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Zeng Z, Luo Y, Tao W, Zhang R, Zeng B, Yao J, Zhang W. Improving access to primary health care through financial innovation in rural China: a quasi-experimental synthetic difference-in-differences approach. BMC PRIMARY CARE 2024; 25:195. [PMID: 38824504 PMCID: PMC11143622 DOI: 10.1186/s12875-024-02450-0] [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: 02/05/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Inadequate financing constrains primary healthcare (PHC) capacity in many low- and middle-income countries, particularly in rural areas. This study evaluates an innovative PHC financing reform in rural China that aimed to improve access to healthcare services through supply-side integration and the establishment of a designated PHC fund. METHODS We employed a quasi-experimental synthetic difference-in-differences (SDID) approach to analyze county-level panel data from Chongqing Province, China, spanning from 2009 to 2018. The study compared the impact of the reform on PHC access and per capita health expenditures in Pengshui County with 37 other control counties (districts). We assessed the reform's impact on two key outcomes: the share of outpatient visits at PHC facilities and per capita total PHC expenditure. RESULTS The reform led to a significant increase in the share of outpatient visits at PHC facilities (14.92% points; 95% CI: 6.59-23.24) and an increase in per capita total PHC expenditure (87.30 CNY; 95% CI: 3.71-170.88) in Pengshui County compared to the synthetic control. These effects were robust across alternative model specifications and increased in magnitude over time, highlighting the effectiveness of the integrated financing model in enhancing PHC capacity and access in rural China. CONCLUSIONS This research presents compelling evidence demonstrating that horizontal integration in PHC financing significantly improved utilization and resource allocation in rural primary care settings in China. This reform serves as a pivotal model for resource-limited environments, demonstrating how supply-side financing integration can bolster PHC and facilitate progress toward universal health coverage. The findings underscore the importance of sustainable financing mechanisms and the need for policy commitment to achieve equitable healthcare access.
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Affiliation(s)
- Zhi Zeng
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Office of Policy Research, Chinese Center for Disease Control and Prevention & Chinese Academy of Preventive Medicine, Beijing, China
| | - Yunmei Luo
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wenjuan Tao
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruiling Zhang
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bo Zeng
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jianhong Yao
- Chinese Academy of Medical Sciences & Peking Union Medical College, No.9, Dongdan Santiao, Beijing, 100730, China.
| | - Wei Zhang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, No.37, Guoxue Xiang, Chengdu, 610041, Sichuan, China.
- Med-X Center for Informatics, Sichuan University, Chengdu, Sichuan, China.
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Ravishankar N, Mathauer I, Barroy H, Vîlcu I, Chaitkin M, Offosse MJ, Co PA, Nakyanzi A, Mbuthia B, Lourenço S, Mardani H, Kutzin J. Reconciling devolution with health financing and public financial management: challenges and policy options for the health sector. BMJ Glob Health 2024; 9:e015216. [PMID: 38816003 PMCID: PMC11138286 DOI: 10.1136/bmjgh-2024-015216] [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: 01/30/2024] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
The interplay between devolution, health financing and public financial management processes in health-or the lack of coherence between them-can have profound implications for a country's progress towards universal health coverage. This paper explores this relationship in seven Asian and African countries (Burkina Faso, Kenya, Mozambique, Nigeria, Uganda, Indonesia and the Philippines), highlighting challenges and suggesting policy solutions. First, subnational governments rely heavily on transfers from central governments, and most are not required to allocate a minimum share of their budget to health. Central governments channelling more funds to subnational governments through conditional grants is a promising way to increase public financing for health. Second, devolution makes it difficult to pool funding across populations by fragmenting them geographically. Greater fiscal equalisation through improved revenue sharing arrangements and, where applicable, using budgetary funds to subsidise the poor in government-financed health insurance schemes could bridge the gap. Third, weak budget planning across levels could be improved by aligning budget structures, building subnational budgeting capacity and strengthening coordination across levels. Fourth, delays in central transfers and complicated procedures for approvals and disbursements stymie expenditure management at subnational levels. Simplifying processes and enhancing visibility over funding flows, including through digitalised information systems, promise to improve expenditure management and oversight in health. Fifth, subnational governments purchase services primarily through line-item budgets. Shifting to practices that link financial allocations with population health needs and facility performance, combined with reforms to grant commensurate autonomy to facilities, has the potential to enable more strategic purchasing.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Joseph Kutzin
- Independent Health Financing Specialist, Genolier, Switzerland
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Hone T, Gonçalves J, Seferidi P, Moreno-Serra R, Rocha R, Gupta I, Bhardwaj V, Hidayat T, Cai C, Suhrcke M, Millett C. Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019. Lancet Glob Health 2024; 12:e744-e755. [PMID: 38614628 DOI: 10.1016/s2214-109x(24)00040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/14/2024] [Accepted: 01/19/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs). METHODS We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables. FINDINGS A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57). INTERPRETATION Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Thomas Hone
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; Instituto de Estudos para Políticas de Saúde, São Paulo, Brazil.
