Strategies for reducing out of pocket payments in the health system: a scoping review

Reproductive, maternal, newborn, child and adolescent health services in humanitarian and fragile settings: A mixed methods study of midwives' and women's experiences

Insufficient progress has been made to reduce morbidity and mortality for women, children and adolescents particularly in Humanitarian and Fragile settings (HFS). Midwives play a critical and unique role in ensuring communities receive quality and safe essential sexual, reproductive, maternal, newborn, child, and adolescent health services. A lack of knowledge exists on the availability and experiences of midwifery services in HFS. This manuscript provides an overview of the midwifery density in HFS and a synthesis of the experiences of women receiving midwifery care, and barriers and facilitators for midwives providing essential SRMNCAH services in HFS. Guided by an expert committee, a concurrent mixed methods approach was applied, using secondary analysis of primary quantitative and qualitative data sources. Quantitative analysis of the global distribution of midwives compared to fragility was undertaken. Qualitative analysis of experiences of receipt and provision of midwifery care was undertaken across four settings providing humanitarian care. There is a critically low density of midwives in humanitarian and fragile settings. Sub-Saharan Africa accounts for the highest levels of fragility yet lowest density of midwives able to provide SRMNCAH services. Lack of finances both constrains midwives from effectively providing services and prevent communities from utilising services. Sub-optimal working conditions through rising workloads, insufficient and/or inconsistent resources were frequently reported to impede midwives from providing care in HFS. Uniquely for HFS, threats to the safety and security of midwives to conduct their work was widely reported. Key facilitators identified included, complex adaptive health system designs to respond effectively to the rapidly changing HFS environment, realisation of supporting "power, agency and status" as instrumental for midwives to provide quality care and promotion of community-centric approaches may enable continuity of care and uptake of essential SRMNCAH services. Midwives are critical to protect the health and well-being of communities. They require urgent protection and prioritisation in HFS areas where the need is greatest.

Mapping evidence on barriers to and facilitators of diagnosing noncommunicable diseases among people living with human immunodeficiency virus in low- and middle-income countries in Africa: A scoping review

Objectives

To map the evidence on the barriers to and facilitators of diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries in Africa.

Introduction

Noncommunicable diseases are increasing among people living with HIV. Thus, strengthened and sustained diagnosis of noncommunicable diseases through integrated noncommunicable diseases and HIV care is needed to improve patient outcomes. However, there is paucity of evidence on the barriers and facilitators diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries.

Methods

The Arksey and O'Malley methodological framework was used. A comprehensive systematic search of academic databases (MEDLINE, Academic Search Complete, APA PsycInfo, CAB, and Health Source/Nursing) was performed via EBSCO search and PubMed. The articles were reviewed independently by three reviewers. The results were structured using Capability-Opportunity-Motivation-Behavior model and Theoretical Domains Framework.

Results

A total of 152 articles were retrieved for full-text review. Forty-one articles met the inclusion criteria. The identified barriers were relevant to all the Capability-Opportunity-Motivation-Behavior constructs and 14 Theoretical Domains Framework domains. A lack of knowledge and awareness of noncommunicable diseases, fear of stigma, financial problems and out-of-pocket payments were the most cited patient-level barriers. Healthcare providers (knowledge and awareness gaps, skill and competence deficiencies, unwillingness, burnout, low motivation, and apathy) were frequently cited. Lack of equipment, noncommunicable disease medications and supply chain challenges, lack of integrated noncommunicable disease and HIV care, and shortage of trained healthcare providers were identified as health-system-level barriers.

Conclusion

This scoping review is the first to identify barriers and facilitators using a theoretical framework. The most cited barriers include a lack of integrated HIV and noncommunicable disease care, equipment and logistics chain challenges for noncommunicable diseases, patients' and healthcare providers' lack of knowledge and awareness of noncommunicable diseases, and healthcare provider's skill and competency deficiencies. Addressing these issues is crucial for improving patient outcomes and reducing the burden on healthcare providers and health systems.

