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

Factors affecting private sector engagement in achieving universal health coverage: a scoping review

BACKGROUND

Universal Health Coverage (UHC) is one of the most important strategies adopted by countries in achieving goals of sustainable development. To achieve UHC, the governments need the engagement of the private sector.

OBJECTIVE

The aim of this study was to identify factors affecting private sector engagement in achieving universal health coverage.

METHODS

The study is a scoping review that utilizes Arkesy & O'Malley frameworks. Data collection was conducted in MEDLINE, Web of Sciences, Embase, ProQuest, SID, and MagIran databases and the Google Scholar search engine. Also, manual searches of journals and websites, reference checks, and grey literature searches were done using specific keywords. To manage and screen the studies, EndNote X8 software was used. Data extraction and analysis was done by two members of the research team, independently and using content analysis.

RESULTS

According to the results, 43 studies out of 588 studies were included. Most of the studies were international (18 studies). Extracted data were divided into four main categories: challenges, barriers, facilitators, goals, and reasons for engagement. After exclusion and integration of identified data, these categories were classified in the following manner: barriers and challenges with 59 items and in 13 categories, facilitators in 50 items and 9 categories, reasons with 30 items, and in 5 categories and goals with 24 items and 6 categories.

CONCLUSION

Utilizing the experience of different countries, challenges and barriers, facilitators, reasons, and goals were analyzed and classified. This investigation can be used to develop the engagement of the private sector and organizational synergy in achieving UHC by policymakers and planners.

Service quality: perspective of people with type 2 diabetes mellitus and hypertension in rural and urban public primary healthcare centers in Iran

OBJECTIVE

This study aimed to assess the service quality (SQ) for Type 2 diabetes mellitus (T2DM) and hypertension in primary healthcare settings from the perspective of service users in Iran.

METHODS

The Cross-sectional study was conducted from January to March 2020 in urban and rural public health centers in the East Azerbaijan province of Iran. A total of 561 individuals aged 18 or above with either or both conditions of T2DM and hypertension were eligible to participate in the study. The study employed a two-step stratified sampling method in East Azerbaijan province, Iran. A validated questionnaire assessed SQ. Data were analyzed using One-way ANOVA and multiple linear regression statistical models in STATA-17.

RESULTS

Among the 561 individuals who participated in the study 176 (31.3%) were individuals with hypertension, 165 (29.4%) with T2DM, and 220 (39.2%) with both hypertension and T2DM mutually. The participants' anthropometric indicators and biochemical characteristics showed that the mean Fasting Blood Glucose (FBG) in individuals with T2DM was 174.4 (Standard deviation (SD) = 73.57) in patients with T2DM without hypertension and 159.4 (SD = 65.46) in patients with both T2DM and hypertension. The total SQ scores were 82.37 (SD = 12.19), 82.48 (SD = 12.45), and 81.69 (SD = 11.75) for hypertension, T2DM, and both conditions, respectively. Among people with hypertension and without diabetes, those who had specific service providers had higher SQ scores (b = 7.03; p = 0.001) compared to their peers who did not have specific service providers. Those who resided in rural areas had lower SQ scores (b = -6.07; p = 0.020) compared to their counterparts in urban areas. In the group of patients with T2DM and without hypertension, those who were living in non-metropolitan cities reported greater SQ scores compared to patients in metropolitan areas (b = 5.09; p = 0.038). Additionally, a one-point increase in self-management total score was related with a 0.13-point decrease in SQ score (P = 0.018). In the group of people with both hypertension and T2DM, those who had specific service providers had higher SQ scores (b = 8.32; p < 0.001) compared to the group without specific service providers.

CONCLUSION

Study reveals gaps in T2DM and hypertension care quality despite routine check-ups. Higher SQ correlates with better self-care. Improving service quality in primary healthcare settings necessitates a comprehensive approach that prioritizes patient empowerment, continuity of care, and equitable access to services, particularly for vulnerable populations in rural areas.

Global and regional quality of care index (QCI) by gender and age in oesophageal cancer: A systematic analysis of the Global Burden of Disease Study 1990-2019

BACKGROUND

The aim of this study was to examine the quality of care by age and gender in oesophageal cancer using Global Burden of Disease (GBD) database.

