Achieving Universal Health Coverage Research Articles

Identifying and prioritizing inefficiency causes in Iran's health system.

Enhancing efficiency is crucial in addressing the escalating scarcity of healthcare resources. It plays a pivotal role in achieving Universal Health Coverage (UHC), with the ultimate goal of ensuring health equity for all. A fundamental strategy to bolster efficiency involves pinpointing the underlying causes of inefficiency within the healthcare system through empirical research. This study aimed to determine and prioritize the causes of inefficiency in Iran's health system. This mixed-method study comprised three phases. The initial phase involved identifying the causes of inefficiency through a comprehensive literature review of relevant studies published between January 1, 2010, to January 1, 2021. The causes were then aligned and prioritized using criteria derived from the literature and expert opinion. Finally, the identified causes were ranked based on their significance using Multiple-Criteria Decision Analysis (MCDA). From an initial pool of 307 causes of inefficiency, they were reduced to 121 causes in the first round of screening which were categorized into 13 thematic topics. The second screening process further narrowed the list to 48 causes. Among these, the leading causes of inefficiency included the inadequate supply and unequal distribution of hospital beds, the overuse of health services, and the mismanagement of the health workforce. In contrast, the use of traditional treatment methods was determined to be the least significant factor contributing to inefficiency. This study identified key inefficiencies in Iran's health system, such as resource misallocation, overuse of services, and workforce mismanagement. Addressing these issues is essential for optimizing resource utilization, enhancing service delivery, and achieving UHC. The findings suggest that policymakers should prioritize reforms in hospital bed distribution, implement strategies to reduce unnecessary health service use, and strengthen human resource management. Additionally, targeted policies that focus on decentralizing healthcare decision-making and enhancing primary care could significantly improve system-wide efficiency. Future research should evaluate the effectiveness of these interventions and explore the role of digital health solutions in mitigating identified inefficiencies.

Out-of-Pocket Expenditure in Patients admitted to Cardiology Department under ABPMJAY scheme in a Tertiary Care Hospital in Delhi: A Cross-Sectional Study

Introduction: The recent National Health Accounts 2019-20 data reveals that Out-of-Pocket Expenditure (OOPE) as a percent of Total Health Expenditure is more than 47% which is still higher compared to out-of-pocket health spending in other developing nations. Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY), the world’s largest public-funded social health insurance scheme is a by-product of National Health Policy 2017 recommendations to achieve Universal Health Coverage and reduce OOPE in health. The present study was conducted to know the OOPE among the patients admitted to the Cardiology department under AB-PMJAY scheme in a tertiary care hospital in New Delhi. Methods: A descriptive cross-sectional study was carried out from January 2021 to April 2022 among the patients admitted under the PMJAY scheme in the Cardiology Department of Tertiary Care Hospital in New Delhi. A total of 320 patients were interviewed using a structured questionnaire divided into eight sections. The collected data was tabulated in Microsoft Excel and analyzed. Results: The study investigated out-of-pocket expenditure (OOPE) for patients, finding the scheme covered doctor consultations, bed charges, physiotherapy, implants, and oxygen, but some patients still faced OOPE for diagnostics (15%), medicines (22.5%), blood transfusions (8.75%), and ambulance with an average direct medical expenditure of approximately Rs. 1511 during the hospital stay at the current hospital. Compared to previous hospitalizations, OOPE for diagnostics, medicines, and blood transfusions significantly decreased under PMJAY. Overall, 60.3% of respondents were satisfied with the PMJAY scheme. Conclusion: The PMJAY scheme helped the beneficiaries to reduce the financial burden of health to a great extent. However, few of the beneficiaries continued to make some payments from their pockets for diagnosis, medication, etc. The main reason for this was a lack of knowledge and awareness about the scheme among the beneficiary population.

