Comprehensive Benefit Package Research Articles

Procedural fairness inbenefit package design: inclusion ofpre-exposure prophylaxis ofHIV inUniversal Coverage Scheme inThailand.

Since 2002, Thailand's Universal Coverage Scheme (UCS) has adopted a comprehensive benefits package with few exclusions. A positive-list approach has gradually been applied, with pre-exposure prophylaxis (PrEP) of HIV recently being included. Disagreements resulting from competing values and diverging interests necessitate an emphasis on procedural fairness when making any decisions. This qualitative study analyses agenda setting, policy formulation and early implementation of PrEP from a procedural fairness lens. Literature reviews and in-depth interviews with 13 key stakeholders involved in PrEP policy processes were conducted. Civil society organizations (CSOs) and academia piloted PrEP service models and co-produced evidence on programmatic feasibility and outcomes. Through a broad stakeholder representation process, the Department of Disease Control proposed PrEP for inclusion in UCS benefits package in 2017. PrEP was shown to be cost-effective and affordable through rigorous health technology assessment, peer review, use of up-to-date evidence and safe-guards against conflicts of interest. In 2021, Thailand's National Health Security Board decided to include PrEP as a prevention and promotion package, free of charge, for the populations at risk. Favourable conditions for procedural fairness were created by Thailand's legislative provisions that enable responsive governance, notably inclusiveness, transparency, safeguarding public interest and accountable budgetallocations; longstanding institutional capacity to generate local evidence; and implementation capacity for realisation of procedural fairness criteria. Multiple stakeholders including CSOs, academia and the government deliberated in the policy process through working groups and sub-committees. However, a key lesson from Thailand's deliberative process concerns a possible 'over interpretation' of conflicts of interest, intended to promote impartial decision-making, which inadvertently limited the voices of key populations represented in the decision processes. Finally, this case study underscores the value of examining the full policy cycle when assessing procedural fairness, since some stages of the process may be more amenable to certain procedural criteria than others.

Equity in Health and the New Normal: The Philippine Universal Health Care Law

The Philippine Universal Health Care (UHC) Law, consistent with the WHO’s Primary Health Care (PHC) Declaration (1978, 2008 and 2018) strives to achieve Equity in Health and Health for all Filipinos by ensuring universal access to health care within a New Normal that ensures inclusive growth. While the series of PHC declarations address gross health inequities among nations; our UHC Law addresses health inequities within our nation. Fifty per cent of Filipinos, who die, continue to die without health professional attendance. Our health outcomes are improving but lag behind those of our ASEAN neighbors. We continue to face what the Department of Health (DOH) describes as the triple burden of disease. Our health inequities persist within a socio-economic context of non-inclusive growth. To address these inequities in health, we need to work for a new normal that would ensure inclusive growth. In health, we need to implement the UHC law based on the philosophy and principles of PHC. There have been initial advances in the implementation of UHC. To accelerate it further, the UHC SG recommended the prioritization of the establishment of an interoperable, real time national health information system to guide governance, human resource for health (HRH) production, deployment and distribution, the provision of medicines and technology, and health financing. In addition to health systems reform, we need to shock and awe the Filipino people with a comprehensive primary care benefit package that can be actually utilized by the poor, generate popular support for UHC, and have significant impact on decreasing Out-of-Pocket health expenditures. To achieve Health for All Filipinos and Equity in Health, we need to ensure universal access to quality health care (UHC) within a new normal that leads to inclusive growth.

Health care utilization and its association with sociodemographic factors among slum-dwellers with type 2 diabetes in Tabriz, Iran: A cross-sectional study.

