Health Financing System Research Articles

Health System Financing and Resource Allocation in Humanitarian Settings: Toward a Collaborative Policy Research Agenda in the Eastern Mediterranean Region

This article discusses key policy questions around health system financing in humanitarian settings, with specific reference to the Eastern Mediterranean region. We discuss key financing functions in the context of different challenges and the potential policy options for addressing these effectively. We also identify areas of collaborative research between academics, policy- and decision-makers and other stakeholders to inform appropriate policy choices that are aligned to universal health coverage in such challenging contexts.

Developing the improved Community Health Fund inTanzania: was it a fair process?

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.

The effect of armed conflict on public health and strengthening of healthcare system during and post -armed conflict in Sudan

Background: Armed conflict has catastrophic effect on public health and overall wellbeing including causalities during war, long lasting physical and psychological effects, the reduction in human and financial resources which available to meet social needs and creation of setting in which violence is primary domain this issues clearly appeared in Sudan since conflict between Sudan army force and Rapid response force in 15th of April 2023. Methodology: This review aimed to reflect the effect of armed conflict on public health especially vulnerable groups and create plan for reform of collapsed health system during and after war in Sudan. Comprehensive review for previous related article using Pub –med, Google scholar Lancet and records from Federal and Local Ministry of Health in Sudan was done. Also SWOT analysis for current complexes was done to detect problems and achieve solutions. Results: The study reflects the effect of armed conflict on public health in countries suffered from war. The vulnerable populations those sufferings during war are elderly, children, neonates and women. SWOT analysis for current situation in Sudan reflects devastating effect of war in healthcare system. The study also offering a plan for strengthening of healthcare system which build on decentralization policy, Innovation related to community healthcare workers (CHWs) adoption and health-financing system strengthens. Conclusion: Strengthening of healthcare systems after disasters is an urgent concern, especially in countries that have experienced armed conflict due to great impact on public health. However, since few studies have been conducted concerning this topic in Sudan, further research is recommended.

In with the good, out with the bad – Investment standards for external funding of health?

In recent decades, external financing of health systems in low- and middle-income countries has helped achieve remarkable improvements across the world. However, these successes have not come without problems. There are a growing number of areas where external assistance can cause harm and even undermine the development of national health systems. Recent decades have seen a surge of knowledge on investing in health systems. We propose the setting up of investment standards for external assistance that aim to incentivize a more efficient evidence-based investment in a country’s health system, led by decision-makers in country. Using a more standardized process would lead to a better use of precious external assistance resources. The long-term goal would be fully functioning health systems with all the necessary essential public health functions in all countries.

Health financing: the impact of shocks and its role in health system resilience

Abstract Introduction Health financing plays a vital role in the performance of the health system. Shocks can have a major impact on health financing but health financing can also protect aspects of the health system during shocks. Understanding the health financing function, how different types of shocks - including pandemics and the current cost-of-living crisis -- affect health financing, and how health financing can be resilient in the presence of shocks is of utmost importance Methods A framework for understanding health financing and how a shock can affect health financing was developed by the European Observatory on Health Systems and Policies. Health financing is broken down into revenue raising, pooling, purchasing and the governance of health financing, referred to as sub-functions of health financing. We use this framework to explore country examples in an effort to identify the ways in which health financing systems are resilient to different types of shocks. Findings There a range of examples demonstrating resilience to shocks across the sub-functions of health financing. First, there are counter-cyclical financing mechanisms where the revenues allocated to health are automatically adjusted to compensate for unemployment shocks (e.g. Lithuania). Second, there are purchasing practices that ensure resources are allocated appropriately within the health system when there are significant changes in utilization patterns, (e.g. Belgium during COVID-19). Third, automatic adjustment of prices occurs, paid by the health system to compensate for inflationary pressures. Fourth,good practices in the governance of health financing involve adjusted coverage policies to improve access to services when households were under severe financial strain (e.g. Ireland). Conclusions There are many different ways to ensure that health financing is resilient to shocks. Policymakers must consider the role of their health financing systems when developing preparedness plans.