Strategy implementation practices and Performance of State Corporations: Case of National Health Insurance Fund, Nairobi City County, Kenya

Many organizations in developed and developing countries and more specifically in Kenya are striving to perform, it is noted that issues of strategy implementation has continued to be uncertain in the Kenyan public sector. Many state-owned corporations are grappling with management problems which have led to their poor performance outcome. The National Health Insurance Fund is a state corporation through National Health Insurance Fund Act No. 9 of 1998. The Fund’s core mandate is to provide social medical insurance cover to all its members and their declared dependents (spouse and children). But according to National Health Insurance Fund Performance Report 2017- 2018, the National Health Insurance Fund has continued to implement social health strategies with a view to achieving Universal Health Coverage for the benefit of all Kenyans. The aim of the study was to examine the strategy implementation practices influencing the performance of state corporations in Kenya, specifically the National Hospital Insurance Fund. The study was grounded on Organizational Higgins’s Eight S Model, the Balanced Scorecard model, and Resource Based View theory. The study employed a descriptive research design. The study population consisted of 411 employees, managers, and patients from the National Health Insurance Fund headquarters. Questionnaires were used to collect primary data, and a pilot test was performed to assess the reliability and validity of the questionnaire. Cronbach’s Alpha coefficient was employed to determine the reliability of the research instrument. Data analysis involved the use of descriptive statistics, supported by the Statistical Package for Social Sciences (SPSS), to calculate frequencies, percentages, means, and standard deviations. A Multiple Linear Regression model was used to determine the influence of independent variables on the dependent variable. The study findings revealed that technological innovation, strategic resource planning, strategic leadership and strategy monitoring had positive and significant effects on the performance of the National Health Insurance Fund in Kenya. This study concluded that strategy implementation factors, including technological innovation, strategic resource planning, strategic leadership, and strategy monitoring, play a significant role in firm performance. The study recommends that the management of the organization should emphasize strategy implementation to improve the performance of their organization. Additionally, continuous investment in technological innovation, effective strategic resource planning, strategic leadership development, and robust strategy monitoring practices should be prioritized to enhance overall organizational performance.

Exploring sustainable health financing strategies in humanitarian settings: Challenges, innovations and efforts towards Achieving Universal Health Coverage

Sustainable health financing is critical in humanitarian settings to ensure that the most vulnerable populations have access to necessary healthcare services. In crises such as conflicts, natural disasters, or prolonged emergencies, healthcare systems are often destabilized, leading to significant challenges in providing adequate care. This review explores innovative financing mechanisms designed to support health services in these contexts, focusing on their potential to achieve Universal Health Coverage (UHC). Key challenges include limited funding, high out-of-pocket costs, and the uneven distribution of healthcare resources. In response, emerging models such as impact bonds, Islamic social finance, disaster risk insurance, and digital financial solutions offer new approaches to mobilizing resources and sustaining health interventions. These strategies are essential to bridging gaps in healthcare access, promoting equity, and strengthening the resilience of health systems. Policy recommendations highlight the importance of integrating emergency and routine health services, engaging communities, and enhancing coordination among stakeholders. Strengthening health financing mechanisms is vital for long-term improvements in health outcomes, especially in fragile settings. This research underscores the need for sustainable, inclusive policies that bolster health systems in the face of humanitarian crises.

'Show me the money': An analysis of US global health funding from 1995 to 2019.

