Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates

Overview of global healthcare policies for patients with chronic kidney disease: an integrative literature review

INTRODUCTION

Chronic kidney disease is a progressive and irreversible loss of kidney function and considerably affects the lives of patients and their families. Its high incidence necessitates efficient public policies for prevention and treatment. However, policies for chronic kidney disease education and awareness are scarce.

OBJECTIVE

To evaluate global public policies for the prevention and treatment of chronic kidney disease adopted in various regions, aiming to comprehend the differences between various models.

METHODS

This integrative review followed PRISMA recommendations and included papers published between 2016 and 2021 across several databases.

RESULTS

The 44 selected articles were categorized into three themes: structural and financial aspects of the organization of renal healthcare, access to renal healthcare or management of chronic kidney disease, and coping strategies for chronic kidney disease or kidney health. Critical analysis of the papers revealed global neglect of kidney disease in political agendas. Considerable policy variations exist between different countries and regions of the same country. Our research highlighted that free and universal health coverage, especially for the most vulnerable patients, is crucial for accessing treatment owing to the prohibitively high treatment costs.

CONCLUSION

Social, economic, and ethnic inequalities strongly correlate with disease occurrence, primarily affecting minority groups who lack health support, especially for the prevention and treatment of chronic kidney disease.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Constraints on the functioning of Community-based Health Planning and Services facilities: A qualitative study in the Jirapa Municipality, Ghana

The declaration of the Alma-Alta on primary health care (PHC) in 1978 enjoined nations to make health care accessible, affordable, and situated within their cultural contexts. The Ghana Community-based Health Planning and Services (CHPS), as a strategy to achieve the goal of PHC, has shown significant successes in communities where it has been implemented. However, a number of challenges continue to affect the effective functioning of CHPS. This study explored the community level and health system constraints on the effective functioning of CHPS in the delivering of PHC services in the Jirapa Municipality. A qualitative approach was implemented. A criterion-based purposive sampling technique was employed to recruit 51 managers and health service providers of CHPS for key informant interviews. The respondents included 25 community health management committee members, 25 health officers in charge of CHPS facilities, and one municipal CHPS coordinator. The interviews were held from September 18 to November 23, 2020. All interviews were face-to-face, audio-recorded and transcribed verbatim. Thematic analysis based on the constant comparative method was employed to analyse the data. The results showed that low community involvement in CHPS activities, disputes over the location and naming of CHPS zones, inadequate understanding of the CHPS concept and religious beliefs were the key community level factors which negatively affected the functioning of CHPS. Also, lack of logistics, financial constraints, poor attitude of health workers and inadequate staff motivation were the health sector constraints on the effective functioning of CHPS. In conclusion, concerted efforts are needed to tackle the community level and health system constraints to improve the overall functioning and effectiveness of the CHPS strategy. We recommend the strengthening of community sensitization, timely disbursement of funding, and provision of infrastructure and supplies to improve upon the effective functioning of CHPS as a strategy for delivery PHC in Ghana.

Do private health providers help achieve Universal Health Coverage? A scoping review of the evidence from low-income countries

Universal Health Coverage (UHC) is the dominant paradigm in health systems research, positing that everyone should have access to a range of affordable health services. Although private providers are an integral part of world health systems, their contribution to achieving UHC is unclear, particularly in low-income countries (LICs). We scoped the literature to map out the evidence on private providers' contribution to UHC progress in LICs. Literature searches of PubMed, Scopus and Web of Science were conducted in 2022. A total of 1049 documents published between 2002 and 2022 were screened for eligibility using predefined inclusion criteria, focusing on formal as well as informal private health sectors in 27 LICs. Primary qualitative, quantitative and mixed-methods evidence was included, as well as original analysis of secondary data. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of the studies. Relevant evidence was extracted and analysed using an adapted UHC framework. We identified 34 papers documenting how most basic health care services are already provided through the private sector in countries such as Uganda, Afghanistan and Somalia. A substantial proportion of primary care, mother, child and malaria services are available through non-public providers across all 27 LICs. Evidence exists that while formal private providers mostly operate in well-served urban settings, informal and not-for-profit ones cater for underserved rural and urban areas. Nonetheless, there is evidence that the quality of the services by informal providers is suboptimal. A few studies suggested that the private sector fails to advance financial protection against ill-health, as costs are higher than in public facilities and services are paid out of pocket. We conclude that despite their shortcomings, working with informal private providers to increase quality and financing of their services may be key to realizing UHC in LICs.

Measurement of unmet healthcare needs to assess progress on universal health coverage - exploring a novel approach based on household surveys

BACKGROUND

Universal Health Coverage (UHC) aims to ensure universal access to quality healthcare according to health needs. The extent to which population health needs are met should be a key measure for progress on UHC. The indicators in use for measuring access mostly relate to physical accessibility or insurance coverage. Or, utilization of services is taken as indirect measure for access but it is assessed against only the perceived healthcare needs. The unperceived needs do not get taken into account. The present study was aimed at demonstrating an approach for measuring the unmet healthcare needs using household survey data as an additional measure of UHC.

METHODS

A household survey was conducted in Chhattisgarh state of India, covering a multi-stage sample of 3153 individuals. Healthcare need was measured in terms of perceived needs which would be self-reported and unperceived needs where clinical measurement supplemented the interview response. Estimation of unperceived healthcare needs was limited to three tracer conditions- hypertension, diabetes and depression. Multivariate analysis was conducted to find the determinants of the various measures of the perceived and unperceived needs.

RESULTS

Of the surveyed individuals, 10.47% reported perceived healthcare needs for acute ailments in the last 15 days. 10.62% individuals self-reported suffering from chronic conditions. 12.75% of those with acute ailment and 18.40% with chronic ailments received no treatment, while 27.83% and 9.07% respectively received treatment from unqualified providers. On an average, patients with chronic ailments received only half the medication doses required annually. The latent need was very high for chronic ailments. 47.42% of individuals above 30 years age never had blood pressure measured. 95% of those identified with likelihood of depression had not sought any healthcare and they did not know they could be suffering from depression.

CONCLUSION

To assess progress on UHC more meaningfully, better methods are needed to measure unmet healthcare needs, taking into account both the perceived and unperceived needs, as well as incomplete care and inappropriate care. Appropriately designed household surveys offer a significant potential to allow its periodic measurement. Their limitations in measuring the 'inappropriate care' may necessitate supplementation with qualitative methods.

Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review

The goal of universal health coverage (UHC) from the United Nations (UN) has metamorphized from its early phase of primary health care (PHC) to the recent sustainable development goal (SDG). In this context, we aimed to document theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC in a global scenario. Searching with broad keywords circumadjacent to UHC with scope and inter-disciplinary linkages in conceptual analysis, we further narrated the review with the historical development of UHC in different time periods. We proposed, chronologically, these frames as eras of PHC, the millennium development goal (MDG), and the ongoing sustainable development goal (SDG). Literature showed that modern healthcare access and coverage were in extension stages during the PHC era flagshipped with "health for all (HFA)", prolifically achieving vaccination, communicable disease control, and the use of modern contraceptive methods. Following the PHC era, the MDG era markedly reduced maternal, neonatal, and child mortalities mainly in developing countries. Importantly, UHC has shifted its philosophic stand of HFA to a strategic health insurance and its extension. After 2015, the concept of SDG has evolved. The strategy was further reframed as service and financial assurance. Strategies for further resource allocation, integration of health service with social health protection, human resources for health, strategic community participation, and the challenges of financial securities in some global public health concerns like the public health emergency and travelers' and migrants' health are further discussed. Some policy departures such as global partnership, research collaboration, and experience sharing are broadly discussed for recommendation.