METHODS

Patients aged 20 and over with oesophageal cancer were included in this longitudinal study using GBD 1990-2019 data. We used the Socio-Demographic Index (SDI) to classify the regions. We used Principal Component Analysis (PCA) method to calculate the Quality of Care Index (QCI). The QCI was rescaled into a 0-100 single index, demonstrating that the higher the score, the better the QC.

RESULTS

The age-standardized QCI for oesophageal cancer dramatically increased from 23.5 in 1990 to 41.1 in 2019 for both sexes, globally. The high SDI regions showed higher QCI than the rest of the regions (45.1 in 1990 and 65.7 in 2019) whereas the low SDI regions had the lowest QCI, which showed a 4.5% decrease through the years (from 13.3 in 1990 to 12.7 in 2019). Globally, in 2019, the QCI showed the highest scores for patients aged 80-84, reported 48.2, and the lowest score for patients aged 25-29 reported 31.5, for both sexes. Globally, in 2019, age-standardized Gender Disparity Ratio (GDR) was 1.2, showing higher QCI in females than males.

CONCLUSION

There were fundamental differences in the QCI both globally and regionally between different age groups as well as between males and females. To achieve the goal of providing high-quality services equally to people in need in all over the world, health systems need to invest in effective diagnostic services, treatments, facilities, and equipment and to plan for screening and surveillance of high-risk individuals.

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.

Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis

Background

Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration’s benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia.

Methods

A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATA^TM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I² tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg’s and Egger’s tests, were used to check for the presence of publication bias.

Results

Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment.

Conclusion

Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.

The 2019 Philippine UHC Act, Pandemic Management and Implementation Implications in a Post-COVID-19 World: A Content Analysis

The 2019 Philippine Universal Health Care Act (Republic Act 11223) was set for implementation in January 2020 when disruptions brought on by the pandemic occurred. Will the provisions of the new UHC Act for an improved health system enable agile responses to forthcoming shocks, such as this COVID-19 pandemic? A content analysis of the 2019 Philippine UHC Act can identify neglected and leverage areas for systems’ improvement in a post-pandemic world. While content or document analysis is commonly undertaken as part of scoping or systematic reviews of a qualitative nature, quantitative analyses using a two-way mixed effects, consistency, multiple raters type of intraclass correlation coefficient (ICC) were applied to check for reliability and consistency of agreement among the study participants in the manual tagging of UHC components in the legislation. The intraclass correlation reflected the individuals’ consistency of agreement with significant reliability (0.939, p < 0.001). The assessment highlighted a centralized approach to implementation, which can set aside the crucial collaborations and partnerships demonstrated and developed during the pandemic. The financing for local governments was strengthened with a new ruling that could alter UHC integration tendencies. A smarter allocation of tax-based financing sources, along with strengthened information and communications systems, can confront issues of trust and accountability, amidst the varying capacities of agents and systems.

How can the healthcare system deliver sustainable performance? A scoping review

BACKGROUND

Increasing health costs, demand and patient multimorbidity challenge the sustainability of healthcare systems. These challenges persist and have been amplified by the global pandemic.

OBJECTIVES

We aimed to develop an understanding of how the sustainable performance of healthcare systems (SPHS) has been conceptualised, defined and measured.

DESIGN

Scoping review of peer-reviewed articles and editorials published from database inception to February 2021.

DATA SOURCES

PubMed and Ovid Medline, and snowballing techniques.

ELIGIBILITY CRITERIA

We included articles that discussed key focus concepts of SPHS: (1) definitions, (2) measurement, (3) identified challenges, (4) identified solutions for improvement and (5) scaling successful solutions to maintain SPHS.

DATA EXTRACTION AND SYNTHESIS

After title/abstract screening, full-text articles were reviewed, and relevant information extracted and synthesised under the five focus concepts.

RESULTS

Of 142 included articles, 38 (27%) provided a definition of SPHS. Definitions were based mainly on financial sustainability, however, SPHS was also more broadly conceptualised and included acceptability to patients and workforce, resilience through adaptation, and rapid absorption of evidence and innovations. Measures of SPHS were also predominantly financial, but recent articles proposed composite measures that accounted for financial, social and health outcomes. Challenges to achieving SPHS included the increasingly complex patient populations, limited integration because of entrenched fragmented systems and siloed professional groups, and the ongoing translational gaps in evidence-to-practice and policy-to-practice. Improvement strategies for SPHS included developing appropriate workplace cultures, direct community and consumer involvement, and adoption of evidence-based practice and technologies. There was also a strong identified need for long-term monitoring and evaluations to support adaptation of healthcare systems and to anticipate changing needs where possible.

