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Feng Y, Tuan TD, Shi J, Li Z, Maimaitiming M, Jin Y, Zheng Z. Progress towards health equity in Vietnam: evidence from nationwide official health statistics, 2010-2020. BMJ Glob Health 2024; 9:e014739. [PMID: 38503427 PMCID: PMC10952956 DOI: 10.1136/bmjgh-2023-014739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION One of the ultimate goals of strengthening the health system is to achieve health equity. Vietnam is considered one of the 'fast-track countries' to achieve the health-related Millennium Development Goals, but research on its equity strategies remains inadequate. METHODS Using Vietnamese official health statistics, we investigated inequity in four dimensions including health resources, service delivery, service utilisation and residents' health status from the perspectives of income levels, poverty rates and subnational regions. The Slope Index of Inequality, concentration curve/Concentration Index, absolute difference and Theil Index were used. RESULTS Four indicators showed 'pro-poor' inequality in health resources, including the per capita health budget, per capita health personnel, per capita health personnel at the community level and per capita hospital beds at the community level, while provincial hospital beds showed 'pro-rich' inequality. Two health service delivery indicators (delivery of antenatal care ≥3 times and proportion of community health service centres with medical doctors) show 'pro-rich' inequality, although two health status indicators, mortality and malnutrition rates for children under five, showed 'pro-poor' inequality. The Northern Midlands and Mountain Areas, and the Central Highlands were disadvantaged regarding service delivery and health status. Intraregional differences were the main factors contributing to the inequalities in delivery of antenatal care ≥3 times, provincial hospital beds and percentage of community health centres with medical doctors, with the Red River Delta and the South East region experiencing the greatest inequalities. CONCLUSION The overall level of health equity in Vietnam has increased over the past decade, although inequality in health service delivery has hindered progress towards health equity based on income, poverty and subnational regions. Targeted policies need to be introduced to reduce inequities relating to the health workforce and service delivery capacity.
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Affiliation(s)
- Yikai Feng
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Tran Diep Tuan
- University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Junyi Shi
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Zhuo Li
- Institute of Area Studies, Peking University, Beijing, China
| | - Mailikezhati Maimaitiming
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Zhijie Zheng
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
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Eze P, Idemili CJ, Lawani LO. Evaluating health systems' efficiency towards universal health coverage: A data envelopment analysis. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241235759. [PMID: 38456456 PMCID: PMC10924553 DOI: 10.1177/00469580241235759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/21/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024]
Abstract
To estimate the technical efficiency of health systems toward achieving universal health coverage (UHC) in 191 countries. We applied an output-oriented data envelopment analysis approach to estimate the technical efficiency of the health systems, including the UHC index (a summary measure that captures both service coverage and financial protection) as the output variable and per capita health expenditure, doctors, nurses, and hospital bed density as input variables. We used a Tobit simple-censored regression with bootstrap analysis to observe the socioeconomic and environmental factors associated with efficiency estimates. The global UHC index improved from the 2019 estimates, ranged from 48.4 (Somalia) to 94.8 (Canada), with a mean of 76.9 (std. dev.: ±12.0). Approximately 78.5% (150 of 191) of the studied countries were inefficient (ϕ < 1.0) with respect to using health system resources toward achieving UHC. By improving health system efficiency, low-income, lower-middle-income, upper-middle-income, and high-income countries can improve their UHC indices by 4.6%, 5.5%, 6.8%, and 4.1%, respectively, by using their current resource levels. The percentage of health expenditure spent on primary health care (PHC), governance quality, and the passage of UHC legislation significantly influenced efficiency estimates. Our findings suggests health systems inefficiency toward achieving UHC persists across countries, regardless of their income classifications and WHO regions, as well as indicating that using current level of resources, most countries could boost their progress toward UHC by improving their health system efficiency by increasing investments in PHC, improving health system governance, and where applicable, enacting/implementing UHC legislation.
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Affiliation(s)
- Paul Eze
- Penn State University, University Park, PA, USA
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Adhikari B, Bayo M, Peto TJ, Callery JJ, Tripura R, Dysoley L, Mshamu S, Gesase S, von Seidlein L, Dondorp AM. Comparing the roles of community health workers for malaria control and elimination in Cambodia and Tanzania. BMJ Glob Health 2023; 8:e013593. [PMID: 38070880 PMCID: PMC10729139 DOI: 10.1136/bmjgh-2023-013593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/12/2023] [Indexed: 12/18/2023] Open
Abstract
The reduction of deaths from malaria in sub-Saharan Africa (SSA) is stalling, whereas many countries in Southeast Asia are approaching malaria elimination. We reviewed the role of community health worker (CHW) programmes in malaria control and elimination between regions, with a more detailed description of the programmes in Tanzania and Cambodia. Compared with Tanzania, Cambodia has a much more developed CHW network, which has been pivotal in the near elimination of malaria. In Tanzania, the malaria burden has remained similar over the last decade and treatment continues to rely on healthcare facilities, which provide more limited access to early diagnosis and treatment. Overall, the proportion of malaria cases treated by CHWs is substantially lower in SSA than in Southeast Asia. Even though networks of CHWs are resource intensive and malaria epidemiology differs substantially between countries, there is a strong case for expanding CHW networks in rural SSA to improve early access to effective malaria treatment and reduce the malaria burden.
