Health Financing System Research Articles

A critical interpretive synthesis of informal payments in maternal health care.

Informal payments for healthcare are widely acknowledged as undercutting health care access, but empirical research is somewhat limited. This article is a critical interpretive synthesis that summarizes the evidence base on the drivers and impact of informal payments in maternal health care and critically interrogates the paradigms that are used to describe informal payments. Studies and conceptual articles identified both proximate and systems drivers of informal payments. These include norms of gift giving, health workforce scarcity, inadequate health systems financing, the extent of formal user fees, structural adjustment and the marketization of health care, and patient willingness to pay for better care. Similarly, there are proximal and distal impacts, including on household finances, patient satisfaction and provider morale. Informal payments have been studied and addressed from a variety of different perspectives, including anti-corruption, ethnographic and other in-depth qualitative approaches and econometric modelling. Summarizing and discussing the advantages and disadvantages of these and other paradigms illustrates the value of an inter-disciplinary approach. The same tacit, hidden attributes that make informal payments hard to measure also make them hard to discuss and address. A multidisciplinary health systems approach that leverages and integrates positivist, interpretivist and constructivist tools of social science research can lead to better insight. With this, we can challenge ‘master narratives’ and meet universalistic, equity-oriented global health objectives.

Looking at the bigger picture: how the wider health financing context affects the implementation of the Tanzanian Community Health Funds.

In Tanzania, the health financing system is extremely fragmented with strategies in place to supplement funds provided from the central level. One of these strategies is the Community Health Fund (CHF), a voluntary health insurance scheme for the informal rural sector. As its implementation has been challenging, we investigated different CHF implementation practices and how these practices and the wider health financing context affect CHF implementation and potentially enrolment. Two councils were purposively selected for this study. Routine data relevant for understanding CHF implementation in the wider health financing context were collected at council and public health facility level. Additionally, an economic costing approach was used to estimate CHF administration cost and analyse its financing sources. Our results showed the importance of considering different CHF implementation practices and the wider health financing context when looking at CHF performance. Exemption policies and healthcare-seeking behaviour influenced negatively the maximum potential enrolment rate of the voluntary CHF scheme. Higher revenues from user fees, user fee policies and fund pooling mechanisms might have furthermore set incentives for care providers to prioritize user fees over CHF revenues. Costing results clearly pointed out the lack of financial sustainability of the CHF. The financial analysis however also showed that thanks to significant contributions from other health financing mechanisms to CHF administration, the CHF could be left with more than 70% of its revenues for financing services. To make the CHF work, major improvements in CHF implementation practices would be needed, but given the wider health financing context and healthcare-seeking behaviours, it is questionable whether such improvements are feasible, scalable and value for money. Thus, our results call for a reconsideration of approaches taken to address the challenges in health financing and demonstrate that the CHF cannot be looked at as a stand-alone system.

A critical analysis of purchasing arrangements in Kenya: the case of micro health insurance

BackgroundStrategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya.MethodsThe study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27).ResultsThe regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership.ConclusionsAdequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI’s role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers’ relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system.

Coping with Out-of-Pocket Health Expenditure in India: Evidence from NSS 71st Round

The present paper seeks to examine the incidence and socio-economic inequality in the utilisation of different sources of finance to cope up with out-of-pocket (OOP) health expenditure in rural and urban India. By employing National Sample Survey Organisation (NSSO), 71st Round (2014) data, the authors found that among inpatient cases, about 60 and 50% households in rural and urban areas respectively rely upon distress sources such as borrowings, contributions from friends and relatives and sale of assets to finance OOP health expenditure. Socio-economically deprived sections in rural areas have a higher likelihood of using distress financing than in urban areas. Greater dependency on debt and sale of assets emphasises the need for a comprehensive health financing system in the country.