Pandemic preparedness and response: exploring the role of universal health coverage within the global health security architecture

In response to the COVID-19 pandemic, several international initiatives have been developed to strengthen and reform the global architecture for pandemic preparedness and response, including proposals for a pandemic treaty, a Pandemic Fund, and mechanisms for equitable access to medical countermeasures. These initiatives seek to make use of crucial lessons gleaned from the ongoing pandemic by addressing gaps in health security and traditional public health functions. However, there has been insufficient consideration of the vital role of universal health coverage in sustainably mitigating outbreaks, and the importance of robust primary health care in equitably and efficiently safeguarding communities from future health threats. The international community should not repeat the mistakes of past health security efforts that ultimately contributed to the rapid spread of the COVID-19 pandemic and disproportionately affected vulnerable and marginalised populations, especially by overlooking the importance of coherent, multisectoral health systems. This Health Policy paper outlines major (although often neglected) gaps in pandemic preparedness and response, which are applicable to broader health emergency preparedness and response efforts, and identifies opportunities to reconceptualise health security by scaling up universal health coverage. We then offer a comprehensive set of recommendations to help inform the development of key pandemic preparedness and response proposals across three themes-governance, financing, and supporting initiatives. By identifying approaches that simultaneously strengthen health systems through global health security and universal health coverage, we aim to provide tangible solutions that equitably meet the needs of all communities while ensuring resilience to future pandemic threats.

Universality of universal health coverage: A scoping review

BACKGROUND

The progress of Universal health coverage (UHC) is measured using tracer indicators of key interventions, which have been implemented in healthcare system. UHC is about population, comprehensive health services and financial coverage for equitable quality services and health outcome. There is dearth of evidence about the extent of the universality of UHC in terms of types of health services, its integrated definition (dimensions) and tracer indicators utilized in the measurement of UHC. Therefore, we mapped the existing literature to assess universality of UHC and summarize the challenges towards UHC.

METHODS

The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews was used. A systematic search was carried out in the Web of Science and PubMed databases. Hand searches were also conducted to find articles from Google Scholar, the World Bank Library, the World Health Organization Library, the United Nations Digital Library Collections, and Google. Article search date was between 20 October 2021 and 12 November 2021 and the most recent update was done on 03 March 2022. Articles on UHC coverage, financial risk protection, quality of care, and inequity were included. The Population, Concept, and Context framework was used to determine the eligibility of research questions. A stepwise approach was used to identify and select relevant studies, conduct data charting, collation and summarization, as well as report results. Simple descriptive statistics and narrative synthesis were used to present the findings.

RESULTS

Forty-seven papers were included in the final review. One-fourth of the articles (25.5%) were from the African region and 29.8% were from lower-middle-income countries. More than half of the articles (54.1%) followed a quantitative research approach. Of included articles, coverage was assessed by 53.2% of articles; financial risk protection by 27.7%, inequity by 25.5% and quality by 6.4% of the articles as the main research objectives or mentioned in result section. Most (42.5%) of articles investigated health promotion and 2.1% palliation and rehabilitation services. Policy and healthcare level and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, weak regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned as a cross-cutting barrier.

CONCLUSIONS

The review showed that majority of the articles were from the African region. Methodologically, quantitative research design was more frequently used to investigate UHC. Palliation and rehabilitation health care services need attention in the monitoring and evaluation of UHC progress. It is also noteworthy to focus on quality and inequity of health services. The study implies that urgent action on the identified policy, health system and cross-cutting barriers is required to achieve UHC.

Hospitals during economic crisis: a systematic review based on resilience system capacities framework

Background

Hospitals are the biggest users of the health system budgets. Policymakers are interested in improving hospital efficiency while maintaining their performance during the economic crisis. This study aims at analysing the hospitals’ policy solutions during the economic crisis using the resilience system capacities framework.

Method

This study is a systematic review. The search strategy was implemented on the Web of Science, PubMed, Embase, Scopus databases, and Econbiz search portal. Data were extracted and analysed through the comparative table of resilience system capacities framework and the World Health Organization (WHO) health system’s six building blocks (i.e., leadership and governance, service delivery, health workforce, health systems financing, health information systems, and medicines and equipment).

Findings

After the screening, 78 studies across 36 countries were reviewed. The economic crisis and adopted policies had a destructive effect on hospital contribution in achieving Universal Health Coverage (UHC). The short-term absorptive capacity policies were the most frequent policies against the economic crisis. Moreover, the least frequent and most effective policies were adaptive policies. Transformative policies mainly focused on moving from hospital-based to integrated and community-based services. The strength of primary care and community-based services, types and combination of hospital financing systems, hospital performance before the crisis, hospital managers’ competencies, and regional, specialties, and ownership differences between hospitals can affect the nature and success of adopted policies.

Conclusion

The focus of countries on short-term policies and undermining necessary contextual factors, prioritizing efficiency over quality, and ignoring the interrelation of policies compromised hospital contribution in UHC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08316-4.

Equity in Scientific Publication

This editorial seeks to draw our attention to the central role of health research in identifying solutions to persistent challenges to meeting health goals, and as a core component of economic development, irrespective of the level of economic development of the country. As such, the 'leave no one behind' principle which underpins the sustainable development agenda applies to health research as well. Health Services Insights (HIS) contributes to meeting the need for equity in health research embracing a multidisciplinary approach to share comprehensive evidence.

An empirical study on factors influencing consumers' motivation towards teleconsultation system use. A preliminary report about the Sehha application from Saudi Arabia

BACKGROUND

The use of the teleconsultation system has increased in recent years, which enabled healthcare providers and patients to share, communicate and transfer information in real-time via different types of telemedicine services and applications. However, there is a lack of studies that underpin factors that motivate patients to use teleconsultation systems.

AIM AND OBJECTIVE

This study aimed to identify factors that influence consumers' motivation to use teleconsultation systems by developing a theoretical framework and empirically testing the developed framework with a real-world teleconsultation system.

METHODS

A cross-sectional study was used for this research to empirically validate the proposed model. The online survey consisted of 51 items, which were developed by the researchers. Partial least squares structural equation modelling (PLS-SEM) was used to analyze the measurement model and structural model.

RESULTS

485 participants completed the online survey, 471 of which were included in the model analysis. The measurement analysis indicated that convergent validity was achieved as all items' outer lording were well above the threshold of 0.70, all indicators reliability and AVEs were well above the threshold of 0.50. Also, the measurement analysis indicated that discriminate validity was achieved as the Heterotrait-Monotrait ratio of correlations for all constructs were below the threshold of 0.90. In the structural model analysis, the inner constructs of the model, autonomy, competence and relatedness explained 60.1% of the variance in users' motivation toward the use of the teleconsultation system. The outer constructs of the model, subjective norm, external and internal facilitating conditions, explained 67.3% of the variance in users' autonomy, whereas attitude, performance expectancy, external and internal facilitating conditions explained 51.9% of the variance in the users' competence, and subjective norm explained 25.6% of the variance in the users' relatedness.

CONCLUSIONS

The developed framework can explain why consumers are motivated to use teleconsultation systems for online medical consultations. The model indicated that a variety of internal and external factors can positively or negatively influence consumers' perceived autonomy, competence and relatedness, which can impact their motivation toward the use of teleconsultation systems.

Identifying priorities for research on financial risk protection to achieve universal health coverage: a scoping overview of reviews

OBJECTIVES

Financial risk protection (FRP) is an indicator of the Sustainable Development Goal 3 universal health coverage (UHC) target. We sought to characterise what is known about FRP in the UHC context and to identify evidence gaps to prioritise in future research.