| | - Judite Gonçalves
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal
| | - Paraskevi Seferidi
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | | | - Rudi Rocha
- Instituto de Estudos para Políticas de Saúde, São Paulo, Brazil; São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - Indrani Gupta
- Institute of Economic Growth, University of Delhi, Delhi, India
| | - Vinayak Bhardwaj
- South African Medical Research Council and Wits Centre for Health Economics and Decision Science, PRICELESS South Africa, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Taufik Hidayat
- Center for Health Economics and Policy Studies, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia; Department of Economics, University of Sussex, Brighton, UK
| | - Chang Cai
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | - Marc Suhrcke
- Centre for Health Economics, University of York, Heslington, York, UK; Luxembourg Institute of Socio-economic Research, Esch-sur-Alzette, Luxembourg
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal
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Bayked EM, Toleha HN, Kebede SZ, Workneh BD, Kahissay MH. The impact of community-based health insurance on universal health coverage in Ethiopia: a systematic review and meta-analysis. Glob Health Action 2023; 16:2189764. [PMID: 36947450 PMCID: PMC10035959 DOI: 10.1080/16549716.2023.2189764] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Ideally health insurance aims to provide financial security, promote social inclusion, and ensure equitable access to quality healthcare services for all households. Community-based health insurance has been operating in Ethiopia since 2011. However, its nationwide impact on universal health coverage has not yet been evaluated despite several studies being conducted. OBJECTIVE We evaluated the impact of Ethiopia's community-based health insurance (2012-2021) on universal health coverage. METHODS On 27 August 2022, searches were conducted in Scopus, Hinari, PubMed, Google Scholar, and Semantic Scholar. Twenty-three studies were included. We used the Joana Briggs Institute checklists to assess the risk of bias. We included cross-sectional and mixed studies with low and medium risk. The data were processed in Microsoft Excel and analyzed using RevMan-5. The impact was measured first on insured households and then on insured versus uninsured households. We used a random model to measure the effect estimates (odds ratios) with a p value < 0.05 and a 95% CI. RESULTS The universal health coverage provided by the scheme was 45.6% (OR = 1.92, 95% CI: 1.44-2.58). Being a member of the scheme increased universal health coverage by 24.8%. The healthcare service utilization of the beneficiaries was 64.5% (OR = 1.95, 95% CI: 1.29-2.93). The scheme reduced catastrophic health expenditure by 79.4% (OR = 4.99, 95% CI: 1.27-19.67). It yielded a 92% (OR = 11.58, 95% CI: 8.12-16.51) perception of health service quality. The health-related quality of life provided by it was 63% (OR = 1.71, 95% CI: 1.50-1.94). Its population coverage was 40.1% (OR = 0.64, 95% CI: 0.41-1.02). CONCLUSION Although the scheme had positive impacts on health service issues by reducing catastrophic costs, the low universal health coverage on a limited population indicates that Ethiopia should move to a broader national scheme that covers the entire population.
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Affiliation(s)
- Ewunetie Mekashaw Bayked
- Department of Pharmacy, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | - Husien Nurahmed Toleha
- Department of Pharmacy, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | - Seble Zewdu Kebede
- Department of Pharmacy, Dessie College of Health Sciences (DCHS), Dessie, Ethiopia
| | - Birhanu Demeke Workneh
- Department of Pharmacy, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | - Mesfin Haile Kahissay
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Binyaruka P, Mtei G, Maiba J, Gopinathan U, Dale E. Developing the improved Community Health Fund in Tanzania: was it a fair process? Health Policy Plan 2023; 38:i83-i95. [PMID: 37963080 PMCID: PMC10645047 DOI: 10.1093/heapol/czad067] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 11/16/2023] Open
Abstract
Tanzania developed its 2016-26 health financing strategy to address existing inequities and inefficiencies in its health financing architecture. The strategy suggested the introduction of mandatory national health insurance, which requires long-term legal, interministerial and parliamentary procedures. In 2017/18, improved Community Health Fund (iCHF) was introduced to make short-term improvements in coverage and financial risk protection for the informal sector. Improvements involved purchaser-provider split, portability of services, uniformity in premium and risk pooling at the regional level. Using qualitative methods and drawing on the policy analysis triangle framework (context, content, actors and process) and criteria for procedural fairness, we examined the decision-making process around iCHF and the extent to which it met the criteria for a fair process. Data collection involved a document review and key informant interviews (n = 12). The iCHF reform was exempt from following the mandatory legislative procedures, including processes for involving the public, for policy reforms in Tanzania. The Ministry of Health, leading the process, formed a technical taskforce to review evidence, draw lessons from pilots and develop plans for implementing iCHF. The taskforce included representatives from ministries, civil society organizations and CHF implementing partners with experience in running iCHF pilots. However, beneficiaries and providers were not included in these processes. iCHF was largely informed by the evidence from pilots and literature, but the evidence to reduce administrative cost by changing the oversight role to the National Health Insurance Fund was not taken into account. Moreover, the iCHF process lacked transparency beyond its key stakeholders. The iCHF reform provided a partial solution to fragmentation in the health financing system in Tanzania by expanding the pool from the district to regional level. However, its decision-making process underscores the significance of giving greater consideration to procedural fairness in reforms guided by technical institutions, which can enhance responsiveness, legitimacy and implementation.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Gemini Mtei
- Abt. Associates Inc, USAID Public Sector Systems Strengthening Plus (PS3+) Project, PO Box 13280, Dar es Salaam, Tanzania
| | - John Maiba
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Unni Gopinathan
- Cluster for Global Health, Division for Health Services, Norwegian Institute of Public Health, Marcus Thranes gt.6, Oslo 0473, Norway
| | - Elina Dale
- Cluster for Global Health, Division for Health Services, Norwegian Institute of Public Health, Marcus Thranes gt.6, Oslo 0473, Norway
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Binyaruka P, Mtenga S. Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002180. [PMID: 37607181 PMCID: PMC10443863 DOI: 10.1371/journal.pgph.0002180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023]
