre de recherche en santé publique, Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, 7101 avenue du Parc, Montréal, QC H3N 1X9, Canada
| | - Valéry Ridde
- Institut de Recherche pour le Développement, Centre Population et Développement - CEPED (IRD-Université de Paris), Université de Paris ERL INSERM SAGESUD, 45 rue des Saints-Peres, Paris 75006, France
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Baatiema L, Abimbola S, de-Graft Aikins A, Damasceno A, Kengne AP, Sarfo FS, Charway-Felli A, Somerset S. Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries. J Neurol Sci 2020; 418:117117. [PMID: 32919367 DOI: 10.1016/j.jns.2020.117117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 12/31/2022]
Abstract
Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.
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Affiliation(s)
- Leonard Baatiema
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana.
| | - Seye Abimbola
- School of Public Health, University of Sydney, Australia.
| | | | | | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Fred S Sarfo
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Department of Medicine, Kumasi, Ghana.
| | | | - Shawn Somerset
- Faculty of Health, University of Canberra, Canberra, Australia.
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Maurya D. Understanding public health insurance in India: A design perspective. Int J Health Plann Manage 2019; 34:e1633-e1650. [DOI: 10.1002/hpm.2856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Dayashankar Maurya
- Healthcare Management Program T A Pai Management Institute Manipal India
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Provider preference for payment method under a national health insurance scheme: A survey of health insurance-credentialed health care providers in Ghana. PLoS One 2019; 14:e0221195. [PMID: 31449530 PMCID: PMC6709917 DOI: 10.1371/journal.pone.0221195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/02/2019] [Indexed: 11/25/2022] Open
Abstract
Background Ghana introduced capitation payment method in 2012 but was faced with resistance from provider groups and civil society organizations for its perceived negative effects on quality care delivery. This study seeks to explore the views of providers to understand their preferred payment method for the various types of services they provide in order to inform the discussion and negotiations during this period of reform. Findings will not only aid the National Health Insurance Authority (NHIA) to improve the implementation arrangements but also provide useful inputs for other low and middle-income countries (LMICs) in their quest to reform their provider payment systems. Materials and methods We conducted a cross-sectional survey of 200 credentialed health care providers’ in the three regions of Ghana on providers’ preference for payment method. We administered closed-ended questionnaires employing 5-point Likert scales for measurement of payment method preference. Descriptive and regression analysis were performed to examine healthcare providers’ background characteristics and their association with preferred payment method for primary care. Results In general, health care providers prefer the Ghana-Diagnosis-Related Grouping (G-DRG) payment method to fee-for-service and capitation payment methods. Result of bivariate analyses showed that healthcare providers’ preference for payment method for primary outpatient services differed significantly by their region of residence (p<0.001). The multinomial logic model showed that being a female (p = 0.013) or healthcare provider in the Volta region (p = 0.008) was significantly associated with health provider preference for G-DRG payment method relative to fee-for-service. Similarly, being a healthcare provider in the Volta region (p = 0.026) or Medical Assistant (p = 0.032) was significantly associated with capitation relative to fee-for-service payment method. Conclusion We conclude that the most preferred payment method across all regions is the G-DRG. However, whereas providers in the Volta region are not willing to accept capitation as payment method, this was not the case in Ashanti and Central regions. Capitation payment method as an option for primary care services in Ghana should, therefore, not be ruled out of the discussion.
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Access to primary health care among women: the role of Ghana's community-based health planning and services policy. Prim Health Care Res Dev 2019; 20:e82. [PMID: 32799990 PMCID: PMC8060816 DOI: 10.1017/s1463423619000185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Ghana in 1999 adopted the Community-based Health Planning and Service (CHPS) policy to enhance access to primary health care (PHC) service. After two decades of implementation, there remains a considerable proportion of the country’s population, especially women who lack access to basic health care services. Aim: The aim of this paper is to understand the contribution of Ghana’s CHPS policy to women’s access to PHC services in the Upper West Region (UWR) of Ghana. Methods: A logistic regression technique was employed to analyse cross-sectional data collected among women (805) from the UWR. Findings: We found that women who resided in CHPS zones (OR = 1.612; P ≤ 0.01) were more likely to have access to health care compared with their counterparts who resided in non-CHPS zones. Also, rural-urban residence, distance to health facility, household wealth status and marital status predicted access to health care among women in the region. Our findings underscore the need to expand the CHPS policy to cover many areas in the country, especially rural communities and other deprived localities in urban settings.