DESIGN

Scoping overview of reviews using the Arksey & O'Malley and Levac & Colquhoun framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guidelines.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL-Plus and PAIS Index were systematically searched for studies published between 1 January 1995 and 20 July 2021.

ELIGIBILITY CRITERIA

Records were screened by two independent reviewers in duplicate using the following criteria: (1) literature review; (2) focus on UHC achievement through FRP; (3) English or French language; (4) published after 1995 and (5) peer-reviewed.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data using a standard form and descriptive content analysis was performed to synthesise findings.

RESULTS

50 studies were included. Most studies were systematic reviews focusing on low-income and middle-income countries. Study periods spanned 1990 and 2020. While FRP was recognised as a dimension of UHC, it was rarely defined as a concept. Out-of-pocket, catastrophic and impoverishing health expenditures were most commonly used to measure FRP. Pooling arrangements, expansion of insurance coverage and financial incentives were the main interventions for achieving FRP. Evidence gaps pertained to the effectiveness, cost-effectiveness and equity implications of efforts aimed at increasing FRP. Methodological gaps related to trade-offs between single-country and multicountry analyses; lack of process evaluations; inadequate mixed-methods evidence, disaggregated by relevant characteristics; lack of comparable and standardised measurement and short follow-up periods.

CONCLUSIONS

This scoping overview of reviews characterised what is known about FRP as a UHC dimension and found evidence gaps related to the effectiveness, cost-effectiveness and equity implications of FRP interventions. Theory-informed mixed-methods research using high-quality, longitudinal and disaggregated data is needed to address these objectives.

Addressing child health inequity through case management of under-five malaria in Nigeria: an extended cost-effectiveness analysis

Background

Under-five malaria in Nigeria is a leading cause of global child mortality, accounting for 95,000 annual child deaths. High out-of-pocket medical expenditure contributes to under-five malaria mortality by discouraging care-seeking and use of effective anti-malarials in the poorest households. The significant inequity in child health outcomes in Nigeria stresses the need to evaluate the outcomes of potential interventions across socioeconomic lines.

Methods

Using a decision tree model, an extended cost-effectiveness analysis was done to determine the effects of subsidies covering the direct and indirect costs of case management of under-five malaria in Nigeria. This analysis estimates the number of child deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. An optimization analysis was also done to determine how to optimally allocate money across wealth groups using different combinations of interventions.

Results

Fully subsidizing direct medical, non-medical, and indirect costs could annually avert over 19,000 under-five deaths, 8600 cases of CHE, and US$187 million in OOP spending. Per US$1 million invested, this corresponds to an annual reduction of 76 under-five deaths, 34 cases of CHE, and over US$730,000 in OOP expenditure. Due to low initial treatment coverage in poorer socioeconomic groups, health and financial-risk protection benefits would be pro-poor, with the poorest 40% of Nigerians accounting for 72% of all deaths averted, 55% of all OOP expenditure averted, and 74% of all cases of CHE averted. Subsidies targeted to the poor would see greater benefits per dollar spent than broad, non-targeted subsidies. In an optimization scenario, the strategy of fully subsidizing direct medical costs would be dominated by a partial subsidy of direct medical costs as well as a full subsidy of direct medical, nonmedical, and indirect costs.

Conclusion

Subsidizing case management of under-five malaria for the poorest and most vulnerable would reduce illness-related impoverishment and child mortality in Nigeria while preserving limited financial resources. This study is an example of how focusing a targeted policy-intervention on a single, high-burden disease can yield large health and financial-risk protection benefits in a low and middle-income country context and address equity consideration in evidence-informed policymaking.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04113-w.

Barriers to uptake of community-based health insurance in sub-Saharan Africa: a systematic review

In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa.

Rethinking Universal Health Coverage: A qualitative study of patient organisation perspectives on the Turkish health-care system

Universal health coverage (UHC) has been elevated to the status of a global policy target, but this was at the expense of losing its aspirational meaning. As a case in point, Turkey has been one of the countries that has achieved UHC, according to the technocratic definition. This article employs a combination of deductive and inductive thematic analysis methods to explore patient organisation (PO) perspectives on the Turkish health-care system based on 26 respondent interviews from 19 POs in Istanbul. Highlighting the inadequacy of the technocratic definition of UHC, the article maintains that an analysis of PO perspectives opens the way for a nuanced and bottom-up assessment of essential service coverage and financial protection by identifying elusive gaps in both dimensions that would otherwise be lost in generalist evaluations. The findings also underline the importance of keeping intact the UHC's aspirational element to enable POs to participate in the politics of priority setting in health care.

Adopting localised health financing models for universal health coverage in Low and middle-income countries: lessons from the National Health lnsurance Scheme in Ghana

The health-related Sustainable Development Goals (SDGs) and the Coronavirus Pandemic (COVID-19) have recently increased awareness of the need for countries to increase fiscal space for health. Prior to these, many Low and Middle-Income Countries (LMICs) had embraced the concept of Universal Health Coverage (UHC) and have either commenced or are in the process of implementing various models of health insurance in order to provide financial access to health care to their populations. While evidence of a relationship between experimentation with UHC and increased access to and utilisation of health care in LMICs is common, there is inadequate research evidence on the specific health financing model that is most appropriate for pursuing the objectives of UHC in these settings. Drawing on a synthesis of empirical and theoretical discourses on the feasibility of UHC in LMICs, this paper argues that the journey towards UHC is not a 'one size fits all' process, but a long-term policy engagement that requires adaptation to the specific socio-cultural and political economy contexts of implementing countries. The study draws on the WHO's framework for tracking progress towards UHC using the implementation of a mildly progressive pluralistic health financing model in Ghana and advocates a comprehensive discourse on the potential for LMICs to build resilient and responsive health systems to facilitate a gradual transition towards UHC.

Analysis of independent National Health Insurance ownership of informal workers: Study of market traders in Gowa District, Indonesia

OBJECTIVE

This study aimed to determine the factors associated with ownership of independent National Health Insurance (NHI) in market traders, Gowa District, Indonesia.

METHOD

This type of research was quantitative with a cross-sectional design. The population was 567 traders. Samples were 85 respondents: data collection using questionnaires, and data processing with Chi-square test analysis.

RESULT

The results indicated that 43 (50.6%) respondents had NHI, and 42 (49.45%) respondents did not. Based on the results obtained bivariate analysis knowledge (p=0.003), income (p=0.039), attitude (p=0.000), social support (p=0.000), age (p=1.000), education (p=0.311), perception (p=0.234) and access to care (p=0.336).

CONCLUSION

Factors related to the ownership of independent NHI traders in the Central Public Market Gowa were knowledge, income, attitude, and social support. It is recommended that market managers include traders in health insurance and the government improve the quality of the NHI program and increase socialization to informal sector traders.

Implementation research approaches to promoting universal health coverage in Africa: a scoping review

BACKGROUND

Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of initiatives promoting the uptake of implementation research in Africa, its role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). Hence, this scoping review aimed to identify and characterise the use of implementation research initiatives for assessing UHC-related interventions or programmes in Africa.

METHODS

The review protocol was developed based on the methodological framework proposed by Arksey and O'Malley, as enhanced by the Joanna Briggs Institute. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). MEDLINE, Scopus and the Cochrane Library were searched. The search also included a hand search of relevant grey literature and reference lists. Literature sources involving the application of implementation research in the context of UHC in Africa were eligible for inclusion.