Abstract
COVID-19 disrupted health care provision and access and reduced household income. Households with chronically ill patients are more vulnerable to these effects as they access routine health care. Yet, a few studies have analysed the effect of COVID-19 on household income, health care access costs, and financial catastrophe due to health care among patients with type 2 diabetes (T2D), especially in developing countries. This study fills that knowledge gap. We used data from a cross-sectional survey of 500 people with T2D, who were adults diagnosed with T2D before COVID-19 in Tanzania (March 2020). Data were collected in February 2022, reflecting the experience before and during COVID-19. During COVID-19, household income decreased on average by 16.6%, while health care costs decreased by 0.8% and transport costs increased by 10.6%. The overall financing burden for health care and transport relative to household income increased by 32.1% and 45%, respectively. The incidences of catastrophic spending above 10% of household income increased by 10% (due to health care costs) and by 55% (due to transport costs). The incidences of catastrophic spending due to health care costs were higher than transport costs, but the relative increase was higher for transport than health care costs (10% vs. 55% change from pre-COVID-19). The likelihood of incurring catastrophic health spending was lower among better educated patients, with health insurance, and from better-off households. COVID-19 was associated with reduced household income, increased transport costs, increased financing burden and financial catastrophe among patients with T2D in Tanzania. Policymakers need to ensure financial risk protection by expanding health insurance coverage and removing user fees, particularly for people with chronic illnesses. Efforts are also needed to reduce transport costs by investing more in primary health facilities to offer quality services closer to the population and engaging multiple sectors, including infrastructure and transportation.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation, and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Sally Mtenga
- Department of Health System, Impact Evaluation, and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
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Huraysi NA, Kattan WM, Alqurashi MA, Fadel BA, Al-Hanawi MK. Preferences on Policy Options for Ensuring the Financial Sustainability of Healthcare Services in the Kingdom of Saudi Arabia. Risk Manag Healthc Policy 2023; 16:1033-1047. [PMID: 37333981 PMCID: PMC10274833 DOI: 10.2147/rmhp.s414823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/03/2023] [Indexed: 06/20/2023] Open
Abstract
Background Escalating global health expenditures pose a threat to healthcare financing sustainability, requiring the exploration of alternative financing policies and resource allocation strategies to curb their adverse effects. The aim of this study was to gather insight into the preferences of healthcare workers, including physicians, nurses, allied healthcare professionals, and healthcare administrators, as well as academics in the field of healthcare management and health sciences in Saudi universities, regarding policy options that can secure the financial sustainability of healthcare services in Saudi Arabia. Methods A cross-sectional research design was employed, and data were collected through an online self-administered survey from August 2022 to December 2022 in Saudi Arabia. The survey garnered responses from 513 participants hailing from all 13 administrative regions in Saudi Arabia. Analyses were performed using non-parametric statistical tests, specifically the two-sample Mann-Whitney U-test and Kruskal-Wallis test, to determine the statistical significance of differences in the policy ranking and policy feasibility options. Results The study findings reveal a consensus among stakeholders on the most and least preferred policies. All stakeholders expressed opposition to financing healthcare by diverting resources from defence, social protection, and education, while they favoured policies that entail imposing penalties on health-related issues such as waste management and pollution. Nevertheless, variations among stakeholders were evident in regard to the rankings for specific policies, particularly between healthcare workers and academics. Moreover, the results highlight that tax-based policies are the most feasible approach to generating healthcare funds, despite ranking lower in terms of preferred policies. Conclusion This study provides a framework for understanding stakeholder preferences on healthcare financing sustainability by ranking 26 policy options according to stakeholder groups. The appropriate mixture of financing mechanisms should be informed by evidence-based and data-driven approaches that consider relevant stakeholder preferences.
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Affiliation(s)
- Najwa Ali Huraysi
- Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
- Human Resources Planning Department, King Abdulaziz Hospital, Makkah, Saudi Arabia
| | - Waleed M Kattan
- Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohamed A Alqurashi
- Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bodour Ayman Fadel
- Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Khaled Al-Hanawi
- Department of Health Services and Hospital Administration, Faculty of Economics and Administration, King Abdulaziz University, Jeddah, Saudi Arabia
- Health Economics Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
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Oshima K. Regular Dental Check-Ups Are Associated with Choosing Uninsured Dental Restoration/Prosthesis Treatment in Japan. Healthcare (Basel) 2023; 11:healthcare11111582. [PMID: 37297722 DOI: 10.3390/healthcare11111582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Since Japan has implemented Universal Health Coverage (UHC), most dental treatments are covered by public health insurance. Therefore, when receiving fixed dental restoration/prosthesis (FDRP) treatment, such as inlays, crowns, and bridges, the patient can choose whether or not it is covered by insurance. This study aimed to evaluate whether those who receive dental check-ups regularly chose uninsured FDRP treatment. Data were collected from 2088 participants, who had undergone FDRP treatment, via a web-based survey and analyzed. Among them, 1233 (59.1%) had received regular dental check-ups (RDC group) and 855 (40.9%) had not (non-RDC group). The multivariate logistic regression model showed that compared to the non-RDC group, those in the RDC group were statistically significantly associated with higher rates of good oral health behaviors (brushing teeth ≥ 3 times daily, odds ratios (OR):1.46; practiced interdental cleaning habitually, OR: 2.22) and received uninsured FDRP treatment more often (OR: 1.59), adjusted for socioeconomic factors. These results suggest that health policy interventions to promote access to RDC among individuals may improve the oral health of people and reduce the financial burden on the public health insurance system.