CONCLUSIONS

To implement lasting change and to respond to new challenges, we need context-relevant definitions and frameworks, and robust, flexible, and feasible measures to support the long-term sustainability and performance of healthcare systems.

Health insurance coverage and timely antenatal care attendance in sub-Saharan Africa

Introduction

Out-of-pocket payments for healthcare remain a significant health financing challenge in sub-Saharan Africa (SSA), preventing women from using maternal health services. There is a paucity of empirical literature on the influence of health insurance coverage on the timeliness of antenatal care (ANC) attendance in low- and middle-income countries. In this study, we examined the association between health insurance coverage and timely ANC attendance among pregnant women in SSA.

Methods

Secondary data from Demographic and Health Surveys conducted between 2015 and 2020 in sixteen (16) sub-Saharan African countries with 113,918 women aged 15-49 years were included in the analysis. The outcome variable was the timing of antenatal care (ANC). A multilevel binary logistic regression analysis was carried out to determine the association between health insurance coverage and timely ANC.

Results

The overall coverage of health insurance and timely antenatal attendance among pregnant women in SSA were 4.4% and 39.0% respectively. At the country level, the highest coverage of health insurance was found in Burundi (24.3%) and the lowest was in Benin (0.9%). For timely ANC attendance, the highest prevalence was in Liberia (72.4%) and the lowest was in Nigeria (24.2%). The results in the model showed that women who were covered by health insurance were more likely to have timely ANC attendance compared to those who were not covered by health insurance (aOR = 1.21, 95% CI = 1.11-1.31).

Conclusion

Our findings show that that being covered under health insurance is associated with higher likelihood of seeking timely ANC attendance. To accelerate progress towards achievement of the Sustainable Development Goal targets by the year 2030, we recommend that governments and health insurance authorities across the sub-Saharan African countries actively implement health insurance policies as well as roll out health educational programmes that facilitate and ensure increased coverage of health insurance.

The influential factors for achieving universal health coverage in Iran: a multimethod study

BACKGROUND

The initial purpose of healthcare systems around the world is to promote and maintain the health of the population. Universal Health Coverage (UHC) is a new approach by which a healthcare system can reach its goals. World Health Organization (WHO) emphasized maximum population coverage, health service coverage, and financial protection, as three dimensions of UHC. In progress for achieving UHC, recognizing the influential factors allows us to accelerate such progress. Therefore, this study aimed to identify the influential factors to achieve UHC in Iran.

METHODS

This is a multi-method study was conducted in four phases: First, a systematic review of the literature was conducted to identify the factors in PubMed, Web of Science, Embase, Scopus, ProQuest, Cochrane library, and Science Direct databases, and hand searching google scholar search engine. For recognizing the unmentioned factors, a qualitative study consisting of one session of Focus Group Discussion (FGD) and five semi-structured interviews with experts was designed. The extracted factors were merged and categorized by round table discussion. Finally, the pre-categorized factors were refined and re-categorized under the health system's control knobs framework during three expert panel sessions.

RESULTS

Finally, 33 studies were included. Eight hundred two factors were extracted through systematic review and 96 factors through FGD and interviews (totally, 898). After refining them by the experts' panel, 105 factors were categorized within the control knob framework (financing 19, payment system7, Organization 23, regulation and supervision 33, Behavior 11, and Others 12). The majority of the identified factors were related to the "regulation and supervision" dimension, whilst the "payment system" entailed the fewest. The political commitment during political turmoil, excessive attention to the treatment, referral system, paying out of pocket(OOP) and protection against high costs, economic growth, sanctions, conflict of interests, weakness of the information system, prioritization of services, health system fragmented, lack of managerial support and lack of standard benefits packages were identified as the leading factors on the way to UHC.

CONCLUSION

Considering the distinctive role of the context in policymaking, the identification of the factors affecting UHC accompanying by the countries' experiences about UHC, can boost our speed toward it. Moreover, adopting a long-term plan toward UHC based on these factors and the robust implementation of it pave the way for Iran to achieve better outcomes comparing to their efforts.