RESULTS

The database search yielded 2153 records. We identified 12 additional records from hand search of reference lists. After the removal of duplicates, we had 2051 unique records, of which 26 studies were included in the review. Implementation research was used within ten distinct UHC-related contexts, including HIV; maternal and child health; voluntary male medical circumcision; healthcare financing; immunisation; healthcare data quality; malaria diagnosis; primary healthcare quality improvement; surgery and typhoid fever control. The consolidated framework for implementation research (CFIR) was the most frequently used framework. Qualitative and mixed-methods study designs were the commonest methods used. Implementation research was mostly used to guide post-implementation evaluation of health programmes and the contextualisation of findings to improve future implementation outcomes. The most commonly reported contextual facilitators were political support, funding, sustained collaboration and effective programme leadership. Reported barriers included inadequate human and other resources; lack of incentives; perception of implementation as additional work burden; and socio-cultural barriers.

CONCLUSIONS

This review demonstrates that implementation research can be used to achieve UHC-related outcomes in Africa. It has identified important facilitators and barriers to the use of implementation research for promoting UHC in the region.

Cleaning Neonatal Units in Low-resource Settings: A Hot-topic in Waiting?

Globally, about 3-quarters of births now occur in healthcare facilities, with the proportion being 50% for sub-Saharan Africa, where healthcare-associated infections among newborns are typically 3-20 times higher than in facilities in high-income countries. As this upward trend in institutional deliveries continues, the demand for specialized neonatal care also rises, with dedicated units often only available in tertiary referral hospitals in the case of low- and middle-income countries. Preventing nosocomial infections among vulnerable newborns requires effective and feasible control strategies and interventions. The role of cleaning and cleaners in reducing risks and maintaining a clean safe environment has until very recently been neglected at policy, program, practice, and research levels. There is now an opportunity to reposition cleaning within global and national initiatives related to Water, Sanitation and Hygiene, Infection Prevention and Control, and Antimicrobial Resistance. The evidence base should also be strengthened on cost-effective bundles of cleaning interventions, particularly in the context of low-resource settings. Here increasing overcrowding and shortages of staff and supplies present major threats to neonatal survival and well-being and heighten the case for optimizing the use of low-cost, back-to-basics interventions like cleaning.

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

BACKGROUND

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

METHOD

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

RESULT

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

CONCLUSION

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

What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India

In many low- and middle-income countries, providers without formal training are an important source of antibiotics, but may provide these inappropriately, contributing to the rising burden of drug resistant infections. Informal providers (IPs) who practise allopathic medicine are part of India's pluralistic health system legacy. They outnumber formal providers but operate in a policy environment of unclear legitimacy, creating unique challenges for antibiotic stewardship. Using a systems approach we analysed the multiple intrinsic (provider specific) and extrinsic (community, health and regulatory system and pharmaceutical industry) drivers of antibiotic provision by IPs in rural West Bengal, to inform the design of community stewardship interventions. We surveyed 291 IPs in randomly selected village clusters in two contrasting districts and conducted in-depth interviews with 30 IPs and 17 key informants including pharmaceutical sales representatives, managers and wholesalers/retailers; medically qualified private and public doctors and health and regulatory officials. Eight focus group discussions were conducted with community members. We found a mosaic or bricolage of informal practices conducted by IPs, qualified doctors and industry stakeholders that sustained private enterprise and supplemented the weak public health sector. IPs' intrinsic drivers included misconceptions about the therapeutic necessity of antibiotics, and direct and indirect economic benefits, though antibiotics were not the most profitable category of drug sales. Private doctors were a key source of IPs' learning, often in exchange for referrals. IPs constituted a substantial market for local and global pharmaceutical companies that adopted aggressive business strategies to exploit less-saturated rural markets. Paradoxically, the top-down nature of regulations produced a regulatory impasse wherein regulators were reluctant to enforce heavy sanctions for illegal sales, fearing an adverse impact on rural healthcare, but could not implement enabling strategies to improve antibiotic provision due to legal barriers. We discuss the implications for a multi-stakeholder antibiotic stewardship strategy in this setting.

Is patient navigation a solution to the problem of "leaving no one behind"? A scoping review of evidence from low-income countries

Patient navigation interventions, which are designed to enable patients excluded from health systems to overcome the barriers they face in accessing care, have multiplied in high-income countries since the 1990s. However, in low-income countries (LICs), indigents are generally excluded from health policies despite the international paradigm of universal health coverage (UHC). Fee exemption interventions have demonstrated their limits and it is now necessary to act on other dimensions of access to healthcare. However, there is a lack of knowledge about the interventions implemented in LICs to support the indigents throughout their care pathway. The aim of this paper is to synthesize what is known about patient navigation interventions to facilitate access to modern health systems for vulnerable populations in LICs. We therefore conducted a scoping review to identify all patient navigation interventions in LICs. We found 60 articles employing a total of 48 interventions. Most of these interventions targeted traditional beneficiaries such as people living with HIV, pregnant women and children. We utilized the framework developed by Levesque et al. (Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013;12:18) to analyse the interventions. All acted on the ability to perceive, 34 interventions on the ability to reach, 30 on the ability to engage, 8 on the ability to pay and 6 on the ability to seek. Evaluations of these interventions were encouraging, as they often appeared to lead to improved health indicators and service utilization rates and reduced attrition in care. However, no intervention specifically targeted indigents and very few evaluations differentiated the impact of the intervention on the poorest populations. It is therefore necessary to test navigation interventions to enable those who are worst off to overcome the barriers they face. It is a major ethical issue that health policies leave no one behind and that UHC does not benefit everyone except the poorest.

Maintaining fair and efficient health care during the COVID-19 pandemic: Theoretical context and practical implications

Coronavirus disease 2019 is a respiratory infection that has evolved to a pandemic with an enormous burden both on human life and health care. States throughout the world have pursued strategies to restrict the transmission of the virus in the community. Health systems have a crucial dual role as they are at the frontline of the fight against the pathogen and at the same time they must continue to offer emergency and routine health services. The provision of health care in the context of the COVID-19 pandemic finds certain barriers. The simultaneous protection of both universal health coverage and health care efficiency is a difficult task due to conflicting challenges of these two goals. Key actions need to be decided and implemented in the fields of health policy, operation of health services, and clinical interaction between health personnel and patients, so that health care continues to perform its mission in a sustainable manner. As the scientific community prepares for the widespread production and application of effective protective and therapeutic agents against COVID-19, it is vital for the general population to remain safe and for the health systems to survive. Allocation of resources and priority setting need to be applied fairly and efficiently for the achievement of the maximum benefit.

Correlation of mesolevel characteristics of the healthcare system and socioeconomic inequality in healthcare use: a scoping review protocol

INTRODUCTION

Although the impact of macrolevel characteristics of health systems on socioeconomic inequity in health has been studied extensively, the impact of access characteristics on a smaller scale of health systems has received less attention. These mesolevel characteristics can influence access to healthcare and might have the potential to moderate or aggravate socioeconomic inequity in healthcare use. This scoping review aims to map the existing evidence of the association of socioeconomic inequity in healthcare use and mesolevel access characteristics of the health system.

METHODS AND ANALYSIS

In conducting the scoping review, we follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols Extension for Scoping Reviews. The search will be carried out in four scientific databases: MEDLINE (via PubMed), Web of Science, Scopus and PsycINFO. Main eligibility criteria are inclusion in the analysis of a measure of socioeconomic position, a measure of individual healthcare use and a mesolevel determinant of access to healthcare services. The selection process consists of two consecutive screening stages (first: title/abstract; second: full text). At both stages, two reviewers independently assess the eligibility of studies. In case of disagreement, a third reviewer will be involved. Cohen's kappa will be calculated to report inter-rater agreement between reviewers. Results are synthesised narratively, as a high heterogeneity of studies is expected.