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Affiliation(s)
- Katsuo Oshima
- Department of Dental Technology, The Nippon Dental University College, Tokyo 102-8159, Japan
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Sodani PR, Nair KS, Agarwal K. Health System Financing: A Comparative Analysis of India and Saudi Arabia. JOURNAL OF HEALTH MANAGEMENT 2023. [DOI: 10.1177/09720634231153214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
The objective of this study is to provide a comparative analysis of the health financing systems in India and the Kingdom of Saudi Arabia (KSA) across three major domains: resource mobilisation, pooling of resources and purchase of health services. This is an observational study using secondary data collected from international organisations, ministries of health and other government and non-government agencies in India and KSA. The study revealed that India has a very low expenditure on healthcare and markedly lower health outcomes compared to KSA. Although India’s health financing system has undergone notable changes in the last two decades, it is lagging behind in many health financing system parameters. However, the share of government expenditure on current health expenditure has been increasing steadily with higher allocations to primary and secondary care. By expanding health insurance coverage and sustainable public health funding, it is likely that India will make significant progress towards achieving UHC.
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Affiliation(s)
| | - Kesavan Sreekantan Nair
- Department of Health Administration, College of Public Health and Health Informatics, Qassim University, Al Bukayriyah, Al Qassim, Kingdom of Saudi Arabia
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Odoch WD, Senkubuge F, Masese AB, Hongoro C. A critical review of literature on health financing reforms in Uganda - progress, challenges and opportunities for achieving UHC. Afr Health Sci 2023; 23:736-746. [PMID: 37545949 PMCID: PMC10398427 DOI: 10.4314/ahs.v23i1.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Background Universal health coverage (UHC) is one of the sustainable development goals (SDG) targets. Progress towards UHC necessitates health financing reforms in many countries. Uganda has had reforms in its health financing, however, there has been no examination of how the reforms align with the principles of financing for UHC. Objective This review examines how health financing reforms in Uganda align with UHC principles and contribute to ongoing discussions on financing UHC. Methods We conducted a critical review of literature and utilized thematic framework for analysis. Results are presented narratively. The analysis focused on health financing during four health sector strategic plan (HSSP) periods. Results In HSSP I, the focus of health financing was on equity, while in HSSP II the focus was on mobilizing more funding. In HSSP III & IV the focus was on financial risk protection and UHC. The changes in focus in health financing objectives have been informed by low per capita expenditures, global level discussions on SDGs and UHC, and the ongoing health financing reform discussions. User fees was abolished in 2001, sector-wide approach was implemented during HSSP I&II, and pilots with results-based financing have occurred. These financing initiatives have not led to significant improvements in financial risk protection as indicated by the high out-of-pocket payments. Conclusion Health financing policy intentions were aligned with WHO guidance on reforms towards UHC, however actual outputs and outcomes in terms of improvement in health financing functions and financial risk protections remain far from the intentions.
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Affiliation(s)
- Walter Denis Odoch
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa
- Afya Research and Development Institute, P.O. Box 21743, Plot 2703, Block 208, Bombo Rd, Kampala, Uganda
- East, Central and Southern Africa Health Community P.O. Box 1009, Arusha Tanzania
| | - Flavia Senkubuge
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa
| | - Ann Bosibori Masese
- Afya Research and Development Institute, P.O. Box 21743, Plot 2703, Block 208, Bombo Rd, Kampala, Uganda
- Centre for Health Solutions Kenya
| | - Charles Hongoro
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa
- Developmental, Capable and Ethical State (DCE) Division, Human Sciences Research Council of South Africa Private Bag X41, Pretoria, 0001, South Africa
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Maritim B, Koon AD, Kimaina A, Lagat C, Riungu E, Laktabai J, Ruhl LJ, Kibiwot M, Scanlon ML, Goudge J. "It is like an umbrella covering you, yet it does not protect you from the rain": a mixed methods study of insurance affordability, coverage, and financial protection in rural western Kenya. Int J Equity Health 2023; 22:27. [PMID: 36747182 PMCID: PMC9901092 DOI: 10.1186/s12939-023-01837-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/21/2023] [Indexed: 02/08/2023] Open
Abstract
Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is being implemented through the national health insurer, the National Hospital Insurance Fund (NHIF), but the level of coverage, affordability and financial risk protection provided by health insurance, especially for rural informal households, is unclear. This study provides as assessment of affordability of NHIF premiums, the need for financial risk protection, and the extent of financial protection provided by NHIF among rural informal workers in western Kenya.Methods We conducted a mixed methods study with a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), and 6 focus group discussions (FGDs) with community stakeholders in rural western Kenya. Health insurance status was self-reported and households were categorized into insured and uninsured. Using survey data, we calculated the affordability of health insurance (unaffordability was defined as the monthly premium being > 5% of total household expenditures), out of pocket expenditures (OOP) on healthcare and its impact on impoverishment, and incidence of catastrophic health expenditures (CHE). Logistic regression was used to assess household characteristics associated with CHE.Results Only 12% of households reported having health insurance and was unaffordable for the majority of households, both insured (60%) and uninsured (80%). Rural households spent an average of 12% of their household budget on OOP, with both insured and uninsured households reporting high OOP spending and similar levels of impoverishment due to OOP. Overall, 12% of households experienced CHE, with uninsured households more likely to experience CHE. Participants expressed concerns about value of health insurance given its cost, availability and quality of services, and financial protection relative to other social and economic household needs. Households resulted to borrowing, fundraising, taking short term loans and selling family assets to meet healthcare costs.Conclusion Health insurance coverage was low among rural informal sector households in western Kenya, with health insurance premiums being unaffordable to most households. Even among insured households, we found high levels of OOP and CHE. Our results suggest that significant reforms of NHIF and health system are required to provide adequate health services and financial risk protection for rural informal households in Kenya.