Slums are known as growing underprivileged areas. One of the health adverse effects of slum-dwelling is health care underutilization. Management of type 2 diabetes mellitus (T2DM) requires an appropriate utilization. This study aimed to investigate the extent of health care utilization among slum-dwellers with T2DM in Tabriz, Iran, in 2022. We conducted a cross-sectional study on 400 patients with T2DM living in slum areas of Tabriz, Iran. Sampling was conducted using a systematic random sampling method. A researcher-made questionnaire was used for data collection. To develop the questionnaire, we used Iran's Package of Essential Noncommunicable (IraPEN) diseases, in which potential needs and essential health care for patients with diabetes and the appropriate time intervals for use are specified. Data were analyzed using SPSS version 22. Although 49.8% of patients needed outpatient services, only 38.3% were referred to health centers and utilized health services. The results of the binary logistic regression model showed that women (OR = 1.871, CI 1.170-2.993), those with higher income levels (OR = 1.984, CI 1.105-3.562), and those with diabetes complications (Adjusted OR = 1.7, CI 0.2-0.603) were almost 1.8 times more likely to utilize outpatient services. Additionally, those with diabetes complications (OR = 1.93, CI 0.189-2.031) and those taking oral medication (OR = 3.131, CI 1.825-5.369) were respectively 1.9 and 3.1 times more likely to utilize inpatient care services. Our study showed that, although slum-dwellers with type 2 diabetes needed outpatient services, a small percentage were referred to health centers and utilized health services. Multispectral cooperation is necessary for improving the status quo. There is a need to take appropriate interventions to strengthen health care utilization among residents with T2DM living in slum sites. Also, insurance organizations should cover more health expenditures and provide a more comprehensive benefits package for these patients.

Eliciting the Economic Value and Preferences for Health Insurance Reform in Nigeria: Evidence from a Discrete Choice Experiment

National health insurance systems across the world are confronted with mounting demands for reforms to make them fit for purpose and deliver as planned. There is, however, a dire paucity of empirical evidence from which policymakers can draw inferences to make informed reform decisions. Such evidence needs to detail the economic cost as well as consumers’ preferences for reforms. Using orthogonal coding to generate three attributes and a full factorial design with all three attributes having three levels each to generate 27 possible scenarios with only 9 scenarios presented to each respondent to reduce the cognitive burden, conditional logistic regression was used to estimate McFadden’s discrete choice model in a discrete choice experiment conducted in Nigeria. McFadden’s R2 value of 0.5346 indicates that the model is well fitted. The Chi-squared statistic of 1057.13 shows that the estimated model has the required explanatory power and statistical significance for the attributes with confidence level set at 95%. Results show that respondents are willing to pay for health insurance reform, opting for health insurance types with attributes that they deem would meet their needs, rather than settle for status quo health insurance. Respondents were willing to pay as high as 24% of annual income to access insurance types that have comprehensive benefits package, which indicates that risk pooling could potentially fund universal health insurance in Nigeria.

Program to Institutionalize Meritocracy and Excellence in Human Resource Management (PRIME-HRM) in the Division of Northern Samar: Achieving Maturity Level II

Effective human resource management is critical to the success of educational institutions, but it can be challenging to manage human resources in the education sector. Recruitment, selection, and retention of highly qualified personnel, providing professional development opportunities, and ensuring employee satisfaction and motivation are some of the challenges that institutions face. This study examines the human resource management practices of the Schools Division Office (SDO) Northern Samar in the Philippines, using a mixed methods concurrent design approach. It collected data through reports, documents, and interviews with SDO officials and school administrators. The qualitative and quantitative findings were merged through simultaneous data analysis. The findings revealed that SDO Northern Samar has met the PRIME-HRM Level 2 – Maturity Level Indicators in the Systems, Practices, and Competencies of the four core Human Resource Management areas. The overall performance rating of 4.950 reflects the excellent service delivery of SDO Northern Samar. Further, most of the recipients of appointments and HR programs were teachers, followed by school administrators and non-teaching personnel. The high number of teachers who received training, seminars, and workshops indicates a strong emphasis on professional development for educators in the school system. The significant participation of school administrators in these events suggests a supportive organizational culture for professional growth. Moreover, most of the scholars receive courses from SEAMEO InnoTech, and most of the rewards and recognition being received are from the division level. These findings highlight the importance of providing opportunities for all staff members to enhance their skills and knowledge and the high level of excellence and dedication of the teaching, non-teaching, and teaching-related personnel within the division. These accomplishments were achieved through best practices in human resource management such as developing a comprehensive recruitment strategy that targets a diverse pool of candidates, providing support for new hires, regularly evaluating staff performance and providing feedback, and creating a culture of appreciation and recognition. Additionally, providing ongoing professional development opportunities, implementing a mentoring program, and developing a comprehensive compensation and benefits package are important for staff advancement and retention. These findings can help educational institutions improve their human resource management practices and enhance the quality of education they provide. Keywords: Human resource management, education sector, Philippines, PRIME-HRM, best practices, mixed methods DOI: 10.7176/JEP/14-11-03 Publication date: April 30 th 2023

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Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders

BackgroundCommunity-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.MethodsThis study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.ResultsThe implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.ConclusionsOur research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.