ETHICS AND DISSEMINATION

No primary data are collected for the presented scoping review. Therefore, ethical approval is not necessary. The scoping review will be published in an international peer-reviewed journal, and findings will be presented on national and international conferences.

Sláintecare implementation status in 2020: Limited progress with entitlement expansion

The Sláintecare report developed by political consensus sets out a ten year plan for achieving Universal Health Care (UHC) in Ireland. This paper evaluates the design and progress of the report to mid 2020, but with some reflection on the new COVID 19 era, particularly as it relates to the expansion of entitlements to achieve UHC. The authors explore how close Sláintecare is to the UHC ideal. They also review the phased strategy of implementation in Sláintecare that utilises a systems-thinking approach with interlinkages between entitlements, funding, capacity and implementation. Finally the authors review the Sláintecare milestones against the reality of implementation since the publication of the report in 2017, cognisant of government policy and practice. Some of the initial assumptions around the context of Sláintecare were not realised and there has been limited progress made toward expanding entitlements, and certainly short of the original plan. Nevertheless there have been positive developments in that there is evidence that Government's Implementation Strategy and Action Plans are focussing on reforming a complex adaptive system rather than implementing a blueprint with such initiatives as integrated care pilots and citizen engagement. The authors find that this may help the system change but it risks losing some of the essential elements of entitlement expansion in favour of organisational change.

Harnessing the Power of Networks of Care for Universal Health Coverage

On the global health agenda, Universal Health Coverage has been displaced by the COVID-19 pandemic while disparities in COVID-19 outcomes have exposed stark gaps in quality, access, equity, and financial risk protection. These disparities highlight the importance of the core goals of Universal Health Coverage and the need for innovative approaches to working toward them. The newly codified concept of "Networks of Care" offers a promising option for implementation. The articles in this special issue present the Networks of Care lexicon and framework and demonstrate the development of leadership, responsibility, intra- and inter-facility cooperation, and dynamic cycles of quality improvement. These elements are associated with better access to services and better health outcomes, the ultimate goals of Universal Health Coverage. Increases in poverty, food insecurity, and deleterious impact on the status of women secondary to the COVID-19 pandemic add urgency to Universal Health Coverage, while the economic impact of pandemic mitigation may reduce availability of resources for years to come. The need for Universal Health Coverage and efficiency and flexibility in health spending, including the ability to contract directly, has become even more important. Countries where Universal Health Coverage efforts have yet to carry through to provision of good quality, accessible and equitable service delivery could potentially benefit from concurrent Networks of Care implementation. Documentation of Networks of Care in the context of Universal Health Coverage should be prioritized to understand how Networks of Care can be used to help realize the goals of Universal Health Coverage around the world.

Achieving universal health coverage for people with stroke in South Africa: protocol for a scoping review

INTRODUCTION

Stroke is the second most common cause of death after HIV/AIDS and a significant health burden in South Africa. The extent to which universal health coverage (UHC) is achieved for people with stroke in South Africa is unknown. Therefore, a scoping review to explore the opportunities and challenges within the South African health system to facilitate the achievement of UHC for people with stroke is warranted.

METHODS AND ANALYSIS

The scoping review will follow the approach recommended by Levac, Colquhoun and O'Brien, which includes five steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarising and reporting the results. Health Systems Dynamics Framework and WHO Framework on integrated people-centred health services will be used to map, synthesise and analyse data thematically.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review, as it will only include published and publicly available data. The findings of this review will be published in an open-access, peer-reviewed journal and we will develop an accessible summary of the results for website posting and stakeholder meetings.

Impact of COVID-19 on the cost of surgical and obstetric care: experience from a Nigerian teaching hospital and a review of the Nigerian situation

The public health impact of the COVID-19 pandemic cannot be overstated. Its impact on the cost of surgical and obstetric care is significant. More so, in a country like Nigeria, where even before the pandemic, out-of-pocket spending (OOPS) has been the major payment method for healthcare. The increased cost of surgical and obstetric care occasioned by the pandemic has principally been due to the additional burden of ensuring the use of adequate/appropriate personal protective equipment (PPE) during patient care as a disease containment measure. These PPE are not readily available in public hospitals across Nigeria. Patients are therefore compelled to bear the financial burden of procuring scarce PPE for use by health care personnel, further increasing the already high cost of healthcare. In this study, we sought to appraise the impact of the COVID-19 pandemic on the cost of surgical and obstetric care in Nigeria, drawing from the experience from one of the major Nigerian teaching hospitals- the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Osun State. The cost of surgical and obstetric care was reviewed and compared pre- and during the COVID-19 pandemic, deriving relevant examples from some commonly performed surgical operations in our centre (OAUTHC). We reviewed patients' hospital bills and receipts of consumables procured for surgery. Our findings revealed that the cost of surgical and obstetric care during the COVID-19 pandemic had significantly increased. We identified gaps and made relevant recommendations on measures to reduce the additional costs of surgical and obstetric care during and beyond pandemic.

A framework for explaining the role of values in health policy decision-making in Latin America: a critical interpretive synthesis

BACKGROUND

Although values underpin the goals pursued in health systems, including how health systems benefit the population, it is often not clear how values are incorporated into policy decision-making about health systems. The challenge is to encompass social/citizen values, health system goals, and financial realities and to incorporate them into the policy-making process. This is a challenge for all health systems and of particular importance for Latin American (LA) countries. Our objective was to understand how and under what conditions societal values inform decisions about health system financing in LA countries.

METHODS

A critical interpretive synthesis approach was utilised for this work. We searched 17 databases in December 2016 to identify articles written in English, Spanish or Portuguese that focus on values that inform the policy process for health system financing in LA countries at the macro and meso levels. Two reviewers independently screened records and assessed them for inclusion. One researcher conceptually mapped the included articles, created structured summaries of key findings from each, and selected a purposive sample of articles to thematically synthesise the results across the domains of agenda-setting/prioritisation, policy development and implementation.

RESULTS

We identified 5925 references, included 199 papers, and synthesised 68 papers. We identified 116 values and developed a framework to explain how values have been used to inform policy decisions about financing in LA countries. This framework has four categories - (1) goal-related values (i.e. guiding principles of the health system); (2) technical values (those incorporated into the instruments adopted by policy-makers to ensure a sustainable and efficient health system); (3) governance values (those applied in the policy process to ensure a transparent and accountable process of decision-making); and (4) situational values (a broad category of values that represent competing strategies to make decisions in the health systems, their influence varying according to the four factors).

CONCLUSIONS

It is an effort to consolidate and explain how different social values are considered and how they support policy decision-making about health system financing. This can help policy-makers to explicitly incorporate values into the policy process and understand how values are supporting the achievement of policy goals in health system financing.

TRIAL REGISTRATION

The protocol was registered with PROSPERO, ID=CRD42017057049 .

Monitoring Process Barriers and Enablers Towards Universal Health Coverage Within the Sustainable Development Goals: A Systematic Review and Content Analysis

BACKGROUND

This study builds on previous successes of using tracer indicators in tracking progress towards Universal Health Coverage (UHC) and complements them by offering a more detailed tool that would allow us to identify potential process barriers and enablers towards such progress.

PURPOSE

This tool was designed accounting for possibly available data in low- and middle-income counties.

METHODOLOGY

A systematic review of relevant studies was carried out using PubMed, ISI Web of Science, Embase, Scopus, and ProQuest databases with no time restriction. The search was complemented by a scoping review of grey literature, using the World Bank and the World Health Organization (WHO) official reports depositories. Next, an inductive content analysis identified determinants influencing the progress towards UHC and its relevant indicators. The conceptual proximity between indicators and categorized themes was explored through three focus group discussion with 18 experts in UHC. Finally, a comprehensive list of indicators was converted into an assessment tool and refined following three consecutive expert panel discussions and two rounds of email surveys.