Historically, the US has been the largest contributor to development assistance for health (DAH), although its allocation has shifted in response to outside forces. This included, for example, the establishment of the Millennium Development Goals (MDGs) in 2000, which emphasised child mortality, maternal health, HIV/AIDS, and malaria. This led to funds being earmarked for disease-specific interventions rather than health system strengthening (HSS). In 2007, the World Health Organization (WHO) published six health system building blocks, representing essential components of strong health systems. In 2015, the MDGs were replaced by the Sustainable Development Goals (SDGs), which emphasised capacity-building as opposed to specific health problems. The Lancet Commission on Global Surgery, meanwhile, highlighted surgical capacity building as essential to achieving Universal Health Coverage (UHC). Given the renewed emphasis on a comprehensive approach rather than disease-specific interventions, one might anticipate the US aligning with this rhetoric in its allocation of DAH. However, we hypothesise that this is not the case. We queried the Organization for Economic Co-operation and Development (OECD) database for allocation of US DAH to low- and middle-income countries between 1995 and 2019, thereby excluding data after 2019 to avoid the influence of the coronavirus disease 2019 pandemic. OECD entries were assigned to health systems strengthening (HSS) or disease-specific interventions categories. The WHO building blocks were used as a framework for health systems strengthening. From 1995 to 1999, US DAH allocated to HSS decreased from 42% to 34%. The allocation decreased further from 34% in 2000 to 4% in 2007; correspondingly, DAH allocated to disease-specific interventions increased from 67% to 96%. Between 2008 and 2019, the distribution of US DAH remained relatively stable, with funds allocated to HSS versus disease-specific interventions ranging from 3-12% and 88-98% respectively. While total US DAH contributions in the 1990s and early 2000s were significantly lower compared to the decade that followed, the distribution of these funds was more evenly divided between HSS and disease-specific interventions. Despite attempts by the WHO and United Nations to redirect attention to HSS as the path to achieving UHC, the US continues to largely support disease-specific interventions and overlook the importance of HSS, including surgical capacity building.

Five Years of National Health Policy in India: Critical Analysis of the Public Health Expenditure from 2017 to 2022 and Way Forward

This retrospective study assesses the impact of India’s National Health Policy (NHP) 2017 on public health expenditure and its implications for achieving Universal Health Coverage (UHC) and Sustainable Development Goal 3 (SDG-3). Using secondary data analysis from government sources, we observed health budget trends relative to GDP from 2017 to 2022. The study found a marginal increase in public health expenditure from 0.9% to 1.6% of GDP, which is below the NHP’s target of 2.5%. The results underscore the challenge of high out-of-pocket expenses, which remain a barrier to UHC. The COVID-19 pandemic has further highlighted the inadequacies of the current funding levels. We conclude that a substantial increase in health budget allocations is crucial for India to make significant strides toward UHC and meet SDG-3 targets. The study also calls for strategic enhancements in healthcare infrastructure and services to address the persistent gaps in healthcare delivery and financing. The findings advocate for a more aggressive approach to public health investment to ensure that quality healthcare services are accessible, affordable, and equitable for all citizens, thereby advancing India’s progress toward comprehensive health coverage.

The Urgent Need for Interprofessional Environmental Health Education to Achieve Universal Health Coverage, Even in Disasters

The Urgent Need for Interprofessional Environmental Health Education to Achieve Universal Health Coverage, Even in Disasters

Assessment of the compliance with minimum quality standards by public primary healthcare facilities in Nigeria

Achieving universal health coverage (UHC) and the Sustainable Development Goals (SDG) by 2030 relies on the delivery of quality healthcare services through effective primary healthcare (PHC) systems. This necessitates robust infrastructure, adequately skilled health workers and the availability of essential medicines and commodities. Despite the critical role of minimum standards in benchmarking PHC quality, no global consensus on these standards exists. Nigeria has established minimum standards to enhance healthcare accessibility and quality, including the Revised Ward Health System Strategy (RWHSS) by the National Primary Health Care Development Agency (NPHCDA). This paper outlines the evolution of PHC minimum standards in Nigeria, evaluates compliance with RWHSS standards across all public PHC facilities, and examines the implications for ongoing PHC revitalization efforts. The study used a cross-sectional descriptive design to assess compliance across 25 736 public PHC facilities in Nigeria. Data collection involved a national survey using a standardized assessment tool focussing on infrastructure, staffing, essential medicines and service delivery. Compliance with RWHSS minimum standards was found to be below 50% across all facilities, with median compliance scores of 40.7%. Outreach posts had a median compliance of 32.6%, level 1 facilities 31.5% and level 2+ facilities 50.9%. Key findings revealed major gaps in health infrastructure, human resources and availability of essential medicines and equipment. Compliance varied regionally, with the North-west showing the highest number of facilities but varied performance across standards. The lessons learned underscore the urgent need for targeted interventions and resource allocation to address the identified deficiencies. This study highlights the critical need for regular, comprehensive compliance assessments to guide policy-makers in identifying gaps and strengthening PHC systems in Nigeria. Recommendations include enhancing monitoring mechanisms, improving resource distribution and focussing on infrastructure and human resource development to meet UHC and SDG targets. Addressing these gaps is essential for advancing Nigeria’s healthcare system and ensuring equitable, quality care for all.