Utilisation, out-of-pocket payments and access before and after COVID-19: Thailand's Universal Health Coverage Scheme

The goal of Universal Health Coverage (UHC) is that everyone needing healthcare can access quality services without financial hardship. Recent research covering countries with UHC systems documents the emergence, and acceleration following the COVID-19 pandemic of unapproved informal payment systems by providers that collect under-the-table payments from patients. In 2001, Thailand extended its '30 Baht' government-financed coverage to all uninsured people with little or no cost sharing. In this paper, we update the literature on the performance of Thailand's Universal Health Coverage Scheme (UCS) with data covering 2019 (pre-COVID-19) through 2021. We find that access to care for Thailand's UCS-covered population (53 million) is similar to access provided to populations covered by the other major public health insurance schemes covering government and private sector workers, and that, unlike reports from other UHC countries, no evidence that informal side payments have emerged, even in the face of COVID-19 related pressures. However, we do find that nearly one out of eight Thailand's UCS-covered patients seek care outside the UCS delivery system where they will incur out-of-pocket payments. This finding predates the COVID-19 pandemic and suggests the need for further research into the performance of the UHC-sponsored delivery system.

An analysis of financial protection and financing incidence of out-of-pocket health expenditures in Kazakhstan from 2018 to 2021

Universal health coverage relies on providing essential medical services and shielding individuals from financial risks. Our study assesses the progressivity of out-of-pocket (OOP) payments, identifies factors contributing to healthcare expenditure inequality, and examines catastrophic health expenditures (CHE) prevalence in Kazakhstan from 2018 to 2021. Using retrospective analysis of National Statistics Bureau data, we employed STATA 13 version for calculations CHE incidence, progressivity, Lorenz and concentration curves. In 2020-2021, OOP expenditures in Kazakhstan decreased, reflecting a nearly twofold reduction in the CHE incidence to 1.32% and 1.24%, respectively. However, during these years, we observe a transition towards a positive trend in the Kakwani index to 0.003 and 0.005, respectively, which may be explained by household size and education level factors. Increased state financing and quarantine measures contributed to reduced OOP payments. Despite a low healthcare expenditure share in gross domestic product, Kazakhstan exhibits a relatively high private healthcare spending proportion. The low CHE incidence and proportional expenditure system suggest private payments do not significantly impact financial resilience, prompting considerations about the role of government funding and social health insurance in the financing structure.

Do hospitalizations push households into poverty in India: evidence from national data

Introduction

High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it.

Methods

The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment.

Results

Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities.

Conclusion

In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

Modelling the national economic burden of non-surgical periodontal management in specialist clinics in Malaysia using a markov model

BACKGROUND

Non-surgical periodontal treatment is the mainstay of periodontal treatment. In Malaysia, the prevalence of periodontal disease is substantial among adults with almost half of them having periodontitis. Therefore, we estimated the economic burden of non-surgical periodontal treatment in specialist clinics in Malaysia.

METHODS

Relevant data from multiple data sources which include national oral health and health surveys, national census, extensive systematic literature reviews, as well as discussion with experts, were used to estimate the economic burden of non-surgical periodontal management in specialist clinics in Malaysia in 2020. This estimation was done from the oral healthcare provider's perspective in both public and private sectors using an irreducible Markov model of 3-month cycle length over a time horizon of one year.

RESULTS

In 2020, the national economic burden of non-surgical periodontal treatment during the first year of periodontal management in specialist clinics in Malaysia was MYR 696 million (USD 166 million), ranging from MYR 471 million (USD 112 million) to MYR 922 million (USD 220 million). Of these, a total of MYR 485 million (USD 115 million) and MYR 211 million (USD 50 million) were the direct oral healthcare cost in public and private dental clinics, respectively.

CONCLUSION

The findings of this study demonstrated substantial economic burden of non-surgical periodontal management in specialist clinics in Malaysia. Being a life-long disease, these findings highlight the importance of enforcing primary and secondary preventive measures. On the strength and reliability of this economic evidence, this study provides vital information to inform policy- and decision-making regarding the future direction of managing periodontitis in Malaysia.