RESULTS

A total of 416 themes (including indicators and determinants factors) were extracted from 166 eligible articles and documents. Based on conceptual proximity, the number of factors was reduced to 119. These were grouped into eight domains: social infrastructure and social sustainability, financial and economic infrastructures, population health status, service delivery, coverage, stewardship/governance, and global movements. The final assessment tool included 20 identified subcategories and 88 relevant indicators.

CONCLUSION

Identified factors in progress towards UHC are interrelated. The developed tool can be adapted and used in whole or in part in any country. Periodical use of the tool is recommended to understand potential factors that impede or advance progress towards UHC.

Medical cost trends under national health insurance benefit extension in Republic of Korea

This study examines whether the burden of medical expenses on households has gradually decreased since South Korea began implementing benefit expansion policies to strengthen health insurance coverage. Using Korea's Household Income & Expenditure Survey from 1995 to 2014, the annual average monthly household expenditures and the catastrophic health expenditure (CHE) indicator were analyzed. The latter is an indicator of household impoverishment resulting from out-of-pocket healthcare expenditures exceeding a defined threshold proportion of the household's income. Through descriptive and frequency data analyses and using P-values, the annual trends and differences in absolute values and share of CHE prevalence across households were measured. The study finds that the proportion of income spent on medical expenses increased from 2.47% (1995) to 4.94% (2014) on average. CHE also increased 3.6 times, 6.3 times, 9.8 times, and 11.1 times for assumed threshold sizes of 10%, 20%, 30%, and 40%, respectively. The lowest income group had the highest increase in CHE incidence. These results suggest that the benefit extension policy has lowered medical use thresholds and led to an increase in medical resource use. Therefore, the Ministries of Health and Welfare, and of Economy and Finance should collaborate to design policies for vulnerable groups.

Going universal? The problem of the uninsured in Europe and in OECD countries

PURPOSE

The aim of this article is to address the following questions: (1) Which OECD (The Organization for Economic Co-operation and Development) and EU countries guarantee health insurance coverage to the entire population and which, conversely, leave part of the resident population without coverage?, (2) How many people do not have health coverage, and what are their characteristics? and (3) Within the OECD and the EU, is there actually a trend toward universal population coverage?

FINDINGS

Approximately one third of OECD and European Union countries do not ensure health insurance coverage to the entire population. At present, the uninsured in European Union countries totals more than seven million people. Considering all 36 OECD countries, the uninsured reach almost 48 million.

CONCLUSION

The diachronic analysis shows that, from the 1970s to present day, the percentage of the uninsured in OECD member countries has gradually decreased. Conversely, in EU countries, the tendency toward universalism shows a fluctuating trend. Until the mid-90s, the number of uninsured decreased. However, a trend reversal took place and the number of uninsured started to rise again from the second half of the 1990s. The number of individuals without insurance coverage is currently 2-fold higher than the figure recorded before the outbreak of the great financial crisis.

Affording unavoidable emergency surgical care - The lived experiences and payment coping strategies of households in Ibadan metropolis, Southwestern Nigeria

BACKGROUND

Pre-payment and risk pooling schemes, central to the idea of universal health coverage, should protect households from catastrophic health expenditure and impoverishment; particularly when emergency care is required. Inadequate financial protection consequent on surgical emergencies occurs despite the existence of risk-pooling schemes. This study documented the experiences and coping strategies of slum and non-slum dwellers in a southwestern metropolis of Nigeria who had undergone emergency surgery.

METHODS

In-depth interviews were conducted with 31 participants (13 slums dwellers, 18 non-slum dwellers) who had recently paid for emergency surgical care in Ibadan. Patients who had experienced catastrophic health expenditure from the use of emergency surgical care were identified and people who paid for the care were purposively selected for the interviews. Using an in-depth interview guide, information on the experiences and overall coping strategies during and after the hospitalization was collected. Data were analyzed inductively using the thematic approach.

RESULTS

The mean age of the 31 participants (consisting of 7 men and 24 women) was 31 ± 5.6years. Apathy to savings limited the preparation for unplanned healthcare needs. Choice of hospital was determined by word of mouth, perceptions of good quality or prompt care and availability of staff. Social networks were relied on widely as a coping mechanism before and during the admission. Patients that were unable to pay experienced poor and humiliating treatment (in severe cases, incarceration). Inability to afford care was exacerbated by double billing and extraneous charges. It was opined that health care should be more affordable for all and that the current National Health Insurance Scheme, that was operating sub-optimally, should be strengthened appropriately for all to benefit.

CONCLUSION

The study highlights households' poor attitude to health-related savings and pre-payment into a social solidarity fund to cover the costs of emergency surgical care. It also highlights the factors influencing costs of emergency surgical care and the role of social networks in mitigating the high costs of care. Improving financial protection from emergency surgical care would entail promoting a positive attitude to health-related savings, social solidarity and extending the benefits of social health insurance.

Effect of two major health reforms on health care cost and utilization in Fars Province of Iran: family physician program and health transformation plan

Background

Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran’s health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services.

Methods

This longitudinal study was conducted on people insured by social security organization in Fars province during 2009–2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms.

Results

FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners’ and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods.

Conclusions

FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people’s access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan.

Households forgoing healthcare as a measure of financial risk protection: an application to Liberia

INTRODUCTION

Access to Liberia's health system is reliant on out-of-pocket (OOP) health expenditures which may prevent people from seeking care or result in catastrophic health expenditure (CHE). CHE and impoverishment due to OOP, which are used by the World Bank and World Health Organization as the sole measures of financial risk protection, are limited: they do not consider households who, following a health shock, do not incur expenditure because they cannot access the healthcare services they need (i.e., households forgoing healthcare (HFH) services). This paper attempts to overcome this limitation and improve financial risk protection by measuring HFH incidence and comparing it with CHE standard measures using household survey data from Liberia.

METHODS

Data from the Liberia Household Income and Expenditure Survey 2014 were analysed. An OOP health expenditure is catastrophic when it exceeds a total or non-food household expenditure threshold. A CHE incidence curve, representing CHE incidence at different thresholds, was developed. To overcome CHE limitations, an HFH incidence measure was developed based on CHE, OOP and health shocks data: households incurring health shocks and having negligible OOP were considered to have forgone healthcare. HFH incidence was compared with standard CHE measures.

RESULTS

CHE incidence and intensity levels depend on the threshold used. Using a 30% non-food expenditure threshold, CHE incidence is 2.1% (95% CI: 1.7-2.5%) and CHE intensity is 37.4% (95% CI: 22.7-52.0%). CHE incidence is approximately in line with other countries, while CHE intensity is higher than in other countries. CHE pushed 1.6% of households below the food poverty line in 2014. c approximately 4 times higher than CHE (8.0, 95% CI, 7.2-8.9%).

CONCLUSION

Lack of financial risk protection is a significant problem in Liberia and it may be underestimated by CHE: this study confirms that HFH incidence can complement CHE measures in providing a complete picture of financial risk protection and demonstrates a simple method that includes measures of healthcare forgone as part of standard CHE analyses. This paper provides a new methodology to measure HFH incidence and highlights the need to consider healthcare forgone in analyses of financial risk protection, as well as the need for further development of these measures.

Revision surgery rates in chronic rhinosinusitis with nasal polyps: meta-analysis of risk factors

BACKGROUND

Wide variations in revision endoscopic sinus surgery (ESS) rates for chronic rhinosinusitis with nasal polyposis (CRSwNP) have been reported. It is important to understand expected revision rates and factors that impact the need for revision.