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Anfaara FW, Atuoye KN, Mkandawire P, Luginaah I. Factors associated with voluntary testing for HBV in the Upper West Region of Ghana. Health Place 2018; 54:85-91. [PMID: 30248596 DOI: 10.1016/j.healthplace.2018.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 08/17/2018] [Accepted: 09/12/2018] [Indexed: 02/03/2023]
Abstract
This study examined the role of health facilities on testing for Hepatitis B virus in a policy context where screening is only available at a cost. We fitted multivariate multinomial logistic regression models to cross-sectional data (n = 1374) collected from Upper West Region of Ghana. The analysis showed that approximately 28% of respondents reported ever testing for HBV. Although source of healthcare influenced HBV testing, traders (RRR = 0.29, p ≤ 0.001) and farmers (RRR = 0.34, p ≤ 0.01) were significantly less likely to test voluntarily. Wealth generally predicted voluntary testing, although less so for mandatory testing. The findings highlight the need for free HBV services targeting the very poor, especially those who use community-level health facilities as their primary source of care.
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Affiliation(s)
- Florence Wullo Anfaara
- Environmental Hazards and Health Lab, Department of Geography, Western University, London, Ontario, Canada.
| | - Kilian Nasung Atuoye
- Environmental Hazards and Health Lab, Department of Geography, Western University, London, Ontario, Canada.
| | - Paul Mkandawire
- Institute of Interdisciplinary Studies, Human Rights Program, Carleton University, Ottawa, Canada.
| | - Isaac Luginaah
- Department of Geography, Western University, London, Ontario, Canada.
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14
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Andoh-Adjei FX, Boudewijns B, Nsiah-Boateng E, Asante FA, van der Velden K, Spaan E. Effects of capitation payment on utilization and claims expenditure under National Health Insurance Scheme: a cross-sectional study of three regions in Ghana. HEALTH ECONOMICS REVIEW 2018; 8:17. [PMID: 30151701 PMCID: PMC6111020 DOI: 10.1186/s13561-018-0203-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/20/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Ghana introduced capitation payment under National Health Insurance Scheme (NHIS), beginning with pilot in the Ashanti region, in 2012 with a key objective of controlling utilization and related cost. This study sought to analyse utilization and claims expenditure data before and after introduction of capitation payment policy to understand whether the intended objective was achieved. METHODS The study was cross-sectional, using a non-equivalent pre-test and post-test control group design. We did trend analysis, comparing utilization and claims expenditure data from three administrative regions of Ghana, one being an intervention region and two being control regions, over a 5-year period, 2010-2014. We performed multivariate analysis to determine differences in utilization and claims expenditure between the intervention and control regions, and a difference-in-differences analysis to determine the effect of capitation payment on utilization and claims expenditure in the intervention region. RESULTS Findings indicate that growth in outpatient utilization and claims expenditure increased in the pre capitation period in all three regions but slowed in post capitation period in the intervention region. The linear regression analysis showed that there were significant differences in outpatient utilization (p = 0.0029) and claims expenditure (p = 0.0003) between the intervention and the control regions before implementation of the capitation payment. However, only claims expenditure showed significant difference (p = 0.0361) between the intervention and control regions after the introduction of capitation payment. A difference-in-differences analysis, however, showed that capitation payment had a significant negative effect on utilization only, in the Ashanti region (p < 0.007). Factors including availability of district hospitals and clinics were significant predictors of outpatient health care utilization. CONCLUSION We conclude that outpatient utilization and related claims expenditure increased in both pre and post capitation periods, but the increase in post capitation period was at slower rate, suggesting that implementation of capitation payment yielded some positive results. Health policy makers in Ghana may, therefore, want to consider capitation a key provider payment method for primary outpatient care in order to control cost in health care delivery.
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Affiliation(s)
| | - Bronke Boudewijns
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | - Eric Nsiah-Boateng
- National Health Insurance Authority, PMB Ministries Post Office, 36-6th Avenue, Ridge, Accra, Ghana
| | - Felix Ankomah Asante
- Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, Legon, Accra Ghana
| | - Koos van der Velden
- Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | - Ernst Spaan
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
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15
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Umeh CA. Challenges toward achieving universal health coverage in Ghana, Kenya, Nigeria, and Tanzania. Int J Health Plann Manage 2018; 33:794-805. [PMID: 30074646 DOI: 10.1002/hpm.2610] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 07/05/2018] [Indexed: 11/09/2022] Open
Abstract
Although many sub-Saharan African countries have made efforts to provide universal health coverage (UHC) for their citizens, several of these initiatives have achieved little success. This study aims to review the challenges facing UHC in Ghana, Kenya, Nigeria, and Tanzania, and to suggest program or policy changes that might bolster UHC. Routine data reported by the World Bank and World Health Organization, as well as annual reports of the national health insurance schemes of Ghana, Kenya, Nigeria, and Tanzania, were analyzed. The data were supplemented by a review of published and gray literature on health insurance coverage in these four countries. The analysis showed that some of the challenges facing UHC in these countries include (1) large proportion of the population living in extreme poverty and unable to pay premiums, (2) large informal sector whose members are mostly uninsured, (3) high dropout rate from insurance schemes, (4) poorly funded primary health care system, and (5) segmented health insurance fund pool. In order to achieve UHC by 2030, it will be important for these countries to (1) raise sufficient revenue to finance their health systems, (2) improve the efficiency of revenue utilization, (3) identify and provide coverage for the very poor, (4) reduce the proportion of the population that is underinsured, and (5) improve access to quality health care in rural areas.