Health Financing Reforms for Moving towards Universal Health Coverage in the Western Pacific Region

This article provides an overview of health financing reforms across countries in the Western Pacific Region as progress is made toward universal health coverage (UHC). Moving toward UHC requires a strong health system with sustainable financing, which countries strive to achieve through various approaches appropriate to their country contexts. Great efforts have been made by financing reforms through resource mobilization, risk pooling, resource allocation, and strategic purchasing. Overall governance of health financing systems has improved within the context of service delivery and budget reforms. But there are still challenges and ongoing needs to continue expanding health financing mechanisms equitably and efficiently, improving stewardship and accountability, strengthening the transition to domestic financing, and enabling evidence-informed priority setting and benefits design processes. Asian countries are rapidly developing and moving to more prepaid financing mechanisms with government subsidies to reduce relatively high out-of-pocket expenses, while facing implementation challenges in the governance and expansion of social health insurance. The Pacific island countries, on the other hand, face stagnating economic growth and rely on government financing, with some countries receiving significant external funding, making it important to have strong stewardship and public financing systems in place. The way forward calls for continuing to strengthen the evidence generation and monitoring function to assess country progress, reorienting primary health care as the foundation of the health sector to ensure that continuity of care is affordable and accountable, and leveraging the private sector to contribute to an equitable and efficient health system.

ЗАРУБІЖНИЙ ДОСВІД ФІНАНСУВАННЯ СИСТЕМ ОХОРОНИ ЗДОРОВ'Я

The article is devoted to the study of foreign experience of health systems' financial support in different countries. The results of its comparative analysis are presented. The main features of the fundraising and financing in the health sector are emphasized. As a result of the comparison, it is proved that there is no one-size-fits-all model. Each country has to take into account the needs and opportunities for social development while building a system of economic relations. It is shown that in 2017 expenditures of Ukrainian consolidated budget for health care 3,4% of gross domestic product. Charitable funds and humanitarian aid providers were also engaged in health system financing. However, official funding coexists with shadow or informal out-of-pocket payments for healthcare services. It is established that the amount of healthcare financing in Ukraine is close to the European one, but the constitutional principle of equal access to health care for different segments of the population is violated. As a solution, we offer to use the experience of the developed countries with health systems recognized as successful. After all, the accumulated experience of different countries indicates the dependence between the effectiveness of the health care system and its ability to use resources rationally. An innovative model of health financing, providing the combined financial support, is offered and developed. It is concluded that in today's society there are four models of health financing. These are the consumer preference model (out-of-pocket health financing system), the Bismarck model (socially oriented health financing system), the Beveridge model (governmental health financing system) and the Semashko model (state budget with tight centralization of industry management). Each of the models analyzed has its advantages and disadvantages. Choosing a health financing model is a strategically important task for every country, which have to build a system of economic relations that takes into account objective needs and opportunities, and is aware of the ever-increasing economic and social value of a healthy society.

Healthcare in selected Islamic countries: a study on the composition of health care expenditure

1. Alami, R. (2017). Health financing systems, health equity and universal health coverage in Arab countries. Development and Change, vol. 48, iss. 1, pp. 146–179. Google Scholar

Public Health aspects of Cesarean section including overuse and underuse of the procedure

Caesarean section (CS) is lifesaving medical procedure that is able to avert both maternal and neonatal mortality. However, across the globe an estimated 3.2 million necessary CSs do not happen in low income countries and an estimate of 6.2 million unnecessary CSs happen in middle and high income countries. The overuse and underuse of this procedure driven by both the supply-side (such as resources within the health system, healthcare policy and strategies, health financing systems and perceptions of the healthcare professional) and demand-side (such as socio-economic status, population preference and perceptions and trust in health system) determinants. There are stark inequities in CS rates between and within regions and countries. Many regions across the globe (Eastern Asia, Northern Europe, Central America, Southern America, Northern America and Oceania) have over double recommended optimal rates, whereas several African regions (Eastern, Middle and Western) have dangerously low rates. Both of these have detrimental impacts on maternal and neonatal outcomes. There is a need now for health policy and decision makers at both national and facility level to try and optimize the CS rates through facilitating strategies that promote positive human relations and encourage standardized evidence based care.