METHODS

A literature search was conducted on PubMed, Scopus, and the Cochrane Database of Systematic Reviews. Following PRISMA guidelines, a systematic review and meta-analysis was performed on studies that reported revision surgery data for CRSwNP patients.

RESULTS

Forty-five studies with 34,220 subjects were meta-analyzed, with an overall revision rate of 18.6% (95% confidence interval, 14.1%-23.6%). Studies with extractable follow-up data reported a mean revision rate of 16.2% over a weighted mean follow-up of 89.6 months. Factors associated with increased revision rates included allergic fungal rhinosinusitis (28.7%), aspirin-exacerbated respiratory disease (27.2%), asthma (22.6%), prior polypectomy (26.0%), and publication prior to 2008 (22.7%) (p < 0.05 for all).

CONCLUSION

Although polyps can recur after ESS, reported long-term ESS revision rates are approximately 14% to 24%. Identifying risk factors for revision surgery can help manage patient expectations and determine optimal personalized treatments.

'Connecting the dots' for generating a momentum for Universal Health Coverage in Bangladesh: findings from a cross-sectional descriptive study

OBJECTIVE

This study was conducted to explore how and whether, the strategic grants made by the Rockefeller Foundation (RF) in different sectors of health systems in the inception phase were able to 'connect the dots' for 'generating a momentum for Universal Health Coverage (UHC)' in the country.

DESIGN

Cross-sectional descriptive study, using document review and qualitative methods.

SETTING

Bangladesh, 17 UHC-related projects funded by the RF Transforming Health Systems (THS) initiative during 2010-2013.

DATA

Available reports of the completed and on-going UHC projects, policy documents of the government relevant to UHC, key-informant interviews and feedback from grant recipients and relevant stakeholders in the policy and practice.

OUTCOME MEASURES

Key policy initiatives undertaken for implementing UHC activities by the government post grants disbursement.

RESULTS

The RF THS grants simultaneously targeted and connected the academia, the public and non-profit development sectors and news media for awareness-building and advocacy on UHC, develop relevant policies and capacity for implementation including evidence generation. This strategy helped relevant stakeholders to come together to discuss and debate the core concepts, scopes and modalities of UHC in an attempt to reach a consensus. Additionally, experiences gained from implementation of the pilot projects helped in identifying possible entry points for initiating UHC activities in a low resource setting like Bangladesh.

CONCLUSIONS

During early years of UHC-related activities in Bangladesh, strategic investments of the RF THS initiative played a catalytic role in sensitising and mobilising different constituencies for concerted activities and undertaking necessary first steps. Learnings from this strategy may be of help to countries under similar conditions of 'low resource, apparent commitment, but poor governance,' on their journey towards UHC.

A systematic review of the health-financing mechanisms in the Association of Southeast Asian Nations countries and the People's Republic of China: Lessons for the move towards universal health coverage

We systematically review the health-financing mechanisms, revenue rising, pooling, purchasing, and benefits, in the Association of Southeast Asian Nations (ASEAN) and the People’s Republic of China, and their impact on universal health coverage (UHC) goals in terms of universal financial protection, utilization/equity and quality. Two kinds of sources are reviewed: 1) academic articles, and 2) countries’ health system reports. We synthesize the findings from ASEAN countries and China reporting on studies that are in the scope of our objective, and studies that focus on the system (macro level) rather than treatment/technology specific studies (micro level).The results of our review suggest that the main sources of revenues are direct/indirect taxes and out of pocket payments in all ASEAN countries and China except for Brunei where natural resource revenues are the main source of revenue collection. Brunei, Indonesia, Philippines, Malaysia, and Viet Nam have a single pool for revenue collection constituting a national health insurance. Cambodia, China, Lao, Singapore, and Thailand have implemented multiple pooling systems while Myanmar has no formal arrangement. Capitation, Fee-for-Service, DRGs, Fee schedules, Salary, and Global budget are the methods of purchasing in the studied countries. Each country has its own definition of the basic benefit package which includes the services that are perceived as essential for the population health. Although many studies provide evidence of an increase in financial protection after reforming the health-financing mechanisms in the studied countries, inequity in financial protection continue to exist. Overall, the utilization of health care among the poor has increased as a consequence of the implementation of government subsidized health insurance schemes which target the poor in most of the studied countries. Inappropriate policies and provider payment mechanisms impact on the quality of health care provision. We conclude that the most important factors to attain UHC are to prioritize and include vulnerable groups into the health insurance scheme. Government subsidization for this kind of groups is found to be an effective method to achieve this goal. The higher the percentage of government expenditure on health, the greater the financial protection is. At the same time, there is a need to weigh the financial stability of the health-financing system. A unified health insurance system providing the same benefit package for all, is the most efficient way to attain equitable access to health care. Capacity building for both administrative and health service providers is crucial for sustainable and good quality health care.

Subnational health management and the advancement of health equity: a case study of Ethiopia

BACKGROUND

Health equity is a cross-cutting theme in the United Nations 2030 Agenda for Sustainable Development, and a priority in health sector planning in countries including Ethiopia. Subnational health managers in Ethiopia are uniquely positioned to advance health equity, given the coordination, planning, budgetary, and administration tasks that they are assigned. Yet, the nature of efforts to advance health equity by subnational levels of the health sector is poorly understood and rarely researched. This study assesses how subnational health managers in Ethiopia understand health equity issues and their role in promoting health equity and offers insight into how these roles can be harnessed to advance health equity.

METHODS

A descriptive case study assessed perspectives and experiences of health equity among subnational health managers at regional, zonal, district and Primary Health Care Unit administrative levels. Twelve in-depth interviews were conducted with directors, vice-directors, coordinators and technical experts. Data were analyzed using thematic analysis.

RESULTS

Subnational managers perceived geographical factors as a predominant concern in health service delivery inequities, especially when they intersected with poor infrastructure, patriarchal gender norms, unequal support from non-governmental organizations or challenging topography. Participants used ad hoc, context-specific strategies (such as resource-pooling with other sectors or groups and shaming-as-motivation) to improve health service delivery to remote populations and strengthen health system operations. Collaboration with other groups facilitated cost sharing and access to resources; however, the opportunities afforded by these collaborations, were not realized equally in all areas. Subnational health managers' efforts in promoting health equity are affected by inadequate resource availability, which restricts their ability to enact long-term and sustainable solutions.

CONCLUSIONS

Advancing health equity in Ethiopia requires: extra support to communities in hard-to-reach areas; addressing patriarchal norms; and strategic aligning of the subnational health system with non-health government sectors, community groups, and non-governmental organizations. The findings call attention to the unrealized potential of effectively coordinating governance actors and processes to better align national priorities and resources with subnational governance actions to achieve health equity, and offer potentially useful knowledge for subnational health system administrators working in conditions similar to those in our Ethiopian case study.