Inclusion of disability in primary healthcare facilities and socioeconomic inequity in Brazil.

To describe disability-related performance and inequality nationwide in Brazil, and the changes that took place between 2012 and 2019 after the introduction of Programme for Improving Primary Care Access and Quality (PMAQ). We derived scores for disability-related care and accessibility of primary healthcare facilities from PMAQ indicators collected in round 1 (2011-2013), and round 3 (2015-2019). We assessed how scores changed after the introduction of PMAQ. We used census data on per capita income of local areas to examine the disability-specific care and accessibility scores by income group. We undertook ordinary least squares regressions to examine the association between PMAQ scores and per capita income of each local area across implementation rounds. Disability-related care scores were low in round 1 (18.8, 95%CI 18.3-19.3, out of a possible 100) and improved slightly by round 3 (22.5, 95%CI 22.0-23.1). Accessibility of primary healthcare facilities was also poor in round 1 (30.3, 95%CI 29.8-30.8) but doubled by round 3 (60.8, 95%CI 60.3-61.3). There were large socioeconomic inequalities in round 1, with both scores approximately twice as high in the richest compared to the poorest group. Inequalities weakened somewhat for accessibility scores by round 3. These trends were confirmed through regression analyses, controlling for other area characteristics. Disability-related and accessibility scores also varied strongly between states in both rounds. People with disabilities are being left behind by the Brazilian healthcare system, particularly in poor areas, which will challenge the achievement of universal health coverage.

A study of India’s ‘People’s Medicine Scheme’: Policy recommendations and insights to promote and improve access to generic medicines based on pilot survey in Bengaluru Urban District, India

Access to affordable and quality medicines plays a vital role for achieving Universal Health Coverage and in reducing out-of-pocket expenditures (OOPE) for households especially in developing nations such as India. Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP), a Government of India initiative, aims to make low-cost and quality generic drugs and surgical equipment accessible to all segments of the population through its dedicated store outlets known as Pradhan Mantri Bhartiya Janaushadhi Kendra (PMBJK). In this study, a pilot survey comprising 20 stores/PMBJKs and 150 citizens was undertaken in the Bengaluru Urban District, India to understand various aspects of the PMBJKs including availability of drugs, stock-outs, accessibility to stores, perception and awareness levels along with challenges faced by store owners and citizens/beneficiaries. Based on the survey results, we capture the availability of drugs for 35 medicines and consumables belonging to 12 therapeutic categories across 20 store outlets. We also provide valuable insights and interdisciplinary recommendations on several facets including adopting technology-based measures for day-to-day functioning of stores, need for in-depth supply chain analysis for ensuring availability of drugs, encouraging prescription of generic medicines, increasing awareness levels in addition to promoting grassroot-level research, surveys and feedback mechanisms. These suggestions are expected to find their utility in policy-making, strengthen the implementation of the PMBJP scheme across Bengaluru and India as well as contribute towards achieving related Sustainable Development Goals.

Analysing the intra and interregional components of spatial accessibility gravity model to capture the level of equity in the distribution of hospital services in Italy: do they influence patient mobility?