Thailand UHC in Action: Universal Access to Comprehensive COVID-19 Services by Thai and Non-Thai Population

Thailand achieved Universal Health Coverage (UHC) in 2002 through three main public health insurance schemes; the tax-financed Civil Servant Medical Benefit Scheme (CSMBS) covers public sector employees and dependants (7.1% of total population), payroll-tax financed Social Health Insurance (SHI) Scheme covers private sector employees (17.2%), and the tax-financed Universal Coverage Scheme (UCS) covers the remaining majority (75.7%) [1,2]. Registered migrant workers are covered by the SHI while voluntary premium-contribution migrant health insurance, managed by Ministry of Public Health (MOPH), covers undocumented migrants and their dependants. Hence, many unregistered migrant workers and their family members are not covered by any financial risk protection systems; services are paid for out-of-pocket [3]. Extensive geographical coverage of district health systems facilitates adequate and equitable access [4] with low levels of unmet needs [5]. The comprehensive benefit package [2] and free-at-point of services result in low and continually decreasing prevalence of catastrophic health spending [6] (6.7% in 1994 to 2.2% in 2017 [7]) and incidence of impoverishment (1.4% in 1996 to 0.4% in 2015 (using international poverty line of US$ 3.1 per capita per day)) [8]. This perspective analyses how Thailand has responded to the COVID-19 pandemic through the UHC lens, covering all Thai and non-Thai populations, including migrant workers, with a comprehensive set of COVID-19-related services for everyone--a key contributing factor to pandemic containment.

A Tale of Two Social Insurance Systems in South Korea and Taiwan: A Financial Risk Protection Perspective

ABSTRACT Universal Health Coverage (UHC) is a widespread policy goal in the 21st century. The aim is to protect people from financial risk while promoting their access to good-quality care. This study examined the social insurance systems of South Korea and Taiwan to explore the critical challenges of achieving effective UHC. By assessing the impact of UHC on financial risk protection (measured by out-of-pocket payment share and catastrophic payment headcount), we found that when South Korea inaugurated its National Health Insurance (NHI) program with a limited benefits package and high cost sharing, it did not reduce the financial burden. Meanwhile, we observed a drop of 5 to 6 percentage points in the catastrophic payment headcount in Taiwan, which offered a universal and rather comprehensive benefits package with a modest cost-sharing design under its single-payer NHI system. The political-economic context of the UHC policy evolution was further explored through an in-depth discussion. We conclude that to provide sufficient financial risk protection against unexpected medical expenses, the design of the insurance scheme, in particular the risk-sharing mechanism, not only matters but is also the key to success.

Recommendations to improve insurance coverage for physiotherapy services in Iran: a multi criteria decision-making approach

BackgroundHigh 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.MethodsThis 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.ResultsWithin 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.ConclusionThe 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.

Exploring willingness to pay for health insurance and preferences for a benefits package from the perspective of women from low-income households of Karachi, Pakistan

BackgroundAchieving universal health coverage (UHC) and reduction in out of pocket (OOP) expenditures on health, is a critical target of the Sustainable Development Goals (SDG). In low-middle income countries, micro-health insurance (MHI) schemes have emerged as a useful financing tool for laying grounds for Universal Health Coverage. The aim of this study was to provide evidence for designing a feasible health insurance scheme targeted at urban poor, by exploring preferences for an insurance benefits package and co-payments among women from low-income households in Karachi, Pakistan.MethodsThis was a descriptive cross-sectional study, conducted using household surveys between July–August 2015. A total of 167 female beneficiaries of Benazir Income Support Programme (BISP), a large-scale cash transfer scheme targeted at low-income households, were recruited in Karachi through a mix of convenience and snowball sampling. Hypothetical insurance benefits packages for a prospective health insurance scheme were formulated to capture respondents’ preferences for health insurance benefits package and co-payments. All data was analyzed using Stata (version 13).ResultsRespondents reporting expenditure on OPD and hospitalization in the last 2 weeks were 93.4 and 11.9% respectively. The highest median expenditure was incurred on medicines. Out of the proposed benefits package, a majority (53%) of the study participants opted for the comprehensive benefits package that provided coverage for emergency care, hospitalization, OPD consultation, diagnostic tests and transportation. For the co-payment plan, 38.9% participants preferred no co-payments that is 100% insurance coverage of medicines followed by hospitalization (25.9%). Nearly half of the respondents (49.4%) chose outpatient consultation for 50% co-payment. A majority of the participants (65.3%) agreed to 100% co-payment for the transportation cost.ConclusionHealth insurance schemes can be introduced in urban areas, against collection of micro-payments, to prevent low-income households from facing financial catastrophe. A comprehensive benefits package covering emergency care, hospitalization, OPD consultation, diagnostic tests and transportation, is the most preferred among low-income beneficiaries.