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Affiliation(s)
- Beryl Maritim
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya.
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Allan Kimaina
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Cornelius Lagat
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Elvira Riungu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jeremiah Laktabai
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, Moi University, Eldoret, Kenya
| | - Laura J Ruhl
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, Indiana University, Indianapolis, USA
| | - Michael Kibiwot
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Michael L Scanlon
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, Indiana University, Indianapolis, USA
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Hatefi A. Universal health coverage is the vital link when health care is a public health good. Lancet Glob Health 2023; 11:e30. [PMID: 36521949 PMCID: PMC9747167 DOI: 10.1016/s2214-109x(22)00516-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Arian Hatefi
- Department of Medicine, Institute for Global Health Sciences, and Philip R Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, CA 94143, USA.
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13
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Maritim B, Koon AD, Kimaina A, Goudge J. Acceptability of prepayment, social solidarity and cross-subsidies in national health insurance: A mixed methods study in Western Kenya. Front Public Health 2022; 10:957528. [PMID: 36311602 PMCID: PMC9614422 DOI: 10.3389/fpubh.2022.957528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/20/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Many low- and middle-income countries are attempting to finance healthcare through voluntary membership of insurance schemes. This study examined willingness to prepay for health care, social solidarity as well as the acceptability of subsidies for the poor as factors that determine enrolment in western Kenya. Methods This study employed a sequential mixed method design. We conducted a cross-sectional household survey (n = 1,746), in-depth household interviews (n = 36), 6 FGDs with community stakeholders and key informant interviews (n = 11) with policy makers and implementers in a single county in western Kenya. Social solidarity was defined by willingness to make contributions that would benefit people who were sicker ("risk cross-subsidization") and poorer ("income cross-subsidization"). We also explored participants' preferences related to contribution cost structure - e.g., flat, proportional, progressive, and exemptions for the poor. Results Our study found high willingness to prepay for healthcare among those without insurance (87.1%) with competing priorities, low incomes, poor access, and quality of health services, lack of awareness of flexible payment options cited as barriers to enrolment. More than half of respondents expressed willingness to tolerate risk and income cross-subsidization suggesting strong social solidarity, which increased with socio-economic status (SES). Higher SES was also associated with preference for a proportional payment while lower SES with a progressive payment. Few participants, even the poor themselves, felt the poor should be exempt from any payment, due to stigma (being accused of laziness) and fear of losing power in the process of receiving care (having the right to demand care). Conclusion Although there was a high willingness to prepay for healthcare, numerous barriers hindered voluntary health insurance enrolment in Kenya. Our findings highlight the importance of fostering and leveraging existing social solidarity to move away from flat rate contributions to allow for fairer risk and income cross-subsidization. Finally, governments should invest in robust strategies to effectively identify subsidy beneficiaries.
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Affiliation(s)
- Beryl Maritim
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Adam D. Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Allan Kimaina
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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14
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Terefe B, Alemu TG, Techane MA, Wubneh CA, Assimamaw NT, Belay GM, Tamir TT, Muhye AB, Kassie DG, Wondim A, Tarekegn BT, Ali MS, Fentie B, Gonete AT, Tekeba B, Kassa SF, Desta BK, Ayele AD, Dessie MT, Atalell KA. Spatial distribution and associated factors of community based health insurance coverage in Ethiopia: further analysis of Ethiopian demography and health survey, 2019. BMC Public Health 2022; 22:1523. [PMID: 35948950 PMCID: PMC9364505 DOI: 10.1186/s12889-022-13950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 08/04/2022] [Indexed: 11/17/2022] Open
Abstract
Background Community-Based Health Insurance is an emerging concept for providing financial protection against the cost of illness and improving access to quality health services for low-income households excluded from formal insurance and taken as a soft option by many countries. Therefore, exploring the spatial distribution of health insurance is crucial to prioritizing and designing targeted intervention policies in the country. Methods A total of 8,663 households aged 15–95 years old were included in this study. The Bernoulli model was used by applying Kulldorff methods using the SaTScan software to analyze the purely spatial clusters of community based health insurance. ArcGIS version 10.3 was used to visualize the distribution of community-based health insurance coverage across the country. Mixed-effect logistic regression analysis was also used to identify predictors of community-based health insurance coverage. Results Community based health insurance coverage among households had spatial variations across the country by regions (Moran’s I: 0.252, p < 0.0001). Community based health insurance in Amhara (p < 0.0001) and Tigray (p < 0.0001) regions clustered spatially. Age from 15–29 and 30–39 years (Adjusted Odds Ratio 0.46(AOR = 0.46, CI: 0.36,0.60) and 0.77(AOR = 0.77, CI: 0.63,0.96), primary education level 1.57(AOR = 1.57, CI: 1.15,2.15), wealth index of middle and richer (1.71(AOR = 1.71, CI: 1.30,2.24) and 1.79(AOR = 1.79, CI: 1.34,2.41), family size > 5, 0.82(AOR = 0.82, CI: 0.69,0.96),respectively and regions Afar, Oromia, Somali, Benishangul Gumuz, SNNPR, Gambella, Harari, Addis Ababa and Dire Dawa was 0.002(AOR = 0.002, CI: 0.006,0.04), 0.11(AOR = 0.11, CI: 0.06,0.21) 0.02(AOR = 0.02, CI: 0.007,0.04), 0.04(AOR = 0.04, CI: 0.02,0.08), 0.09(AOR = 0.09, CI: 0.05,0.18),0.004(AOR = 0.004,CI:0.02,0.08),0.06(AOR = 0.06,CI:0.03,0.14), 0.07(AOR = 0.07, CI: 0.03,0.16) and 0.03(AOR = 0.03, CI: 0.02,0.07) times less likely utilize community based health insurance than the Amhara region respectively in Ethiopia. Conclusion Community based health insurance coverage among households in Ethiopia was found very low still. The government needs to develop consistent financial and technical support and create awareness for regions with lower health insurance coverage.