BackgroundAn equal distribution of hospital structures represents an important factor to achieve Universal Health Coverage. Generally, the most diffused approach to measure the potential availability to healthcare is the provider-to-population ratio based on the number of beds or professionals. However, this approach considers only the availability of resources provided at regional or local level ignoring the spatial accessibility of interregional facilities that are particularly accessed by patients living at the borders. Aim of this study is to outline the distribution of the intra and interregional services in Italy to capture the level of equity across the country. Moreover, it explores the impact of the accessibility to these resources on interregional patient’s mobility to receive care.MethodsTo compute spatial accessibility, we propose an alternative approach that applies the enhanced two-step floating catchment area (ESFCA) to capture the level of attraction of intra and interregional hospitals to a given population. Moreover, the adoption of process and outcome indices captured to what extent the quality of structures influenced patients in choosing services located inside or outside their region of residence.ResultsThe study confirms that there is an unequal distribution of high-quality resources at regional and national level with a high level of inequality in the availability and accessibility of quality resources between the north and south part of Italy. This is particularly true considering the accessibility of intraregional resources in the southern part of the country that clearly influences patient choice and contribute to a significant cross border passive mobility to northern regions. This is confirmed by an econometric model that showed a significant effect of spatial accessibility with the propensity of patients of travel from the region of residence to receive care.ConclusionsThe analysis of intra and interregional components of spatial accessibility may contribute to identify to what extent patients are willing to travel outside their region of residence to access to care services. Moreover, it can contribute to gain a deeper understanding of the allocation of health resources providing input for policy makers on the basis of the principles of service accessibility in order to contain patient mobility.

Evaluating the Impact and Awareness of the Ayushman Bharat Scheme in Bihar

The Ayushman Bharat Scheme, India's largest health insurance initiative, was launched in 2018 with the goal of achieving Universal Health Coverage as outlined in the National Health Policy 2017. This scheme comprises two components: the National Health Mission, which focuses on strengthening health services and promoting awareness in rural and urban areas, and the National Health Protection Mission, which provides free treatment up to Rs. 5 lakhs for 50 crore individuals from economically disadvantaged families. A survey conducted in four districts of Bihar—Bhagalpur, Banka, Munger, and Khagaria—revealed that rural areas have a higher registration rate (58%) compared to urban areas (37%). Social media (31%) and newspapers (21%) are the primary sources of information about the scheme, while gender participation is relatively balanced, with 44% women and 56% men registered. Despite these positive indicators, issues such as paperwork, Aadhaar card problems, and lack of information hindered some from registering. The scheme received an average rating of 3.83 out of 5, reflecting general satisfaction and strong trust (97%) among respondents, though no respondents had yet used the card. To improve the scheme’s reach and effectiveness, it is recommended to increase awareness through targeted social media and newspaper campaigns, simplify the registration process, expand information dissemination, address technical issues, and encourage active usage of the Ayushman Bharat card.

“It's very much part of this movement to undermine democracy”: A qualitative study of European Union level opposition strategies against reproductive health and rights

Despite increasing contestations of agreed global commitments on sexual and reproductive health and rights (SRHR), our understanding of strategies of opposition in global health policymaking remains limited. This article explores the opposition to SRHR at the European level focusing on the decision-making institutions of the European Union (EU). The central research questions ask i) how SRHR opposition actors seek to influence EU institutions and ii) what challenges their actions pose for health policymaking at the EU level. Our empirical focus is based on the qualitative method of framework analysis, with data collected from multiple sources, including documentary data on European Parliamentary debates, Council conclusions of the European Union, reports of nongovernmental organisations, and key informant interviews. Our study is in line with observations on globally coordinated efforts to restrict access to SRH services. This is a challenge for specific forums and countries, but as well for European Union's wider internal and external policies. We present a toolbox of strategies and actors operational at the European Union level. Our findings on opposition to SRHR indicate that it can be seen as a political tool that is part of a broader anti-democratic movement. Understanding strategies of anti-SRHR opposition is important for health policymakers as it shapes debates and the achievement of universal health coverage (UHC).

Rethinking and advancing the movement of resistance, activism, and advocacy in health in four central arenas of the Middle East Region