Measuring the value of solidarity: The abem financial assistance program for out-of-pocket payments on pharmacy medicines in Portugal

OBJECTIVE

Out-of-pocket payments for prescribed medicines are still comparatively high in Portugal. The abem program was launched in Portugal in May 2016 to aid vulnerable groups by completely covering out-of-pocket costs of prescribed medicines in community pharmacies. This study assesses the impact of the program on poverty and catastrophic health expenditures.

METHODS

A longitudinal study was carried out with the analysis of several program databases (from the beginning of the program in May 2016 to September 2018) covering the cohorts of beneficiaries, daily data on medicines dispensed, social referencing entities, and solidarity pharmacies. The study provides estimates of standard poverty measures (intensity and severity) as well as the incidence of catastrophic health expenditures.

RESULTS

More than 6000 beneficiaries were supported (56.8% female, 34.7% aged 65 or over), encompassing 127,510 medicines (mainly nervous system and cardiovascular system) with an average 26.9% co-payment (payments totalling €1.5 million). The program achieved substantial reductions in poverty (3.4% in intensity, 5.6% in severity), and eliminated cases with catastrophic health expenditures in medicines that would have affected 7.5% of the beneficiaries.

CONCLUSIONS

Findings confirm a continuous increase in the number of beneficiaries, enabling access to medicines especially for the vulnerable elderly, and a sizable impact on eliminating out-of-pocket payments for medicines in the target population.

Survival differences by race and surgical approach in early-stage operable cervical Cancer

OBJECTIVE

To evaluate if the higher rate of open radical hysterectomy in Black patients, prior to the widespread return to open surgical techniques, mitigated survival disparities and to identify other actionable factors to target for systemic change.

METHODS

This is a retrospective cohort study including patients from the National Cancer Database with cervical cancer who underwent radical hysterectomy from 2010 to 2018. Patient demographics, clinical characteristics and survival were compared by race and surgical route. Kaplan-Meier plots were constructed. Cox proportional hazards modeling was used to adjust for covariates.

RESULTS

7201 patients were eligible for inclusion, 687 (9.5%) Black and 4870 (68%) White. We found that 51% of Black patients and 39% of White patients underwent open surgery. Black patients were 10% less likely to receive Guideline Concordant Care (GCC). Those with publicly-funded insurance had a 40% higher hazard of death compared to private insurance (CI 1.19-1.73 p < 0.001). Black patients who had open surgery had similar 5-year survival compared to White patients who had MIS surgery (0.90 vs 0.91, NS). After adjusting for potential confounders including age, insurance, nodal status, and lymphovascular space invasion, Black patients who had surgery had a 40% higher hazard for death (HR 1.40 95% CI 1.10-1.79, p = 0.007) compared to White patients.

CONCLUSIONS

A lower 5 and 10-year survival was seen in Black patients, regardless of surgical approach. Adjustment for significant covariates did not resolve this disparity, confirming that these factors do not fully account racial disparities.

Equity in out-of-pocket health expenditure: Evidence from a health insurance program reform in Mexico

Background

The fragmentation of health systems in low- and middle-income countries (LMICs) deepens health inequities and shifts the economic burden of health care to families via out-of-pocket spending (OOPHE). This problem has been addressed by introducing public health insurance programs for poor people; however, there is a lack of knowledge about how equitable these programs are. We aimed to analyse the long-term effects of the Seguro Popular (SP) voluntary health insurance program, recently phased out and replaced by the Health Institute for Welfare (Instituto de Salud para el Bienestar (INSABI)), on OOPHE equity in the poor Mexican population.

Methods

We conducted a pooled cross-sectional analysis using eleven waves of the National Household Income and Expenditure Survey (2002-2020). We identified the effect of SP by selecting households without social security (with SP or without health insurance (n = 169 766)) and matched them by propensity score to reduce bias in the decision to enrol in SP. We estimated horizontal and vertical equity metrics and assessed their evolution across subpopulations.