Financial risk protection of Thailand\u2019s universal health coverage: results from series of national household surveys between 1996 and 2015

BackgroundThailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002.MethodsWe used data from a 15-year series of annual national household socioeconomic surveys (SES) between 1996 and 2015, which were conducted by the National Statistic Office (NSO). The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payment (OOP) for health by households exceeding 10 and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments.ResultsUsing the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8 to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4 and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low.ConclusionThe significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand’s UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefits package concertedly support the achievement of UHC goals of access and financial risk protection.

Feasibility and desirability of scaling up Community\u2013based Health Insurance (CBHI) in rural communities in Uganda: lessons from Kisiizi Hospital CBHI scheme

BackgroundCommunity-based Health Insurance (CBHI) schemes have been implemented world over as initial steps for national health insurance schemes. The CBHI concept developed out of a need for financial protection against catastrophic health expenditures to the poor after failure of other health financing mechanisms. CBHI schemes reduce out-of-pocket payments, and improve access to healthcare services in addition to raising additional revenue for the health sector. Kisiizi Hospital CBHI scheme which was incepted in 1996, has 41,500 registered members, organised in 210 community associations known as ‘Bataka’ or ‘Engozi’ societies. Members pay annual premiums and a co-payment fee before service utilisation. This study aimed at exploring the feasibility and desirability of scaling up CBHI in Rubabo County, with specific objectives of: exploring community perceptions and determining acceptability of CBHI, identifying barriers, enablers to scaling up CBHI and documenting lessons regarding CBHI expansion in a rural community.MethodsExplorative study using qualitative methods of Key informant interviews and Focus Group Discussions (FGDs). Seventeen key informant interviews, three focus group discussions for scheme members and three for non-scheme members were conducted using a topic guide. Data was analysed using thematic approach.ResultsScaling up Kisiizi Hospital CBHI is desirable because: it conforms to the government social protection agenda, society values, offers a comprehensive benefits package, and is a better healthcare financing alternative for many households. Scaling up Kisiizi Hospital CBHI is largely feasible because of a strong network of community associations, trusted quality healthcare services at Kisiizi Hospital, affordable insurance fees, trusted leadership and management systems. Scheme expansion faces some obstacles that include: long distances and high transport costs to Kisiizi Hospital, low levels of knowledge about health insurance, overlapping financial priorities at household level and inability of some households to pay premiums.ConclusionsCBHI implementation requires the following considerations: conformity with society values and government priorities, a comprehensive benefits package, trusted quality of healthcare services, affordable fees, trusted leadership and management systems.

Equity in Health Benefit Utilization and Financial Risk Protection in Outpatient and Inpatient Care: Baseline Survey of Two Socioeconomic Groups of a Pilot Primary Care Benefits Scheme in the Catchment Areas of a University-Based Health Facility

Background. Health inequities in the Philippines are driven by health workforce maldistribution and health system fragmentation. These can be addressed by strengthening primary care through central social health insurance (PhilHealth) coverage. However, high reported PhilHealth population coverage and health provider accreditation have not necessarily increased health benefit utilization or financial risk protection.
 Objective. This study aims to examine the impact of an enhanced, comprehensive primary care benefits package at a university-based health facility. This paper reports baseline utilization of health services and health benefits, and out-of-pocket health spending in two socioeconomic strata of the catchment population, for outpatient and inpatient services.
 Methods. A questionnaire-guided survey was done among randomly selected faculty (higher income group) and non-faculty (lower income group) employees to determine the frequencies and costs of using outpatient and inpatient health services, and amounts paid out-of-pocket.
 Results. Annually, both groups had approximately 1 consultation/patient and about 15 hospitalizations per 100 families annually. For hospitalizations, non-faculty inpatients utilized health insurance more frequently than faculty inpatients (75.7% vs. 66.7%), but paid higher out-of-pocket proportions (73.3% or Php 92,479/hospitalization vs. 57.4% or Php 16,273/hospitalization). For outpatient care, health benefit utilization rates were higher among non-faculty (12.4% vs 2.1% of consultations) although low overall, with similar total (Php 2,319 vs Php 1,741) and out-of-pocket expenses (100%).
 Conclusion. These findings confirm inequities in accessing outpatient and inpatient health services and utilizing health insurance benefits in the target population.

