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Sumankuuro J, Griffiths F, Koon AD, Mapanga W, Maritim B, Mosam A, Goudge J. The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review. Int J Health Policy Manag 2023; 12:7352. [PMID: 38618795 PMCID: PMC10699827 DOI: 10.34172/ijhpm.2023.7352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/18/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals. METHODS We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively. RESULTS Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members. CONCLUSION We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.
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Affiliation(s)
- Joshua Sumankuuro
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Public Policy and Management, SD Dombo University of Business and Integrated Development Studies, Wa, Ghana
- School of Community Health, Charles Sturt University, Orange, NSW, Australia
| | - Frances Griffiths
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Adam D. Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Witness Mapanga
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Beryl Maritim
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Atiya Mosam
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mhazo AT, Maponga CC. Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa. BMJ Glob Health 2022; 7:bmjgh-2022-010228. [PMID: 36455987 PMCID: PMC9717331 DOI: 10.1136/bmjgh-2022-010228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/09/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA. METHODS We conducted a scoping review using Arksey and O'Malley (2005) to understand the drivers of health reforms in SSA. RESULTS We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion. CONCLUSION Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.
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Affiliation(s)
- Alison T Mhazo
- Community Health Sciences Unit (CHSU), Ministry of Health, Lilongwe, Malawi
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Christmals CD, Aziato L, Rispel LC. Perceptions of the functioning and effectiveness of nursing regulators in Ghana and South Africa: a cross-sectional study. BMJ Open 2021; 11:e050580. [PMID: 34862283 PMCID: PMC8647556 DOI: 10.1136/bmjopen-2021-050580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 11/02/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Nursing regulators are important governance structures for nurses who are critical to the achievement of universal health coverage (UHC). This study examined the perspectives of the heads of nursing education institutions (NEIs) in Ghana and South Africa on the functioning and effectiveness of the respective nursing regulators. DESIGN This was a cross-sectional survey. SETTING This study was conducted in Ghana and South Africa PARTICIPANTS: Heads of accredited NEIs in Ghana (n=65) and in South Africa (n=39). RESULTS In South Africa, the mean score for overall functioning of the South African Nursing Council (SANC) was 4.6 (SD 1.97), whereas the mean score for overall functioning of the Nursing and Midwifery Council of Ghana (N&MC) was 7.1 (SD 1.7) (p<0.0001). Similarly, the mean score for effectiveness of the SANC by NEIs was 5.1, compared with the mean effectiveness score of 7.2 for the N&MC (p<0.001).Compared to the SANC, the heads of NEIs scored the N&MC higher on each of the six functional areas of policy-making (Ghana=7.06; SA=4.56); accreditation (Ghana=7.40; SA=4.10) legal and disciplinary actions (Ghana=6.45; SA=5.52); examination (Ghana=7.84; SA=5.00); registration (Ghana=8.27; SA=5.96) and communication and transparency (Ghana=6.87; SA=6.05). CONCLUSION Both the N&MC and SANC are well-established regulators and are vital to ensure that the nursing workforce in each country is able to deliver quality healthcare, thereby contributing to UHC and population health improvements. However, the study findings suggest the need for concerted efforts to improve the functioning and effectiveness of the regulators, especially the SANC. The six functional areas could guide the necessary improvements in regulator functioning and effectiveness, in partnership with relevant stakeholders.
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Affiliation(s)
- Christmal Dela Christmals
- SARChI Chair: Research on the Health Workforce for Equity and Quality, Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg-Braamfontein, Gauteng, South Africa
| | - Lydia Aziato
- Adult Health, University of Ghana College of Health Sciences, Accra, Ghana
| | - Laetitia Charmaine Rispel
- SARChI Chair: Research on the Health Workforce for Equity and Quality, Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg-Braamfontein, Gauteng, South Africa
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Whyle EB, Olivier J. Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis. Int J Health Policy Manag 2021; 10:414-429. [PMID: 32861236 PMCID: PMC9056134 DOI: 10.34172/ijhpm.2020.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/15/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the 'social value of health systems.' METHODS We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between 'health systems' and 'social values.' We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory. RESULTS We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen's understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups. CONCLUSION We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.