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Affiliation(s)
- Bewuketu Terefe
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Tewodros Getaneh Alemu
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Masresha Asmare Techane
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Chalachew Adugna Wubneh
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Nega Tezera Assimamaw
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getaneh Mulualem Belay
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadesse Tarik Tamir
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Addis Bilal Muhye
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Destaye Guadie Kassie
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Wondim
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Bethelihem Tigabu Tarekegn
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mohammed Seid Ali
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Beletech Fentie
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Almaz Tefera Gonete
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Berhan Tekeba
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Selam Fisiha Kassa
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Bogale Kassahun Desta
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Demsie Ayele
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Melkamu Tilahun Dessie
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kendalem Asmare Atalell
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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15
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Karim A, de Savigny D, Awor P, Cobos Muñoz D, Mäusezahl D, Kitoto Tshefu A, Ngaima JS, Enebeli U, Isiguzo C, Nsona H, Ogbonnaya I, Ngoy P, Alegbeleye A. The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions. BMJ Glob Health 2022; 7:bmjgh-2022-008493. [PMID: 35772810 PMCID: PMC9247653 DOI: 10.1136/bmjgh-2022-008493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/30/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. Methods We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. Results The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. Conclusion The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.
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Affiliation(s)
- Aliya Karim
- University of Basel, Basel, Switzerland .,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Don de Savigny
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Cobos Muñoz
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Daniel Mäusezahl
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Jean Serge Ngaima
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ugo Enebeli
- Department of Community Medicine, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Chinwoke Isiguzo
- School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Society for Family Health Nigeria, Abuja, Nigeria
| | - Humphreys Nsona
- IMCI, Malawi Ministry of Health, Lilongwe, Central Region, Malawi
| | - Ikechi Ogbonnaya
- Department of Health, Planning, Research & Statistics, Federal Ministry of Health, Abuja, Federal Capital Territory, Nigeria
| | - Pascal Ngoy
- PROSANI, USAID, Washington, District of Columbia, USA
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16
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Borghi J, Brown GW. Taking Systems Thinking to the Global Level: Using the WHO Building Blocks to Describe and Appraise the Global Health System in Relation to COVID-19. GLOBAL POLICY 2022; 13:193-207. [PMID: 35601655 PMCID: PMC9111126 DOI: 10.1111/1758-5899.13081] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 01/10/2022] [Accepted: 02/08/2022] [Indexed: 06/15/2023]
Abstract
Adequately preparing for and containing global shocks, such as COVID-19, is a key challenge facing health systems globally. COVID-19 highlights that health systems are multilevel systems, a continuum from local to global. Goals and monitoring indicators have been key to strengthening national health systems but are missing at the supranational level. A framework to strengthen the global system-the global health actors and the governance, finance, and delivery arrangements within which they operate-is urgently needed. In this article, we illustrate how the World Health Organization Building Blocks framework, which has been used to monitor the performance of national health systems, can be applied to describe and appraise the global health system and its response to COVID-19, and identify potential reforms. Key weaknesses in the global response included: fragmented and voluntary financing; non-transparent pricing of medicines and supplies, poor quality standards, and inequities in procurement and distribution; and weak leadership and governance. We also identify positive achievements and identify potential reforms of the global health system for greater resilience to future shocks. We discuss the limitations of the Building Blocks framework and future research directions and reflect on political economy challenges to reform.
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17
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Rouyard T, Mano Y, Daff BM, Diouf S, Fall Dia K, Duval L, Thuilliez J, Nakamura R. Operational and Structural Factors Influencing Enrolment in Community-Based Health Insurance Schemes: An Observational Study Using 12 Waves of Nationwide Panel Data from Senegal. Health Policy Plan 2022; 37:858-871. [PMID: 35413098 PMCID: PMC9347027 DOI: 10.1093/heapol/czac033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Community-based health insurance (CBHI) has been implemented in many low and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programs is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes-also termed 'mutual health organisations' (MHO) in francophone countries-and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017-2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrollees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrollees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrollees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (-16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalising and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time.