Private equity investment in Germany's primary care sector

Abstract Background A major reform of the primary care sector in Germany that included a new law on health system financing in 2004 introduced new tools to be used by “entrepreneurial doctors”. These new tools provided opportunities for corporate investments into primary care, including through private equity funds (PEFs). Since then, there has been a stark increase of private investments. Methods A review of academic and grey literature, media reports and relevant organizational websites. Results Investments by PEFs in Ambulatory Health Care Centres (in German: Medizinische Versorgungszentren, MVZs) have increased continuously in recent years, and latest estimates suggest that in 2020 about 750 of overall 3800 MVZs were owned by PEFs. However, exact and robust data on how many MVZs are owned by PEFs do not exist, as there are no (legal) requirements for disclosures of these investment and ownership structures in Germany. Often, investors are located in tax havens, making the identification of ownership difficult. In addition, a PEF investing into an MVZ may include one health care facility, several dozens or over 100, depending on how well developed the network is (sometimes including long-term care facilities), further complicating an understanding of ownership status. The public debate on private equity investments in Germany's health system has been intensifying in recent years and a number of concerns have been raised, leading to calls by medical chambers for stricter regulation. Federal Minister of Health, Karl Lauterbach, announced in late 2022 that a law prohibiting private equity acquisitions of MVZs would be forthcoming in 2023. Conclusions The involvement of PEFs in Germany's ambulatory health care centres has increased substantially in recent years, leading to increasing public concerns and calls for stricter regulation.

How do health system factors (funding and performance) impact on access to healthcare for populations experiencing homelessness: a realist evaluation

BackgroundPeople experiencing long-term homelessness face significant difficulties accessing appropriate healthcare at the right time and place. This study explores how and why healthcare performance management and funding arrangements contribute to healthcare accessibility or the lack thereof using long-term homeless adults as an example of a population experiencing social exclusion.MethodsA realist evaluation was undertaken. Thirteen realist interviews were conducted after which data were transcribed, coded, and analysed.ResultsFourteen CMOCs were created based on analysis of the data collected. These were then consolidated into four higher-level CMOCs. They show that health systems characterised by fragmentation are designed to meet their own needs above the needs of patients, and they rely on practitioners with a special interest and specialised services to fill the gaps in the system. Key contexts identified in the study include: health system fragmentation; health service fragmentation; bio-medical, one problem at a time model; responsive specialised services; unresponsive mainstream services; national strategy; short health system funding cycles; and short-term goals.ConclusionWhen health services are fragmented and complex, the needs of socially excluded populations such as those experiencing homelessness are not met. Health systems focus on their own metrics and rely on separate actors such as independent NGOs to fill gaps when certain people are not accommodated in the mainstream health system. As a result, health systems lack a comprehensive understanding of the needs of all population groups and fail to plan adequately, which maintains fragmentation. Policy makers must set policy and plan health services based on a full understanding of needs of all population groups.

Mapping and analysis of health financing in South Kivu province (DRC)

In South-Kivu, the health system is underfunded due to numerous constraints. Several initiatives have been tested but are insufficient for increasing and sustaining health financing. Analyze the health financing system in South-Kivu, through a mapping as well as quantitative and qualitative analysis of health financing mechanisms. The provincial health financing system is fragmented, with poorly coordinated mechanisms and interventions, leading to duplication of health system strengthening activities in addition to the absence of a mechanism for pooling external funding flows. Costs recovery (i.e. user fees) and external supports are the most widely used schemes while the government hardly contributes to the financing of the provincial health system. Mutual health insurance is supposed to improve access to health care, but its coverage is still extremely low. Results-Based Financing and free health care programs, fully financed by external donors, are irregular and insufficiently sustainable. It would be critical to implement a strategic purchasing model that is anchored in local institutions, owned by all stakeholders, and integrating all existing financing mechanisms, which could be supported by a common fund supporting the provincial health system. The “Single Contract” initiative developed to harmonize, pool, and sustain external programs, could be a good basis in this respect. This would involve strengthening policy dialogue, developing an investment case to support resource mobilization and implementing a joint monitoring and evaluation platform for disbursements led by the provincial health authorities.