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Affiliation(s)
- Eleanor Beth Whyle
- Health Policy and Systems Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Jones CM, Gautier L, Ridde V. A scoping review of theories and conceptual frameworks used to analyse health financing policy processes in sub-Saharan Africa. Health Policy Plan 2021; 36:1197-1214. [PMID: 34027987 DOI: 10.1093/heapol/czaa173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2020] [Indexed: 11/15/2022] Open
Abstract
Health financing policies are critical policy instruments to achieve Universal Health Coverage, and they constitute a key area in policy analysis literature for the health policy and systems research (HPSR) field. Previous reviews have shown that analyses of policy change in low- and middle-income countries are under-theorised. This study aims to explore which theories and conceptual frameworks have been used in research on policy processes of health financing policy in sub-Saharan Africa and to identify challenges and lessons learned from their use. We conducted a scoping review of literature published in English and French between 2000 and 2017. We analysed 23 papers selected as studies of health financing policies in sub-Saharan African countries using policy process or health policy-related theory or conceptual framework ex ante. Theories and frameworks used alone were from political science (35%), economics (9%) and HPSR field (17%). Thirty-five per cent of authors adopted a 'do-it-yourself' (bricolage) approach combining theories and frameworks from within political science or between political science and HPSR. Kingdon's multiple streams theory (22%), Grindle and Thomas' arenas of conflict (26%) and Walt and Gilson's policy triangle (30%) were the most used. Authors select theories for their empirical relevance, methodological rational (e.g. comparison), availability of examples in literature, accessibility and consensus. Authors cite few operational and analytical challenges in using theory. The hybridisation, diversification and expansion of mid-range policy theories and conceptual frameworks used deductively in health financing policy reform research are issues for HPSR to consider. We make three recommendations for researchers in the HPSR field. Future research on health financing policy change processes in sub-Saharan Africa should include reflection on learning and challenges for using policy theories and frameworks in the context of HPSR.
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Affiliation(s)
- Catherine M Jones
- London School of Economics and Political Science, LSE Health, Houghton Street, London WC2A 2AE, UK
| | - Lara Gautier
- Département de Gestion, d'Évaluation et de Politique de Santé, École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, QC H3N 1X9, Canada.,Centre de recherche en santé publique, Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, 7101 avenue du Parc, Montréal, QC H3N 1X9, Canada
| | - Valéry Ridde
- Institut de Recherche pour le Développement, Centre Population et Développement - CEPED (IRD-Université de Paris), Université de Paris ERL INSERM SAGESUD, 45 rue des Saints-Peres, Paris 75006, France
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Ogundeji YK, Ohiri K, Agidani A. A checklist for designing health insurance programmes - a proposed guidelines for Nigerian states. Health Res Policy Syst 2019; 17:81. [PMID: 31438972 PMCID: PMC6704650 DOI: 10.1186/s12961-019-0480-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 07/23/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is widespread and growing interest in designing and implementing social health insurance schemes (SHIS) across many low- and middle-income countries as a means to improve financial protection and achieve universal health coverage. SHIS recently gained traction in Nigeria, but evidence regarding optimal design features of SHIS is sparse and there is lack of a simple and standardised checklist that scheme designers, implementers and researchers could use to assess, guide and inform the design of SHIS. This paper seeks to develop a checklist based on concepts as well as theoretical and empirical evidence that can inform and guide scheme designers and implementers on design options to maximise the effectiveness of the scheme. METHODS We conducted a review of literature exploring the relevant concepts for the development of a framework and checklist to identify the key factors or variables required to inform the design of SHIS. The checklist details critical considerations/questions to address and options for design. The developed checklist was then used to examine conditions for readiness and appropriateness of SHIS design in two states in Nigeria (Kaduna and Niger). RESULTS This paper describes the development of a SHIS checklist. The findings also demonstrate that the newly developed checklist, consisting of six design domains, can be used by scheme designers and policy-makers as a simple and effective tool to assess and inform SHIS design features across Nigeria to maximise the chances of the effectiveness of the schemes. CONCLUSION In conclusion, given that the development of SHIS in the Nigerian states is still in its early stages, applying the SHIS design checklist can serve as a first step to ensuring a feasible and sustainable insurance scheme. The introduction of SHIS, if properly designed and implemented, can be a significant first step towards improving the accessibility, equity and efficiency of healthcare in Nigeria.
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Affiliation(s)
| | - Kelechi Ohiri
- Health Strategy and Delivery Foundation, 1980 Wikki Spring street, Maitama, Abuja, Nigeria
| | - Azara Agidani
- Health Strategy and Delivery Foundation, 1980 Wikki Spring street, Maitama, Abuja, Nigeria
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Kansanga MM, Asumah Braimah J, Antabe R, Sano Y, Kyeremeh E, Luginaah I. Examining the association between exposure to mass media and health insurance enrolment in Ghana. Int J Health Plann Manage 2018; 33:e531-e540. [DOI: 10.1002/hpm.2505] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | - Roger Antabe
- Department of GeographyWestern University London Ontario Canada
| | - Yuji Sano
- Department of SociologyWestern University London Ontario Canada
| | | | - Isaac Luginaah
- Department of GeographyWestern University London Ontario Canada
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