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Affiliation(s)
- Thomas Rouyard
- Research Center for Health Policy and Economics, Hitotsubashi University, Tokyo, Japan
| | - Yukichi Mano
- Graduate School of Economics, Hitotsubashi University, Tokyo, Japan
| | - Bocar Mamadou Daff
- National Agency for Universal Health Financial Protection, Dakar, Senegal
| | - Serigne Diouf
- National Agency for Universal Health Financial Protection, Dakar, Senegal
| | | | - Laetitia Duval
- Centre d'Économie de la Sorbonne, UMR 8174, Centre National de la Recherche Scientifique-Université Paris 1 Panthéon-Sorbonne, Paris, France
| | - Josselin Thuilliez
- Centre d'Économie de la Sorbonne, UMR 8174, Centre National de la Recherche Scientifique-Université Paris 1 Panthéon-Sorbonne, Paris, France
| | - Ryota Nakamura
- Research Center for Health Policy and Economics, Hitotsubashi University, Tokyo, Japan
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18
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Ly MS, Bassoum O, Faye A. Universal health insurance in Africa: a narrative review of the literature on institutional models. BMJ Glob Health 2022; 7:bmjgh-2021-008219. [PMID: 35483710 PMCID: PMC9052052 DOI: 10.1136/bmjgh-2021-008219] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Several African countries have introduced universal health insurance (UHI) programmes. These programmes aim to extend health insurance to groups that are usually excluded, namely informal workers and the indigent. Countries use different approaches. The purpose of this article is to study their institutional characteristics and their contribution to the achievement of universal health coverage (UHC) goals. Method This study is a narrative review. It focused on African countries with a UHI programme for at least 4 years. We identified 16 countries. We then compared how these UHI schemes mobilise, pool and use funds to purchase healthcare. Finally, we synthesised how all these aspects contribute to achieving the main objectives of UHC (access to care and financial protection). Results Ninety-two studies were selected. They found that government-run health insurance was the dominant model in Africa and that it produced better results than community-based health insurance (CBHI). They also showed that private health insurance was marginal. In a context with a large informal sector and a substantial number of people with low contributory capacity, the review also confirmed the limitations of contribution-based financing and the need to strengthen tax-based financing. It also showed that high fragmentation and voluntary enrolment, which are considered irreconcilable with universal insurance, characterise most UHI systems in Africa. Conclusion Public health insurance is more likely to contribute to the achievement of UHC goals than CBHI, as it ensures better management and promotes the pooling of resources on a larger scale.
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Affiliation(s)
- Mamadou Selly Ly
- Institut Santé et Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal
| | - Oumar Bassoum
- Institut Santé et Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal
| | - Adama Faye
- Institut Santé et Développement (ISED), Cheikh Anta Diop University, Dakar, Senegal
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19
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Darrudi A, Ketabchi Khoonsari MH, Tajvar M. Challenges to Achieving Universal Health Coverage Tthroughout the World: A Systematic Review. J Prev Med Public Health 2022; 55:125-133. [PMID: 35391524 PMCID: PMC8995934 DOI: 10.3961/jpmph.21.542] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/03/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives No systematic review has explored the challenges related to worldwide universal health coverage (UHC). This study reviewed challenges on the road to UHC. Methods A systematic electronic search of all studies that identified the challenges of worldwide UHC was conducted, without any restrictions related to the publication date or language. A hand search and a bibliographic search were also conducted to identify which texts to include in this study. These sources and citations yielded a total of 2500 articles, only 26 of which met the inclusion criteria. Relevant data from these papers were extracted, summarized, grouped, and reported in tables. Results Of the 26 included studies, 7 (27%) were reviews, 6 (23%) were reports, and 13 (50%) had another type of study design. The publication dates of the included studies ranged from 2011 to 2020. Nine studies (35%) were published in 2019. Using the World Health Organization conceptual model, data on all of the challenges related to UHC in terms of the 4 functions of health systems (stewardship, creating resource, financing, and delivering services) were extracted from the included studies and reported. Conclusions This study provides a straightforward summary of previous studies that explored the challenges related to UHC and conducted an in-depth analysis of viable solutions.
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Affiliation(s)
- Alireza Darrudi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Maryam Tajvar
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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20
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Shahabi S, Skempes D, Behzadifar M, Tabrizi R, Nazari B, Ghanbari MK, Heydari ST, Zarei L, Lankarani KB. Recommendations to improve insurance coverage for physiotherapy services in Iran: a multi criteria decision-making approach. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:80. [PMID: 34895282 PMCID: PMC8666042 DOI: 10.1186/s12962-021-00333-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/24/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND High toll of traffic-related injuries, climate change, natural disasters, population aging, as well as chronic diseases have all made considerable demands on receiving physiotherapy services in Iran. Nevertheless, there is an assortment of complications facing utilization of such services, particularly poor insurance coverage. Therefore, the present study investigated and identified gaps in insurance coverage in order to inform future policy reforms and the design of a more comprehensive and universal benefits package for physiotherapy services in Iran. METHODS This project was carried out in Iran, using a mix-methods (viz. qualitative-quantitative) approach. Within the first phase, a qualitative study was completed to find policy recommendations. Such recommendations were then prioritized through the Analytical Hierarchy Process (AHP), in the second phase, based on effectiveness, acceptability, cost, fairness, feasibility, and time. RESULTS Within the first phase, a total number of 30 semi-structured interviews with health policy-makers, health insurers, faculty members, rehabilitation experts, and physiotherapists were completed. Several policy recommendations were also proposed by the study participants. Following the second phase, prioritized recommendations were provided to promote stewardship (e.g., informing policy-makers about physiotherapy services), collection of funds (e.g., placing value-added taxes on luxury goods and services), pooling of funds (e.g., moving allocated resources towards insurance (viz. third-party) mechanism), purchasing (e.g., using strategic purchasing), and benefit package (e.g., considering preventive interventions) as the main components of insurance coverage. CONCLUSION The study findings provided a favorable ground to improve insurance coverage for physiotherapy services in Iran. As well, decision- and policy-makers can place these recommendations on the agenda in the health sector to protect population health status, especially that of groups with disabilities.