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Affiliation(s)
- Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, Oxford, UK
| | - Makhily Bayo
- Faculty of Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas J Peto
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, Oxford, UK
| | - James J Callery
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, Oxford, UK
| | - Rupam Tripura
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, Oxford, UK
| | - Lek Dysoley
- C.N.M National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Salum Mshamu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, Oxford, UK
- CSK Research Solutions, Mtwara, Tanzania
| | - Samwel Gesase
- Korogwe Research Laboratory, National Institute for Medical Research, Tanga, Tanzania
| | - Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, Oxford, UK
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Kang J, Peng R, Feng J, Wei J, Li Z, Huang F, Yu F, Su X, Chen Y, Qin X, Feng Q. Health systems efficiency in China and ASEAN, 2015-2020: a DEA-Tobit and SFA analysis application. BMJ Open 2023; 13:e075030. [PMID: 37673450 PMCID: PMC10496685 DOI: 10.1136/bmjopen-2023-075030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE To evaluate the health systems efficiency in China and Association of Southeast Asian Nations (ASEAN) countries from 2015 to 2020. DESIGN Health efficiency analysis using data envelopment analysis (DEA) and stochastic frontier approach analysis. SETTING Health systems in China and ASEAN countries. METHODS DEA-Malmquist model and SFA model were used to analyse the health system efficiency among China and ASEAN countries, and the Tobit regression model was employed to analyse the factors affecting the efficiency of health system among these countries. RESULTS In 2020, the average technical efficiency, pure technical efficiency and scale efficiency of China and 10 ASEAN countries' health systems were 0.700, 1 and 0.701, respectively. The average total factor productivity (TFP) index of the health systems in 11 countries from 2015 to 2020 was 0.962, with a decrease of 1.4%, among which the average technical efficiency index was 1.016, and the average technical progress efficiency index was 0.947. In the past 6 years, the TFP index of the health system in Malaysia was higher than 1, while the TFP index of other countries was lower than 1. The cost efficiency among China and ASEAN countries was relatively high and stable. The per capita gross domestic product (current US$) and the urban population have significant effects on the efficiency of health systems. CONCLUSIONS Health systems inefficiency is existing in China and the majority ASEAN countries. However, the lower/middle-income countries outperformed high-income countries. Technical efficiency is the key to improve the TFP of health systems. It is suggested that China and ASEAN countries should enhance scale efficiency, accelerate technological progress and strengthen regional health cooperation according to their respective situations.
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Affiliation(s)
- Jing Kang
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
- School of Nursing, Guangxi Medical University, Nanning, China
| | - Rong Peng
- School of Public Policy and Management, Guangxi University, Nanning, China
| | - Jun Feng
- School of Global management, Hongik University, Seoul, Korea
| | - Junyuan Wei
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- Department of Emergency Management of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Zhen Li
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
| | - Fen Huang
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
| | - Fu Yu
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
| | - Xiaorong Su
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
| | - Yujun Chen
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
| | - Xianjing Qin
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
| | - Qiming Feng
- Health and Policy Research Center, Guangxi Medical University, Nanning, China
- School of Information and Management, Guangxi Medical University, Nanning, China
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Beiter D, Koy S, Flessa S. Improving the technical efficiency of public health centers in Cambodia: a two-stage data envelopment analysis. BMC Health Serv Res 2023; 23:912. [PMID: 37641129 PMCID: PMC10463960 DOI: 10.1186/s12913-023-09570-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 05/17/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Cambodia is undergoing a series of reforms with the objective of reaching universal health coverage. Information on the causes of inefficiencies in health facilities could pave the way for a better utilization of limited resources available to ensure the best possible health care for the population. OBJECTIVES The purpose of this study is to evaluate the technical efficiency of health centers and the determinants for inefficiencies. METHODS This cross-sectional study used secondary data from a costing study on 43 health centers in six Cambodian provinces (2016-2017). Firstly, the Data Envelopment Analysis method with output-orientation was applied to calculate efficiency scores by selecting multiple input and output variables. Secondly, a tobit regression was performed to analyze potential explanatory variables that could influence the inefficiency of health centers. RESULTS Study findings showed that 18 (43%) health centers were operating inefficiently with reference to the variable returns to scale efficiency frontier and had a mean pure technical efficiency score of 0.87. Overall, 22 (51%) revealed deficits in producing outputs at an optimal scale size. Distance to the next referral hospital, size and quality performance of the health centers were significantly correlated with health center inefficiencies. CONCLUSION Differences in efficiency exist among health centers in Cambodia. Inefficient health centers can improve their technical efficiency by increasing the utilization and quality of health services, even if it involves higher costs. Technical efficiency should be continuously monitored to observe changes in health center performance over time.