Assessing Equity in Bulgarian Health System

The aim of the study is to assess the equity in Bulgarian health system based on a set of interrelated indicators. The most common equity indicators used for health system performance assessment are explored, and a set of several reliable and available indicators is constructed. Indicators related to health status and health outcomes, access to health services, health system financing and financial protection of the population and quality of health services are selected. The selected indicators are analysed by separate population groups, and the results of the analysis and assessment show that the equity in the health system in Bulgaria is disturbed and severe inequalities between different socio-economic groups are identified.

Espacio fiscal para el financiamiento sostenible de los sistemas de salud y la salud universal

Espacio fiscal para el financiamiento sostenible de los sistemas de salud y la salud universal

The Impact of Community Based Health Insurance Schemes on Out-of-Pocket Healthcare Spending: Evidence from Rwanda

Achieving universal health coverage, including financial risk protection and access to quality essential health-care services, is one of the main Sustainable Development Goals. In low-income countries, innovative and affordable health financing systems are key to realize these goals. This paper assesses the impacts of Community-Based Health Insurance Scheme in Rwanda on health-related financial risks using a nationally representative household survey data collected over a ten-year period. We find that the scheme significantly reduce annual per capita out-of-pocket spending by about 3,600 Rwandan Franc (about US$12) or about 83 percent of average per capita healthcare expenditure compared to the baseline level in 2000.The impacts however favor the rich as compared to the poor. The program also reduces the incidence of catastrophic healthcare spending significantly.

The Impact of Community Based Health Insurance Schemes on Out-of-Pocket Healthcare Spending: Evidence from Rwanda

Achieving universal health coverage, including financial risk protection and access to quality essential health-care services, is one of the main Sustainable Development Goals. In low-income countries, innovative and affordable health financing systems are key to realize these goals. This paper assesses the impacts of Community-Based Health Insurance Scheme in Rwanda on health-related financial risks using a nationally representative household survey data collected over a ten-year period. We find that the scheme significantly reduce annual per capita out-of-pocket spending by about 3,600 Rwandan Franc (about US$12) or about 83 percent of average per capita healthcare expenditure compared to the baseline level in 2000.The impacts however favor the rich as compared to the poor. The program also reduces the incidence of catastrophic healthcare spending significantly.

A situational analysis of eye care services in Swaziland.

Compared to other African countries, Swaziland performs the worst in terms of providing eye health care services. A priority goal of the World Health Organization (WHO) is to alleviate childhood blindness, particularly in low-income countries such as Swaziland, where many people live in poverty, which is a contributor to poor health outcomes. A mixed method approach that entailed a document review, key informant interviews and clinical facility assessment questionnaires was used. Hospitals and mission clinics offering ophthalmic services were identified through the website of the Ministry of Health and verified during key informant interviews. A saturated sampling procedure was applied due to the few facilities that offer eye care services. Six framework components from the WHO for analysing health systems were utilised in an eye health care service context: leadership and governance, eye health services, eye health workforce, eye health financing systems, eye health medical supplies and technologies, and eye health information systems. Poor management, lack of accountability, poor monitoring and evaluation mechanisms, weak coordination and ineffective private-public sector regulations were identified as factors that lead to poor eye care in the country. The optometrists indicated that refractive services are the most rendered ophthalmic services. The exodus of healthcare practitioners has contributed to the downfall of the public health sector in the country. Five government eye care facilities, 3 government hospitals, 1 non-governmental organization (NGO) and a church mission clinic were included in this analysis. The eye services distribution favors the more affluent areas, particularly the more urban Hhohho Region, which is also where most of the eye health professionals are located. No campaigns have been conducted to prevent childhood blinding diseases or create awareness about getting children’s eyes tested for refractive correction. The burden of eye diseases among children in Swaziland remains unknown. More eye health care personnel and equipped facilities are needed throughout the country, and the eye health care program needs to be adopted.