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16
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Maurya D, Ramesh M. Program design, implementation and performance: the case of social health insurance in India. HEALTH ECONOMICS, POLICY, AND LAW 2018; 14:1-22. [PMID: 30049293 DOI: 10.1017/s1744133118000257] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Published works on health insurance tend to focus on program design and its impact, neglecting the implementation process that links the two and affects outcomes. This paper examines the National Health Insurance [Rashtriya Swasthya Bima Yojana (RSBY)] in India with the objective of assessing the role of implementation structures and processes in shaping performance. The central question that the paper addresses is: why does the performance of RSBY vary across states despite similar program design? Using a comparative case study approach analyzing the program's functioning in three states, it finds the answer in the differences in governance of implementation. The unavoidable gaps in design of health care program allow abundant scope for opportunistic behavior on the part of different stakeholders. The study finds that the performance of the program, as a result, depends on the extent to which the governance mechanism is able to contain and channel opportunistic behavior during implementation. By opening up the black box of implementation, the paper contributes to improving the performance of national health insurance in India and elsewhere.
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Affiliation(s)
- Dayashankar Maurya
- 1Chairperson Healthcare Management,T.A. Pai Management Institute,Karnataka,India
| | - M Ramesh
- 2UNESCO Chair on Social Policy Design in Asia,Lee Kuan Yew School of Public Policy,National University of Singapore,Bukit Timah,Singapore
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17
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Kansanga MM, Asumah Braimah J, Antabe R, Sano Y, Kyeremeh E, Luginaah I. Examining the association between exposure to mass media and health insurance enrolment in Ghana. Int J Health Plann Manage 2018; 33:e531-e540. [DOI: 10.1002/hpm.2505] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | - Roger Antabe
- Department of GeographyWestern University London Ontario Canada
| | - Yuji Sano
- Department of SociologyWestern University London Ontario Canada
| | | | - Isaac Luginaah
- Department of GeographyWestern University London Ontario Canada
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18
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Agyepong IA, Sewankambo N, Binagwaho A, Coll-Seck AM, Corrah T, Ezeh A, Fekadu A, Kilonzo N, Lamptey P, Masiye F, Mayosi B, Mboup S, Muyembe JJ, Pate M, Sidibe M, Simons B, Tlou S, Gheorghe A, Legido-Quigley H, McManus J, Ng E, O'Leary M, Enoch J, Kassebaum N, Piot P. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. Lancet 2017; 390:2803-2859. [PMID: 28917958 DOI: 10.1016/s0140-6736(17)31509-x] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/25/2017] [Accepted: 05/01/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Irene Akua Agyepong
- Ghana Health Service, Accra, Ghana; Ghana College of Physicians and Surgeons, Public Health Faculty, Accra, Ghana
| | | | | | | | | | - Alex Ezeh
- African Population and Health Research Center, Nairobi, Kenya
| | - Abebaw Fekadu
- Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nduku Kilonzo
- National AIDS Control Council, Ministry of Health, Nairobi, Kenya
| | - Peter Lamptey
- FHI360, Durham, NC, USA; London School of Hygiene & Tropical Medicine, London, UK
| | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Bongani Mayosi
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Souleymane Mboup
- Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formation, Dakar, Senegal
| | | | | | | | | | - Sheila Tlou
- Regional Support Team for Eastern and Southern Africa, UNAIDS, Johannesburg, South Africa
| | - Adrian Gheorghe
- London School of Hygiene & Tropical Medicine, London, UK; Oxford Policy Management, Oxford, UK
| | - Helena Legido-Quigley
- London School of Hygiene & Tropical Medicine, London, UK; Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Edmond Ng
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Jamie Enoch
- London School of Hygiene & Tropical Medicine, London, UK
| | - Nicholas Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Peter Piot
- London School of Hygiene & Tropical Medicine, London, UK.
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