AbstractThe Middle East region has a long history of resistance, activism, and advocacy movements in health, most recently as part of the 2011 region‐wide Arab Spring. Despite this storied history, however, movements of resistance, activism, and advocacy in health in the region are rarely unpacked, examined, or documented. This historical and contextual analysis aims to examine the long‐standing confiscated health rights and subsequent experiences of resistance, activism, and advocacy in health in populations in Palestine, Lebanon, Egypt, and Iraq. Promoting a health equity and health rights‐based approach is key to achieving Universal Health Coverage and health‐related Sustainable Development Goals, particularly in contexts that experience fragile socioeconomic and humanitarian conditions and political instability such as many countries in the Middle East. Marginalized populations, including Palestinians living under Israeli occupation, Lebanese Lesbian, Gay, Bisexual, and Transgender+ (LGBT) communities, Egyptian women and girls affected by Female Genital Mutilation, and Iraqi refugees and Internally Displaced Persons, have been severely impacted by decades of oppression, conflict, and displacement. These populations have faced various forms of discrimination, neglect, and violence that have hindered their access to quality healthcare and basic health rights. Rather than relying on government efforts, local and international movements to advocate for and protect the health rights of these populations are key. Innovative approaches, strategic dialogue and collective actions are prerequisites for promoting resistance, activism, and advocacy in health in all country's systems structure. This analysis highlights the important of this social public health issue in the most turbulent region and provides evidence to guide all countries to realize equitable human rights for health for all populations.

Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middle-income countries: evidences from China

BackgroundTo achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform.MethodsWe identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics.ResultsThe findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket.ConclusionsThis study shares the lessons from China’s health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing.

Effect of health insurance on outpatient health service utilization among households affected by non-communicable diseases in busia county, Kenya

Background: Non-communicable diseases (NCDs) are increasingly becoming important agents of illness and premature deaths globally, killing up to 41 million people annually, 77% of which occur in LMICs. In Kenya, major NCDs are cancer, diabetes, cardio-vascular and chronic respiratory diseases. They account for 50% of all hospital admissions and 39% of hospital deaths. Patients with NCDs go through expensive treatment regiments, restraining them from utilizing available care. NCDs deepen inequality and are the major drivers of unending poverty. Kenya successively reformed the National Health Insurer to include a package that cover the blight of NCDs and transform it into a primary enabler for achieving Universal Health Coverage. There is however no evidence whether health insurance (HI) improves utilization of outpatient NCDs care. This study examined whether health insurance has an effect on utilization of outpatient NCDs care among households of people with NCDs. Methods: A quasi-experimental design was conducted among eligible households with HI cover and those without, involving a representative sample of 350 households. Interviewers conducted interviews at baseline and after 1 year among household heads. Results: Utilization of outpatient NCDs care improved by 1.24 (95% CI=1.048-1.474) times among insured households, (p=0.012). Conclusions: Health insurance improves utilization of outpatient NCDs care. To accelerate progress towards UHC, national government should scale up the program to all counties. County government and partners should ensure availability of essential NCDs commodities.

From PERFORM to PERFORM2Scale: lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries.

Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localized examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of 'how' to scale-up these initiatives. The aim of this paper is thus to examine the 'process' of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC. Qualitative methods were used to identify lessons learned from scaling-up the MSI in Ghana, Malawi and Uganda. We conducted 14 interviews with district health management team (DHMT) members, three scale-up assessments with 20 scale-up stakeholders, and three reflection discussions with 11 research team members. We also kept records of activities throughout MSI and scale-up implementation. Data were recorded, transcribed and analysed against the Theory of Change to identify both scale-up outcomes and the factors affecting these outcomes. The MSI was ultimately scaled-up across 27 districts. Repeated MSI cycles over time were found to foster greater feelings of autonomy among DHMTs to address longstanding local problems, a more innovative use of existing resources without relying on additional funding and improved teamwork. The use of 'resource teams' and the emergence of MSI 'champions' were instrumental in supporting scale-up efforts. Challenges to the sustainability of the MSI include limited government buy-in and lack of sustained financial investment.

Improving Sustainable Financing for Universal Health Coverage in Bhutan: Exploring Policy Options and Financial Strategies