Results

The program's entry years (2003-2010) show a positive redistributive effect associated with a focalised stage of the program, while oversaturation could have diluted these effects during 2010-2014, with adverse results in terms of vertical equity and re-ranking among insured families. SP is more horizontally inequitable than for those uninsured. Within SP, the redistributive effect could improve up to 13% if all families with similar expenditures were spending equal OOPHE and horizontal equity was eliminated. Regarding vertical equity, SP outperforms the insured population with middle-range coverage some years after the implementation, but this progress disappears.

Conclusions

To achieve universal health coverage, health authorities need to create and execute financial protection mechanisms that effectively address structural inequalities. This involves implementing a more comprehensive risk-pooling mechanism that makes social insurance sustainable in the long-run by increasing the social-economic influx of resources. It is essential to monitor oversaturation and financial sustainability to achieve optimal results. The replacement of the SP with INSABI highlights the complexity of maintaining a social insurance program where the ideology of different governments can influence the program structure, regulation, financing, and even its existence.

Health technology assessment (HTA) readiness in Uganda: stakeholder's perceptions on the potential application of HTA to support national universal health coverage efforts

INTRODUCTION

Health technology assessment (HTA) is an area that remains less implemented in low- and lower middle-income countries. The aim of the study is to understand the perceptions of stakeholders in Uganda toward HTA and its role in decision making, in order to inform its potential implementation in the country.

METHODS

The study takes a cross-sectional mixed methods approach, utilizing an adapted version of the International Decision Support Initiative questionnaire with both semi-structured and open-ended questions. We interviewed thirty key informants from different stakeholder institutions in Uganda that support policy and decision making in the health sector.

RESULTS

All participants perceived HTA as an important tool for decision making. Allocative efficiency was regarded as the most important use of HTA receiving the highest average score (8.8 out of 10), followed by quality of healthcare (7.8/10), transparency (7.6/10), budget control (7.5/10), and equity (6.5/10). There was concern that some of the uses of HTA may not be achieved in reality if there was political interference during the HTA process. The study participants identified development partners as the most likely potential users of HTA (66.7 percent of participants), followed by Ministry of Health (43.3 percent).

CONCLUSION

Interviewed stakeholders in Uganda viewed the role of HTA positively, suggesting that there exists a promising environment for the establishment and operationalization of HTA as a tool for decision making within the health sector. However, sustainable development and application of HTA in Uganda will require adequate capacity both to undertake HTAs and to support their use and uptake.

Determinants of Out-of-Pocket Health Spending in Households in Peru in the Times of the Pandemic (COVID-19)

In 2021, the expenses paid by households worldwide due to COVID-19 showed an increasing behavior and directly affected economic income since they were part of unforeseen expenses among households and became a factor that contributed to the increase in the levels of poverty mainly in households that were not part of the health system. The objective of this research was to establish the main determinants of out-of-pocket spending on health in Peruvian households in the times of the pandemic. A quantitative approach, of a nonexperimental type, with a descriptive and correlational methodological design was considered. The database of the National Household Survey of the National Institute of Statistics and Informatics for 2021 was used as a source of information, applying the binomial logit econometric model. Out-of-pocket expenses during the pandemic compared to normal periods were shared by the members of the households. Since they were part of unforeseen expenses, these expenses mainly impacted the heads of the households and strongly affected household budgets. For this reason, the type of insurance, the suffering of household members from a disease, the results of tests for COVID-19, the expenditure on individual health, the existence of permanent limitations to any member of the household, the presence of an older adult in the household, and the marital status of the head of the household determined and positively influenced out-of-pocket spending in households in Peru with 36.85, 8.48, 6.50, 0.0065, 23.73, 16.79, and 2.44 percentage units. However, the existence of a drinking water service in the household, educational level, and the area of residence determined and negatively influenced out-of-pocket spending in households in Peru with 4.81, 6.75, and 19.26 percentage units, respectively. The type of insurance, the suffering of an individual from a disease, the results of COVID-19 tests, health spending, the existence of permanent limitations, the presence of an older adult in the household, and the marital status of the head of the household positively determined out-of-pocket spending in households in Peru, while the existence of a potable water service, educational level, and the area of residence determined out-of-pocket expenses in a negative or indirect way.