Integrated care in a Beveridge system: experiences from England and Denmark.

Health systems internationally face demands to deliver care that is better coordinated and integrated. The health system financing and delivery model may go some, but not all the way in explaining health system fragmentation. In this paper, we consider the road to care integration in two countries with Beveridge style health systems, England and Denmark, that are both ranked as highly Integrated systems in Toth's health integration index. We use the SELFIE framework to compare the policies and reforms that have affected care integration over the past 30 years in the two countries. The countries both started their reform path by reforming to introduce choice and competition, but did so in different ways that set them on different pathways. Nevertheless, after two decades, the countries ended the period with largely similar structures that emphasised the creation of a cross-sectoral governance structure. In the relatively centralised England, by introducing decentralised Integrated Care Systems, and in the relatively decentralised Denmark with a centralising element in the form of new Health Clusters.

The birthing experiences of mothers with clinical healthcare professionals and community birth attendants in rural northern Ghana

BackgroundThe use of non-professional birth attendants, such as untrained family members and traditional birth attendants, contributes to birth-related complications such as neonatal and maternal mortality. Strategies such as professionally conducted home births and placement of community health professionals close to homes to ensure easy access to skilled birth attendants aim to reduce complications. However, women in labour continue to access the services of unskilled birth attendants in developing settings. AimTo explore the experiences of women in labour who received care from professional birth attendants and community birth attendants to understand the reasons for continued use of non-professional community birth attendants. MethodsA qualitative approach was used to explore the birthing experiences of nine mothers, aged 20–45 years. In-depth face-to-face interviews were conducted to generate data with the help of an interview guide. A content analysis approach was used to organise and interpret the data. FindingsThe participants reported hostile interactions with professional birth attendants, imposition of birthing positions by professional birth attendants, high cost of birthing services by professional birth attendants, and safety risks with non-professional community birth attendants. ConclusionThere is a need for explicit health financing systems that ensure mothers are aware and adequately prepared for labour-related costs. Mothers wish to receive care from professional birth attendants, but feel compelled by negative experiences to choose family members and non-professional birth attendants instead. The adherence of health professionals to the fundamental principles of ‘Respectful Maternity Care’ could reduce their negative attitudes towards women in labour.

Dynamics of Health Financing among the BRICS: A Literature Review

Despite economic progress, government efforts, and increased healthcare investments, health deprivation continues to persist in the countries of Brazil, Russia, India, China, and South Africa (BRICS). Hence, addressing the growing demand for health financing in a sustainable way and adopting unique approaches to healthcare provision is essential. This paper aims to review publications on the existing health financing systems in the BRICS countries, analyze the core challenges associated with health financing, and explore potential solutions for establishing a sustainable health financing system. This paper adhered to the PRISMA guidelines when conducting the keyword search and determining the criteria for article inclusion and exclusion. Relevant records were obtained from PubMed Central using nine keyword combinations. Bibliometrics analysis was carried out using R software (version 4.1.3), followed by a comprehensive manual narrative review of the records. BRICS countries experienced increased health expenditure due to aging populations, noncommunicable diseases, and medical advancements. The majority of this increased spending has come from out-of-pocket payments, which often lead to impoverishment. Due to limited fiscal capabilities, administrative difficulties, and inefficiency, providing comprehensive healthcare through public funding alone has become exceedingly difficult for these countries. Public-private partnerships are essential for achieving sustainable health financing and addressing challenges in healthcare provision.

Scourge of out-of-pocket expenditure on health: A study on its burden and predictors in a rural community of West Bengal.