Migrant and refugee populations: a public health and policy perspective on a continuing global crisis

The 2015-2017 global migratory crisis saw unprecedented numbers of people on the move and tremendous diversity in terms of age, gender and medical requirements. This article focuses on key emerging public health issues around migrant populations and their interactions with host populations. Basic needs and rights of migrants and refugees are not always respected in regard to article 25 of the Universal Declaration of Human Rights and article 23 of the Refugee Convention. These are populations with varying degrees of vulnerability and needs in terms of protection, security, rights, and access to healthcare. Their health status, initially conditioned by the situation at the point of origin, is often jeopardised by adverse conditions along migratory paths and in intermediate and final destination countries. Due to their condition, forcibly displaced migrants and refugees face a triple burden of non-communicable diseases, infectious diseases, and mental health issues. There are specific challenges regarding chronic infectious and neglected tropical diseases, for which awareness in host countries is imperative. Health risks in terms of susceptibility to, and dissemination of, infectious diseases are not unidirectional. The response, including the humanitarian effort, whose aim is to guarantee access to basic needs (food, water and sanitation, healthcare), is gripped with numerous challenges. Evaluation of current policy shows insufficiency regarding the provision of basic needs to migrant populations, even in the countries that do the most. Governments around the world need to rise to the occasion and adopt policies that guarantee universal health coverage, for migrants and refugees, as well as host populations, in accordance with the UN Sustainable Development Goals. An expert consultation was carried out in the form of a pre-conference workshop during the 4th International Conference on Prevention and Infection Control (ICPIC) in Geneva, Switzerland, on 20 June 2017, the United Nations World Refugee Day.

Single-payer or a multipayer health system: a systematic literature review

OBJECTIVES

Healthcare systems worldwide are actively exploring new approaches for cost containment and efficient use of resources. Currently, in a number of countries, the critical decision to introduce a single-payer over a multipayer healthcare system poses significant challenges. Consequently, we have systematically explored the current scientific evidence about the impact of single-payer and multipayer health systems on the areas of equity, efficiency and quality of health care, fund collection negotiation, contracting and budgeting health expenditure and social solidarity.

STUDY DESIGN

This is a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

METHODS

A search for relevant articles published in English was performed in March 2015 through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online through PubMed and Ovid, Health Technology Assessment Database, Cochrane database and WHO publications. We also searched for further articles cited by eligible papers.

RESULTS

A total of 49 studies were included in the analysis; 34 studied clinical outcomes of patients enrolled in different health insurances, while 15 provided a qualitative assessment in this field.

CONCLUSION

The single-payer system performs better in terms of healthcare equity, risk pooling and negotiation, whereas multipayer systems yield additional options to patients and are harder to be exploited by the government. A multipayer system also involves a higher administrative cost. The findings pertaining to the impact on efficiency and quality are rather tentative because of methodological limitations of available studies.

Universal Health Coverage in Rural Ecuador: A Cross-sectional Study of Perceived Emergencies

INTRODUCTION

In many low- and middle-income countries emergency care is provided anywhere in the health system; however, no studies to date have looked at which providers are chosen by patients with perceived emergencies. Ecuador has universal health coverage that includes emergency care. However, earlier research indicates that patients with emergencies tend to seek private care. Our primary research questions were these: What is the scope of perceived emergencies?; What is their nature?; and What is the related healthcare-seeking behavior? Secondary objectives were to study determinants of healthcare-seeking behavior, compare health expenditure with expenditure from the past ordinary illness, and measure the prevalence of catastrophic health expenditure related to perceived emergencies.

METHODS

We conducted a cross-sectional survey of 210 households in a rural region of northwestern Ecuador. The households were sampled with two-stage cluster sampling and represent an estimated 20% of the households in the region. We used two structured, pretested questionnaires. The first questionnaire collected demographic and economic household data, expenditure data on the past ordinary illness, and presented our definition of perceived emergency. The second recorded the number of emergency events, symptoms, further case description, healthcare-seeking behavior, and health expenditure, which was defined as being catastrophic when it exceeded 40% of a household's ability to pay.

RESULTS

The response rate was 85% with a total of 74 reported emergency events during the past year (90/1,000 inhabitants). We further analyzed the most recent event in each household (n=54). Private, for-profit providers, including traditional healers, were chosen by 57.4% (95% confidence interval [CI] [44-71%]). Public providers treated one third of the cases. The mean health expenditure per event was $305.30 United States dollars (USD), compared to $135.80 USD for the past ordinary illnesses. Catastrophic health expenditure was found in 24.4% of households.

CONCLUSION

Our findings suggest that the provision of free health services may not be sufficient to reach universal health coverage for patients with perceived emergencies. Changes in the organization of public emergency departments and improved financial protection for emergency patients may improve the situation.

Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados

RESUMO Este artigo revisa e sintetiza evidências sobre o impacto da Estratégia Saúde da Família (ESF) a partir do marco conceitual de sistemas de saúde da Organização Mundial da Saúde, o qual agrega os conceitos de acesso, proteção financeira, qualidade dos serviços, eficiência no sistema, impacto na saúde e equidade. Os resultados sugerem que a ESF contribuiu para a melhoria em todos esses indicadores, com alguns efeitos no acesso e equidade com resultados quase chegando aos níveis observados nos países da Organização para Cooperação e Desenvolvimento Econômico. Embora ainda haja bastante espaço para melhorias, a evidência é clara de que a ESF é uma abordagem poderosa e eficaz para a organização da atenção primária à saúde no Brasil.

OVERCOMING THE BARRIERS TO ACHIEVING UNIVERSAL HEALTH CARE IN THE ASIAN REGION

OBJECTIVES

The Health Technology Assessment International (HTAi) Asia Policy Forum (HAPF) met to discuss the challenges of achieving universal health care (UHC) in Asia.

METHODS

Group discussions and presentations at the 2017 HAPF, informed by a background paper, including a literature review and the results of pre-meeting surveys of health technology assessment (HTA) agencies and industry, formed the basis of this article.

RESULTS

Affordability was identified as the greatest barrier to establishing UHC; however, other impediments include the lack of political will to implement UHC, and the cultural issue of deference to expert opinion instead of evidence-based assessments. Although HTA was identified as an important prioritization tool when adding new technologies to benefit packages, it is used inconsistently in the region, resulting in a less transparent decision-making process for stakeholders. Although regional challenges exist around real-world data (RWD), including a lack of capacity to enable information and data sharing, most policy or funding decision makers in the region have access to data. However, there appears to be a disconnect with the experience of industry, whose representatives identify the lack of RWD as their primary issue. To overcome these issues, both HTA agencies and industry agree that collaboration and transparency should be fostered to support the development of robust evidence generation in the region.

CONCLUSIONS

There is a willingness for HTA agencies and industry to collaborate to develop HTA methodology for the prioritization of technologies in the Asia region that support healthcare systems to achieve the ultimate outcome of UHC.

Monetary and nonmonetary household consumption of health services and the role of insurance benefits: An analysis of the Mexico's National Household Income and Expenditure Survey

OBJECTIVES

To study the monetary and nonmonetary consumption of healthcare services at household level in Mexico and the magnitude of the contribution of public programs.

METHODS

By using the National Household Income and Expenditure Survey 2012, we performed a cross-sectional and observational analysis of actual household consumption of health services by insurance type (no insurance, social security, Seguro Popular (SP)). Household consumption was divided into 2 categories: consumption related to "monetary" expenditure in health care and "nonmonetary" consumption in health care by the household. Nonmonetary included self-consumption or gifts received from other households and institutional contributions such as government payments or private organization transfers.

RESULTS

In SP households, monetary and nonmonetary consumption of health services represented the highest proportion of available household expenditure (11.2%) compared to uninsured (8.4%) and social security (5.9%) households. The prevalence of outpatient consultation and medicine use is the highest among the health service consumption categories regardless of insurance status. Distribution of nonmonetary versus monetary consumption of health services was pro-poor: The poorer the households, the larger the proportion of nonmonetary consumption.

CONCLUSIONS

The higher probability of receiving nonmonetary resources as a component of health service consumption in SP households is likely to increase the affordability to health services and likely to reduce healthcare expenditures. Future research should focus on the type of nonmonetary consumption of health services at household level to better understand financial protection and access to health care in Mexico.