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Affiliation(s)
- Saeed Shahabi
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Masoud Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
- Clinical Research Development Unit, Vali Asr Hospital, Fasa University of Medical Sciences, Fasa, Iran
| | - Behrooz Nazari
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | | | - Seyed Taghi Heydari
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Leila Zarei
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kamran Bagheri Lankarani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
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21
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Derakhshani N, Maleki M, Pourasghari H, Azami-Aghdash S. The influential factors for achieving universal health coverage in Iran: a multimethod study. BMC Health Serv Res 2021; 21:724. [PMID: 34294100 PMCID: PMC8299681 DOI: 10.1186/s12913-021-06673-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/23/2021] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Naser Derakhshani
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Maleki
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Pourasghari
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Saber Azami-Aghdash
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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22
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Barasa E, Mathauer I, Kabia E, Ezumah N, Mbau R, Honda A, Dkhimi F, Onwujekwe O, Phuong HT, Hanson K. How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them. Health Policy Plan 2021; 36:861-868. [PMID: 33948635 PMCID: PMC8227448 DOI: 10.1093/heapol/czab003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/14/2022] Open
Abstract
Provider payment methods are a key health policy lever because they influence healthcare provider behaviour and affect health system objectives, such as efficiency, equity, financial protection and quality. Previous research focused on analysing individual provider payment methods in isolation, or on the actions of individual purchasers. However, purchasers typically use a mix of provider payment methods to pay healthcare providers and most health systems are fragmented with multiple purchasers. From a health provider perspective, these different payments are experienced as multiple funding flows which together send a complex set of signals about where they should focus their effort. In this article, we argue that there is a need to expand the analysis of provider payment methods to include an analysis of the interactions of multiple funding flows and the combined effect of their incentives on the provision of healthcare services. The purpose of the article is to highlight the importance of multiple funding flows to health facilities and present a conceptual framework to guide their analysis. The framework hypothesizes that when healthcare providers receive multiple funding flows, they may find certain funding flows more favourable than others based on how these funding flows compare to each other on a range of attributes. This creates a set of incentives, and consequently, healthcare providers may alter their behaviour in three ways: resource shifting, service shifting and cost shifting. We describe these behaviours and how they may affect health system objectives. Our analysis underlines the need to align the incentives generated by multiple funding flows. To achieve this, we propose three policy strategies that relate to the governance of healthcare purchasing: reducing the fragmentation of health financing arrangements to decrease the number of multiple purchaser arrangements and funding flows; harmonizing signals from multiple funding flows; and constraining providers from responding to undesirable incentives.
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Affiliation(s)
- Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Evelyn Kabia
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Nkoli Ezumah
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Rahab Mbau
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ayako Honda
- Research Center for Health Policy and Economics at the Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Japan
| | - Fahdi Dkhimi
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Hoang Thi Phuong
- Health Strategy and Policy Institute, Ministry of Health, Hanoi, Vietnam
| | - Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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23
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Harish R, Suresh RS, Rameesa S, Laiveishiwo PM, Loktongbam PS, Prajitha KC, Valamparampil MJ. Health insurance coverage and its impact on out-of-pocket expenditures at a public sector hospital in Kerala, India. J Family Med Prim Care 2020; 9:4956-4961. [PMID: 33209828 PMCID: PMC7652147 DOI: 10.4103/jfmpc.jfmpc_665_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/10/2020] [Accepted: 06/18/2020] [Indexed: 11/04/2022] Open
Abstract
Background Health insurance coverage ensures protection from catastrophic health-care expenditure, especially to the underprivileged sections of society. Health insurance schemes such as Ayushman Bharat are coming up in addition to the existing schemes such as Rashtriya Swasthya Bima Yojana in India. The objectives are to find the health insurance coverage and its impact on out-of-pocket (OOP) expenditure for public sector tertiary health-care hospitalization. Methods A cross-sectional study was conducted at a tertiary care hospital in Kerala. Insurance coverage was assessed among patients seeking inpatient care in various medical and surgical departments. OOP expenses incurred for those receiving and not receiving insurance coverage were compared. In addition, factors influencing enrolment and availing of insurance schemes were determined. Results The coverage of health insurance was found to be 74%. Awareness campaigns and activities of local self-government (LSG) departments were the important reasons for enrolment and availing, respectively. Significantly lower OOP expenditures occurred in insured persons with regard to expenses incurred for treatment procedures (P = 0.019), investigations (P = 0.004), and medicines (P = 0.001). Among the enrolled patients, 45% expressed dissatisfaction regarding available services. Conclusion A quarter of patients still remain out of insurance coverage. All patients are incurring OOP expenditures, though the insured patients have significantly lower OOP expenses. The role of primary care providers and LSG is pivotal in creating awareness and ensuring enrolment. Availing services depend on the availability of resources at the respective institution. Improvements in enrolment and use of health insurance should ultimately result in improved patient satisfaction.
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Affiliation(s)
- Ravindran Harish
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - Ranjana S Suresh
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - S Rameesa
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - P M Laiveishiwo
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - Prosper Singh Loktongbam
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - K C Prajitha
- Junior Resident, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - Mathew J Valamparampil
- PhD Student, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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24
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Tangcharoensathien V, Mills A, Patcharanarumol W, Witthayapipopsakul W. Universal health coverage: time to deliver on political promises. Bull World Health Organ 2020; 98:78-78A. [PMID: 32015572 PMCID: PMC6986228 DOI: 10.2471/blt.20.250597] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | - Anne Mills
- London School of Hygiene and Tropical Medicine, University of London, London, England
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