Globally, one-third of current health expenditure had been out-of-pocket expenditure (OOPE). The health system financing of almost all low- and middle-income countries including India rely heavily on out-of-pocket (OOP) payments for health care. OOPE on health payments is particularly hard on any community, especially the poor leading to incomplete or even no treatment during their ill health. This study estimated OOPE among residents of a rural community in West Bengal and explored the associated factors with high OOP expenses. A community-based cross-sectional study was conducted in a rural community in Singur, West Bengal from June 2019 to February 2020. The study was done among 398 villagers selected from 15 clusters or villages. Households were randomly selected in each village. All members of the selected households were interviewed. SPSS was used for data analysis both for descriptive and inferential statistics. Only 14.6% of morbid persons had catastrophic expenditure. The incidence of catastrophic expenditure was higher among those who opted for private practitioners and or ayurveda, yoga and naturopathy, unani, siddha, and homeopathy (AYUSH) facilities. There was zero catastrophic expenditure for the unqualified sector. There was an increasing trend of OOP payments among the lower socioeconomic groups. Again, low-income individuals had a higher share in cumulative expenditure (Gini coefficient of 0.35). Most of the participants (78.4%) had no health insurance coverage. Promotion for higher utilization of public health facilities may reduce the burden of OOP expenses. Government health insurance schemes must be widened with the inclusion of coverage of outpatient services. Integrating AYUSH services in the public sector is another option to reduce OOP expenses.

Prioritization, Incentives, and Resource Use for Sustainable Dentistry: The EU PRUDENT Project.

The EU PRUDENT project aims to enhance the financing of oral health systems through novel evidence and implementation of better financing solutions together with citizens, patients, providers, and policy makers. The multicountry nature of the project offers unique windows of opportunity for rapid learning and improving within and across various contexts. PRUDENT is anticipated to strengthen capacities for better oral care financing in the EU and worldwide.

Avoidable hospital admissions depend on the primary healthcare governance model? A global health perspective from Europe countries

AbstractPrimary healthcare (PHC) governance model, namely its financing scheme, might impact the health outcomes, particularly in chronic conditions, through avoidable hospital admissions (AvH). Therefore, the study aims to assess how the PHC financial governance model determines AvH, as well as how this interacts with the health system financing (HSF) scheme. An observational study comparing the GP employment type (publicly and self/privately) with asthma and COPD, and Diabetes AvH per 100,000 habitants in 26 countries of the European Region, was performed. It considered 4 regression models with structural determinants, service delivery and HSF schemes. GP self/privately employed group associated with social health insurance scheme was significantly associated with higher total AvH (OR = 28.27 [CI 95% 2.34–77.54]), and for asthma and COPD AvH (OR = 21.88 [CI 95% 6.69–180.18]). Diabetes AvH were significantly associated with increasing GP outpatient coverage (model 1) and GP availability (model 2) under a GP self/privately employed group (respectively, OR = 17.01 [CI 95% 3.67–20.63] and OR = 17.80 [CI 95% 8.12–130.35]). The study evidenced that publicly employed GPs working in a tax‐based HSF scheme ensure better health outcomes for the population. Although some limitations of equity and categorisation, the results show that the governance model might influence population health outcomes.

Coping strategies for health care financing among informal sector workers in Dar es Salam, Tanzania