Financing health system elements in Africa: A scoping review

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

Developing Standard Treatment Workflows-way to universal healthcare in India

Primary healthcare caters to nearly 70% of the population in India and provides treatment for approximately 80-90% of common conditions. To achieve universal health coverage (UHC), the Indian healthcare system is gearing up by initiating several schemes such as National Health Protection Scheme, Ayushman Bharat, Nutrition Supplementation Schemes, and Inderdhanush Schemes. The healthcare delivery system is facing challenges such as irrational use of medicines, over- and under-diagnosis, high out-of-pocket expenditure, lack of targeted attention to preventive and promotive health services, and poor referral mechanisms. Healthcare providers are unable to keep pace with the volume of growing new scientific evidence and rising healthcare costs as the literature is not published at the same pace. In addition, there is a lack of common standard treatment guidelines, workflows, and reference manuals from the Government of India. Indian Council of Medical Research in collaboration with the National Health Authority, Govt. of India, and the WHO India country office has developed Standard Treatment Workflows (STWs) with the objective to be utilized at various levels of healthcare starting from primary to tertiary level care. A systematic approach was adopted to formulate the STWs. An advisory committee was constituted for planning and oversight of the process. Specialty experts' group for each specialty comprised of clinicians working at government and private medical colleges and hospitals. The expert groups prioritized the topics through extensive literature searches and meeting with different stakeholders. Then, the contents of each STW were finalized in the form of single-pager infographics. These STWs were further reviewed by an editorial committee before publication. Presently, 125 STWs pertaining to 23 specialties have been developed. It needs to be ensured that STWs are implemented effectively at all levels and ensure quality healthcare at an affordable cost as part of UHC.

Is Mechanical Thrombectomy or Thrombolysis Universally Cost-Effective? A Systematic Review of the Literature

BACKGROUND

Thrombolysis (rTPA) and mechanical thrombectomy (MT) are cost-effective treatments for ischemic stroke. However, little is known about the impact of different types of health systems (HSs) on the outcome and cost of ischemic stroke.

METHODS

Literature search was performed on PubMed/OVID for studies without time limits. The year of publication, type of HS, cost of intervention treatment (rTPA/MT), cost of control strategy (conservative treatment or rTPA), quality-adjusted life years (QALYs) gained, and percentage of gross domestic product spent on health were recorded. The inclusion criteria were English literature, cost-effectiveness, and cost-utility analyses. The exclusion criterion was the absence of geographic coherence between the derived QALYs and the costs. The costs were inflated to 2021 and then converted to US dollar/euro. An analysis of variance or Kruskal-Wallis test was used to compare the percentage of cost reduction and the QALYs gained. Gross domestic product percentage was correlated with the QALYs gained.

RESULTS

Thirty-five studies were analyzed. No significant differences in the percentage of cost reduction were found among the different types of HS (Beveridge -14.74% [95% confidence interval {CI} -57.94/53.08] vs. Bismarck -2.27% [95% CI -122.73/118.18] vs. national insurance -0.015% [95% CI -16.96/51.00] vs. private insurance -4.05% [95% CI -32.62/13.18]). No differences were found in QALYs gained among the different HS (Beveridge 1021 [95% CI -36.37/1705.04] vs. Bismarck 440 [95% CI -2290.68/3870.68] vs. national insurance 643 [95% CI -137.54/2366.21] vs. private insurance 550 [95% CI 131.54/1128.06]). No differences were found among the QALYs gained between rTPA/conservative treatment versus rTPA/MT and rtPA + MT/MT. The percentage of gross domestic product spent on health did not correlate with the QALYs gained (rho = -0.16; P = 0.56).

CONCLUSIONS

MT and rTPA are independently cost-effective among different HS.