AbstractDeeply rooted in its developmental philosophy of gross national happiness (GNH), Bhutan's healthcare system strives towards achieving a shared goal of universal health coverage (UHC). Despite being primarily financed by the government, the health system faces a plethora of challenges. To overcome these hurdles and achieve UHC goals, expanding the fiscal space for health and improving operational efficiency are crucial. This article aims to address Bhutan's evolving healthcare landscape and advance the achievement of UHC through two policy options. The first policy option focuses on the dual objective of improving health outcomes and promoting financial sustainability by leveraging health taxes, whereas the second option emphasizes reinforcing a systematic health technology assessment (HTA) in the Bhutanese health system. First, drawing lessons from global experiences, the policy brief recommends leveraging health taxes to reduce societal and healthcare costs and enhance financial sustainability in the health sector. Considering Bhutan's high prevalence of tobacco and alcohol consumption, and taking opportunity from the ongoing Goods and Services Tax (GST) reform, continued advocacy on health taxes is essential, and soft earmarking the health taxes may be considered to finance a broader array of public health programmes, particularly focusing on the promotion of healthy lifestyle, health screening and outreach public health activities. Second, the integration of HTA into policymaking and decision‐making processes is essential for effective resource allocation in UHC. Nurturing and strengthening the existing HTA governance structure under the Ministry of Health (MoH) and establishing a dedicated multidisciplinary HTA Committee will ensure informed decision‐making and resource optimization. HTA evidence should inform the revision of health service standards, clinical guidelines development, procurement decisions and healthcare priorities. These policy options can assist the country in improving financial sustainability, enhancing effective resource allocation and utilization and improving healthcare delivery, aligning with its vision of GNH and ultimately accelerating progress towards achieving UHC.

Transforming Lives Through Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY): A Review

Background: The Pradhan Mantri Jan Arogya Yojana (PMJAY) program was created in line with the global goal of Universal Health Coverage (UHC), and aims to ensure everyone has access to quality healthcare services without suffering financial difficulties. In India, over 60% of healthcare spending is still borne by households, and a significant portion of the population lacks any form of health protection coverage. Discussion: The High-Level Expert Group (HLEG) recommended a shift from supply-side healthcare financing to demand-side financing, leading to the introduction of government-sponsored health insurance schemes. To achieve Universal Health Coverage (UHC), the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched following the recommendations of the National Health Policy 2017. The PMJAY program is the world's largest publicly sponsored social health insurance program, delivering comprehensive healthcare services covering primary, secondary, and tertiary care levels. The scheme covers approximately 12 crore households, including more than 50 crore beneficiaries, offering healthcare coverage of up to Rs. 5 lakh per family annually. PMJAY operates nationwide in India, covering all states and union territories except for a few.. Conclusion: To move forward, PMJAY can play a transformative role in the healthcare landscape, integrate with primary healthcare, contribute to economic development, and expand its scope to include more healthcare services.

Efficiency evaluation and promoter identification of primary health care system in China: an enhanced DEA-Tobit approach

BackgroundWith Primary Health Care (PHC) being a cornerstone of accessible, affordable, and effective healthcare worldwide, its efficiency, especially in developing countries like China, is crucial for achieving Universal Health Coverage (UHC). This study evaluates the efficiency of PHC systems in a southwest China municipality post-healthcare reform, identifying factors influencing efficiency and proposing strategies for improvement.MethodsUtilising a 10-year provincial panel dataset, this study employs an enhanced Data Envelopment Analysis (DEA) model integrating Slack-Based Measure (SBM) and Directional Distance Function (DDF) with the Global Malmquist-Luenberger (GML) index for efficiency evaluation. Tobit regression analysis identifies efficiency determinants within the context of China’s healthcare reforms, focusing on horizontal integration, fiscal spending, urbanisation rates, and workforce optimisation.ResultsThe study reveals a slight decline in PHC system efficiency across the municipality from 2009 to 2018. However, the highest-performing county achieved a 2.36% increase in Total Factor Productivity (TFP), demonstrating the potential of horizontal integration reforms and strategic fiscal investments in enhancing PHC efficiency. However, an increase in nurse density per 1,000 population negatively correlated with efficiency, indicating the need for a balanced approach to workforce expansion.ConclusionsHorizontal integration reforms, along with targeted fiscal inputs and urbanisation, are key to improving PHC efficiency in underdeveloped regions. The study underscores the importance of optimising workforce allocation and skillsets over mere expansion, providing valuable insights for policymakers aiming to strengthen PHC systems toward achieving UHC in China and similar contexts.