Early experience of universal health coverage in Turkey on access to health services for the poor: regression kink design analysis.

BackgroundIn 2003, the Turkish government introduced a major health system reform, the Health Transformation Program (HTP), aimed at achieving Universal Health Coverage (UHC). HTP has helped to expand insurance coverage and health benefits for the uninsured population groups, which included low-income households and the unemployed, through the Green Card scheme, a non-contributory health insurance funded by the government. The Green Card scheme expansion began in 2005 and increased rapidly after 2008, following the introduction of a new comprehensive benefits package, to cover an additional 13 million people.MethodsWe examine the impact of the Green Card scheme on the utilization of outpatient, inpatient, specialist, and diagnostics services using the Turkish Health Survey data (2010), using a kinked regression design. We take advantage of a sharp break in the availability of health insurance at a particular income level (minimum wage) to examine the impact of the Green Card scheme on health service utilization.ResultsOur results show that having a Green Card increases the fraction of people using outpatient services by 68.30 percentage points, inpatient visit by 34.60 percentage points, and specialist visit by 74.10 percentage points.ConclusionsOur findings suggest that a non-contributory health insurance program, such as the Green Card scheme in Turkey, could provide increased access to health care services by the poor and provide important lessons for countries which aim to introduce health programs targeting poor as part of a transition to UHC.

Advancing health coverage of informal workers in three Latin American countries

AbstractAdvancing universal health coverage (UHC) in Latin America (LA) requires that governments address the inclusion of informal workers, who represent a significant proportion of the working population. Based on case studies and a literature review, this article analyzes health policy reforms of three LA countries and examines their ability to promote the inclusion of informal workers. The analysis focuses on three dimensions: eligibility criteria, benefit packages, and financial protection. The countries analyzed are Chile, Uruguay, and Colombia, each having a different type of welfare regime. These three countries have applied relevant reforms for UHC. Chile has made strenuous efforts to provide a comprehensive benefit package for all, while Uruguay has promoted the extension of health coverage based on principles of citizen rights. Colombia, meanwhile, has significantly expanded the coverage of informal workers, although it still faces challenges in terms of providing them with a comprehensive benefit package. The analysis shows the linkages between eligibility criteria, benefit packages, and financial protection, in such a way that strategies to extend the coverage of informal workers need to be coupled with the harmonization of benefit packages, financial protection, and equal opportunity of access to providers.

The Barriers to Achieve Financial Protection in Iranian Health System: A Qualitative Study in a Developing Country.

The move to universal health coverage and consequently health promotion is influenced by political, socio-economic and other contextual factors in a country. Iran, as a developing country with an upper-middle national income, has developed policies to achieve universal health coverage through financial protection. This study aims to investigate barriers to develop financial protection as a requirement to achieve universal health coverage. This qualitative study was conducted using 20 in-depth interviews with experts in social welfare, health insurance and financing. The framework analysis method was used to analyze the data. The results have been categorized in three major themes that were extracted from ten sub-themes. The major themes included the political, social and economic context of the country, the context and structure of healthcare system and dimensions of UHC. Achieving financial protection as a long-term objective should be considered as a priority among Iranian policy makers that requires an inter-sectoral collaboration with a defined in-charge body. Health policy makers in Iran should develop a more comprehensive benefits package for diseases and health conditions with catastrophic consequences. They also should develop a plan to cover the poor people.