Background: In low- and middle-income countries (LMICs) health financing systems has been dependent on out-of-pocket payments (OOP). This type of payment is thought to increase income to finance health care but it’s unaffordable to economically disadvantaged persons. Health insurance was introduced in order to reduce catastrophic health expenditure caused by OOP but its implementation to informal sector workers is a challenge. Therefore, this study examines the coping strategies for managing health care costs among informal sector workers in Dar es Salaam, Tanzania. Methods: This cross-sectional descriptive study was conducted between September and December 2020 to 889 informal sector workers. The study respondents were randomly selected and questionnaire was used to collect data. Chi-square test and multivariate logistic regression were used to analyze data through the use of Statistical Package for Social Sciences (SPSS) version 23. Results: The findings showed that the mean age of the respondents was 34.8 years (SD±10.4) and majority, (90.1%) of the respondents were uninsured. The methods to carter for medical expenditures were cash payments (p=0.297; 95%CI=0.195-0.452), selling assets (p=0.672, 95%CI=0.507-0.891) and borrowing money (p=0.578, 95%CI=0.412-0.811). Conclusions: The health care financing methods that the informal sector workers use in order to access health services are effective in reducing short run problems of health care accessibility but it contributes to impoverishment. Designing an affordable insurance scheme with consideration of the social economic aspects of individuals will improve uptake to insurance schemes and hence achievement of the Sustainable Development Goals (SDGs).

The Impact of Supplemental Nutrition Assistance Program (SNAP) Enrollment on Health and Cost Outcomes

Summary In the United States, food insecurity is prevalent in low-income households and is associated with elevated risk of chronic disease, poor health outcomes, and excess avoidable health care utilization and costs. Individuals dually eligible for Medicare and Medicaid are a unique low-income group with significant social challenges, complex health conditions, and higher-than-average health care costs. Interventions to address social determinants of health (SDOH) — such as food insecurity — have the potential to reduce avoidable health care utilization and cost, and the health insurers are increasingly integrating them into care delivery. Using Supplemental Nutrition Assistance Program (SNAP) data from the Pennsylvania Department of Human Services and health care claims data from an integrated health care delivery and finance system, this study reports findings of an innovative collaboration between a health care payer and a nonprofit organization to enroll dual-eligible individuals in SNAP. Data were collected prospectively from 661 SNAP-enrolled individuals and 1,320 individuals in a matched comparison group to explore the effect of SNAP enrollment on health care utilization (inpatient hospitalization, ED visits, and unplanned care) and health care costs (medical, pharmacy, and total cost of care) during the first and second years after SNAP enrollment. Data analysis was designed to answer questions that are important to payer and health care stakeholders, namely, when (i.e., how long after the start of SNAP benefits), how (i.e., what health outcome), and for whom (i.e., what population subgroups) is SNAP enrollment associated with health and cost outcomes. Compared with a propensity score–matched group not enrolled in SNAP, the SNAP enrollees had 16% and 21% lower total health care costs and pharmacy costs, respectively, within the first year postenrollment in SNAP. These group differences remained significant during the second year postenrollment, when SNAP enrollees had 16% and 20% lower total health care costs and pharmacy costs, respectively. Specifically, lower costs were seen among individuals who do not qualify for skilled nursing care. This study contributes to the growing evidence that novel payer-led interventions to address SDOH can influence positive changes in health care utilization and cost reduction, especially among disadvantaged populations.

Healthcare Financing in Nigeria: A Policy Review.

A good health financing system is crucial for the effective performance of a country's health system. Many health systems around the world, especially in lower- and middle-income countries such as Nigeria, grapple with perennial challenges such as chronic underfunding, wastefulness, and lack of accountability rendering these systems inefficient. Nigeria's health system faces additional extraneous challenges such as a huge and rapidly growing population, a stagnant economy, and worsening insecurity of lives and property. Furthermore, recent disease outbreaks such as the Ebola epidemic and the COVID-19 pandemic and an evolving disease demography evidenced by an increasing prevalence of chronic, noncommunicable diseases asphyxiate an already floundering health system. To address these challenges and to bolster its efforts in attaining universal health coverage (UHC) and meeting the targets of the Sustainable Development Goals, the Nigerian government launched a new health policy in 2017. A review of the health financing section of this policy shows a focus on improving funding for health care by all levels of government and guaranteeing affordable and equitable access to health services by all Nigerians, albeit with insufficient clarity on how these will be achieved. A more critical review of the country's health financing system also reveals deep-seated systemic issues. Its out-of-pocket payments for funding health care are among the highest in the world, with abysmally low government contributions to health. Successive governments seem to lack the political will to address these shortfalls. Critical gaps exist in the country's health laws, making it difficult to implement the strategies proposed in the new policy. Nigeria must strengthen its health laws to, among other things, mandate health insurance and provide adequate funding for the health system by the government. It should also formulate a dedicated, more precise health financing policy with specific, measurable aims targeting identified problems to enable it to attain universal health coverage.