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Affiliation(s)
- Dominik Beiter
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia.
| | - Sokunthea Koy
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
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Kaiser AH, Okorafor O, Ekman B, Chhim S, Yem S, Sundewall J. Assessing progress towards universal health coverage in Cambodia: Evidence using survey data from 2009 to 2019. Soc Sci Med 2023; 321:115792. [PMID: 36842307 DOI: 10.1016/j.socscimed.2023.115792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/27/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
Over the past decades, many low- and middle-income countries have implemented health financing and system reforms to progress towards universal health coverage (UHC). In the case of Cambodia, out-of-pocket expenditure (OOPE) remains the main source of current health expenditure after several decades of reform, exposing households to financial risks when accessing healthcare and violating UHC's key tenet of financial protection. We use pre-pandemic data from the nationally representative Cambodia Socio-Economic Surveys of 2009 to 2019 to assess progress in financial protection to evaluate the reforms and obtain internationally comparable estimates. We find that following strong improvements in financial protection between 2009 and 2017, there was a reversal in the trend thereafter. The OOPE budget share rose, and the incidence of catastrophic spending and impoverishment increased in nearly all geographical and socioeconomic strata. For example, 17.7% of households experienced catastrophic health expenditure in 2019 at the threshold of 10% of total household consumption expenditure, and 3.9% of households were pushed into poverty by OOPE. The distribution of all financial protection indicators varied strongly across socioeconomic and geographical strata in all years. Fundamentally, the demonstrated trend reversal may jeopardize Cambodia's ability to progress towards UHC. To improve financial protection in the short term, there is a need to address the burden created by OOPE through targeted interventions to household groups that are most affected. In the medium term, our findings emphasize the importance of expanding health pre-payment schemes to currently uncovered vulnerable groups, specifically the near-poor. The government also needs to consider extending the scope of services covered and the range of providers to include the private sector under these schemes to reduce reliance on OOPE.
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Affiliation(s)
- Andrea Hannah Kaiser
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden; Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH Cambodia, Improving Social Protection and Health Project, Sayon Building, Samdach Pan Ave No. 41, 12211, Phnom Penh, Cambodia.
| | - Okore Okorafor
- Forte Metrix Consulting, 58 Sara Circle, Langeberg Heights, Durbanville, 7550, Western Cape, South Africa.
| | - Björn Ekman
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden.
| | - Srean Chhim
- National Institute of Public Health Cambodia, Lot 80, Street 566 & Corner with Street 289, Boeung Kak 2, Toul Kork, Phnom Penh, Cambodia.
| | - Sokunthea Yem
- National Institute of Public Health Cambodia, Lot 80, Street 566 & Corner with Street 289, Boeung Kak 2, Toul Kork, Phnom Penh, Cambodia.
| | - Jesper Sundewall
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden; HEARD, University of KwaZulu-Natal, South Africa.
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Koy S, Fuerst F, Tuot B, Starke M, Flessa S. The Flipped Break-Even: Re-Balancing Demand- and Supply-Side Financing of Health Centers in Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1228. [PMID: 36674006 PMCID: PMC9858853 DOI: 10.3390/ijerph20021228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Supply-side healthcare financing still dominates healthcare financing in many countries where the government provides line-item budgets for health facilities irrespective of the quantity or quality of services rendered. There is a risk that this approach will reduce the efficiency of services and the value of money for patients. This paper analyzes the situation of public health centers in Cambodia to determine the relevance of supply- and demand-side financing as well as lump sum and performance-based financing. Based on a sample of the provinces of Kampong Thom and Kampot in the year 2019, we determined the income and expenditure of each facility and computed the unit cost with comprehensive step-down costing. Furthermore, the National Quality Enhancement Monitoring Tool (NQEMT) provided us with a quality score for each facility. Finally, we calculated the efficiency as the quotient of quality and cost per service unit as well as correlations between the variables. The results show that the largest share of income was received from supply-side financing, i.e., the government supports the health centers with line-item budgets irrespective of the number of patients and the quality of care. This paper demonstrates that the efficiency of public health centers increases if the relevance of performance-based financing increases. Thus, the authors recommend increasing performance-based financing in Cambodia to improve value-based healthcare. There are several alternatives available to re-balance demand- and supply-side financing, and all of them must be thoroughly analyzed before they are implemented.
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Affiliation(s)
- Sokunthea Koy
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Franziska Fuerst
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Bunnareth Tuot
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Maurice Starke
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Steffen Flessa
- Department of Health Care Management, University of Greifswald, 17487 Greifswald, Germany
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