What can be achieved with a single-payer NHI system: The case of Taiwan

The United Nations has incorporated the noble goal of Universal Health Coverage (UHC) in its 2030 Agenda for Sustainable Development. Most nations have already embraced UHC as their goal. However, an intense policy debate has risen about which health system structure can best achieve UHC. Is a single-payer system more efficient, equitable and effective than a multiple-payer system for middle income countries? We argue that empirical evidence and in-depth analysis of single-payer and multiple-payer systems should inform this debate. First, we need a clear definition of single- and multiple-payer health systems that enables us to compare their differences and clarify the issues to be debated. Second, at least four key issues confront any nation that wishes to achieve UHC: (1) how to design an affordable comprehensive health benefit package for UHC and to finance it (2) how the health expenditure inflation rate can be managed to sustain UHC (3) how modern information technology can be used to enhance efficiency and quality of healthcare and (4) how to assure an adequate supply of high-quality services will be distributed equitably throughout a nation. This paper offers a definition of single- and multiple-payer and compares them. We then use Taiwan's National Health Insurance system to address the four key issues, and illuminate how its policies and operations led to Taiwan's successful UHC.

Linkage of Palliative Care from Hospital to Home in Northern Thailand

Background: At the end of life, most people would choose to stay and die at home. However, over half of all deaths take place at an acute care hospital due to lack of services to support coping at home during the terminal stage. Objective: To explore strategies used for promoting linkage of palliative care from hospital to home in Northern Thailand. Methods: A descriptive study collected data on symptom management and management support for terminal stage patients at home. Three tertiary hospitals, two community hospitals, one health promotion hospital, and one local administrative office in Northern Thailand were chosen to represent settings where hospital-based and community-based palliative care services were provided. Focus groups and in-depth interviews were utilized with hospitalized and stay-at-home patients diagnosed with advanced cancer, caregivers, health care providers, and senior executive managing directors. Results: Symptom management, especially pain and dyspnea at home, is inadequate and inappropriate. Physicians in general and community hospitals commonly prescribed controlled-release and intermediate-release oral morphine to in-home patients. Transdermal fentanyl and injectable morphine were less available in community hospitals. In terms of management support, some physicians utilized diagnosis code Z51.5 for palliative care which allowed patients to receive a comprehensive benefits package under the universal coverage scheme that included oxygen therapy, pain management and wound care within 30 days of discharge. Only a few general and community hospitals set up specialty palliative care clinics with palliative care managers. Also, few support staff received training to strengthen their capacity to manage palliative care and provide better care services. Both short (2–3 days) and intermediate (6–16 weeks) courses are available. The referral system was not properly managed to assure continuity of care. Conclusion: Findings have significant implications for policy-makers and health care professionals to improve quality of palliative care.

Policy Choices for Progressive Realization of Universal Health Coverage Comment on "Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage".

In responses to Norheim’s editorial, this commentary offers reflections from Thailand, how the five unacceptable trade-offs were applied to the universal health coverage (UHC) reforms between 1975 and 2002 when the whole 64 million people were covered by one of the three public health insurance systems. This commentary aims to generate global discussions on how best UHC can be gradually achieved. Not only the proposed five discrete trade-offs within each dimension, there are also trade-offs between the three dimensions of UHC such as population coverage, service coverage and cost coverage. Findings from Thai UHC show that equity is applied for the population coverage extension, when the low income households and the informal sector were the priority population groups for coverage extension by different prepayment schemes in 1975 and 1984, respectively. With an exception of public sector employees who were historically covered as part of fringe benefits were covered well before the poor. The private sector employees were covered last in 1990. Historically, Thailand applied a comprehensive benefit package where a few items are excluded using the negative list; until there was improved capacities on technology assessment that cost-effectiveness are used for the inclusion of new interventions into the benefit package. Not only cost-effectiveness, but long term budget impact, equity and ethical considerations are taken into account. Cost coverage is mostly determined by the fiscal capacities. Close ended budget with mix of provider payment methods are used as a tool for trade-off service coverage and financial risk protection. Introducing copayment in the context of fee-for-service can be harmful to beneficiaries due to supplier induced demands, inefficiency and unpredictable out of pocket payment by households. UHC achieves favorable outcomes as it was implemented when there was a full geographical coverage of primary healthcare coverage in all districts and sub-districts after three decade of health infrastructure investment and health workforce development since 1980s. The legacy of targeting population group by different prepayment mechanisms, leading to fragmentation, discrepancies and inequity across schemes, can be rectified by harmonization at the early phase when these schemes were introduced. Robust public accountability and participation mechanisms are recommended when deciding the UHC strategy.