United Kingdom aid cuts: implications for financing health systems.

The United Kingdom (UK) used to be the second largest bilateral provider of official development assistance (ODA) for health. However, in 2021 the UK government cut its annual aid budget by 30%. We aim to understand how these cuts might affect financing for health systems in UK aid recipient countries. We conducted a retrospective analysis of domestic and external funding for 134 countries that received UK aid for the 2019-2020 budget year. We grouped countries into two cohorts: those that continued to receive aid in 2020-2021 ("budget") and those that did not ("no budget"). Data was collected from publicly available datasets and we compared UK's ODA, UK's health ODA with total ODA, general government expenditures and domestic general government health expenditure to assess the donor dependency and donor concentration of budget and no budget countries. Budget countries are more reliant on external aid to finance their governments and health systems than no budget countries, with a handful of exceptions. While the UK does not appear to be a major ODA contributor among most no budget countries, it is in many budget countries. Two no budget countries in particular may be faced with health systems financing challenges given their high ratios of UK health aid to domestic government health expenditures: the Gambia (1.24:1) and Eritrea (0.33:1). Although "safe" for this budget cycle, a number of low-income countries in Sub-Saharan Africa have very high ratios of UK health aid to domestic government health expenditures, including South Sudan (3.15:1), Sierra Leone (0.48:1), and the Democratic Republic of Congo (0.34:1). The 2021-2022 UK aid cuts could have negative impacts in a few countries highly dependent on UK health aid. Its departure could leave these countries with rather large funding gaps to fill and create a more concentrated donor climate.

A Financing Strategy to Expand Surgical Health Care.

Despite an evolving need to provide surgical health care globally, few health systems, particularly in low-income and middle-income countries (LMICs), can sufficiently provide such care. The vast majority of the world's people-an estimated 5 billion-are unable to access safe and affordable surgical health care when they need it. This is a significant concern for global public health because the demand for these services is rising with the epidemiological and demographic transitions occurring worldwide. A principal driver of weak surgical health care services is a lack of adequate health system financing for surgical health care. This article examines the financing of surgical health care by analyzing global trends in health system financing, approaches to expand fiscal space for health, and empirical perspectives on the design, introduction, and scale-up of policies to improve surgical systems. We describe a surgical health care financing strategy, together with broader political and economic considerations, to provide policy recommendations to fund the expansion of surgical health care and an essential surgical package as part of universal health coverage in LMICs.

Is contributory health insurance indeed an addiction to a bad idea? A comment on its relevance for low- and middle-income countries

Financing of health systems is an enduring concern world wide. Yazbeck and colleagues in their paper make an important point that when there is a choice between financing in which contributions from citizens take place in the form of generalised taxes versus those in which they are in the form of insurance premiums, the overwhelming evidence suggests that tax-based financing is unambiguously superior even in low- and middle-income countries. Despite the strength of their case against contributory insurance, we suggest that the path forward may be more complex than they envisage for a number of reasons. The problem of a high proportion of informal sector workers that they argue impacts contributory approaches is also an issue with taxes because of the very low numbers of people who file returns. Taxes in most developing countries are in fact largely derived from highly regressive indirect taxes which the poor are forced to pay. Additionally, in most developing countries, including large ones like India and Nigeria, the only choice on offer is continued dependence on out-of-pocket expenditures. In such a situation exploring alternatives which are superior to out-of-pocket expenditures becomes imperative. Asking citizens to wait interminably for additional tax resources to be made available would be a grave disservice to them.