The Community Perception Toward Health Quality Service Provided in Malaysia

The purpose of this research to find out about community perceptions toward health quality services provided by the Malaysia government. The type of research was used descriptive qualitative with data collection techniques in the form of observation, interviews, and documentation. The type of data in the form of primary and secondary data obtained from interviews with the public about the perception of health quality services provided by the Malaysia government. The results of the research obtained the data that community perceptions of health quality services provided by the Malaysia government to indigenous people with the migrant population were the same, the difference was that the financing of treatment for migrants was slightly more expensive than the indigenous population. Both in the royal hospital and in private hospitals. The Malaysian government sets Universal Coverage, that was, all citizens were guaranteed health services received by paying only 1 RM (Malaysian Ringgit) for treatment with a general practitioner and 5 RM for treatment with a specialist. However, severe illnesses were not included in this health financing system because it was expensive. In medicine must be ensured complete self-document so that treatment can run well.

Female Genital Fistula Repair Performance of Ad-din Hospitals 2013-2018

Aims: The aim of this paper is to document the female genital fistula repair services at Ad-din hospitals and to describe the etiology of fistula cases and care outcomes.
 Methods: Data from fistula services provided by Ad-din Hospitals in Dhaka, Khulna and Jashore were regularly captured using an aggregated DHIS2 established by the Fistula Care Plus project since December 2013. In January 2017, the FC+ project introduced a Safe Surgery Tool Kit (SST) to capture and analyze individual client data.
 Results: During the period of data collection, the Ad-din Hospitals have provided repair surgery to 259 clients including 134 female genital fistula cases, and 95 cases of complete perineal tear. Out of the fistula cases, 25% were iatrogenic. There is a trend of increasing iatrogenic fistula over this period. Over the data collection period, the closed and dry rate among fistula cases was 80%.
 Conclusions: Ad-din hospitals are a major provider of fistula surgery to women suffering from fistula in Bangladesh. Ad-din institutions are linked with social financing and community health system. Ad-din community networks made significant contribution in case identification at field level, case referral and community based rehabilitation of fistula cases.

Awareness and Willingness to Pay for Community Based Health Insurance Scheme in North-Western Nigeria

There is a need for the communities to develop their health financing system, most especially those that were not covered by the National Health Insurance Scheme (NHIS). This will give the people an opportunity to finance their medical care which in turn would alleviate financial burden at the point of treatment. Therefore, this study is aimed to determine the level of awareness for Community Based Health Insurance Scheme (CBHIS) among communities and to measure the degree of willingness to pay for the scheme in Katsina, North-Western Nigeria. Semi structured interviewer-assisted questionnaires were used to collect information from the respondents. Statistical analyses were performed using SPSS version 20.0. The results indicates that majority of the respondents attained tertiary level of education (68.3%) and 81.1% were employed. About 74.2% were earning more than the Nigerian minimum wage N18, 000 (≈$59). About 52.2% of the respondents were aware of the CBHIS. And 81% were willing to pay for premium while 62.2% will pay between N 1, 000 – 5, 000 (≈$3.3- $16.4). There was strong significant relationship between monthly income and knowledge of CBHIS (p = < 0.0001). However, gender and educational level were not significantly associated with the knowledge of CBHIS. Awareness about CBHIS was not sufficiently adequate but a significant number of the respondents were willing to pay for CBHIS after learning about the scheme. Factors such as level of education and income levels were found to have positive effect on willingness to pay.Bangladesh Journal of Medical Education Vol.9(2) 2018: 19-23

Assessing determinants of health care prepayment in China: Economic growth or government willingness? New evidence from the continuous wavelet analysis.

Significant prepayment of health care is a crucial factor to ensure that all individuals have access to effective health services at affordable prices. The research questions we address here are as follows: What role does economic growth play in changing the level of health care prepayment? Does government's willingness to spend more on health mean higher prepayment rates in the health financing system? What are their dynamic relationships? These questions are addressed in China over the 1978 to 2014 period by employing the continuous wavelet analysis. We focus in particular on their correlations and lead-lag relationships across different frequency bands. Our findings clearly show that overall government willingness has a positive effect on health care prepayment level, while the impact of economic growth varies in the time-frequency domain. This variation could be demonstrated in 1980 to 1998, when the positive correlation between economic growth and health care prepayment level in the short term turned negative in the medium and long term, which indicated that China could not achieve mutual development of economic growth and social welfare within the market-oriented health system. Notably, the time-varying analysis indicates that China's new round of medical system reform since 2006 plays an important role in changing the correlations and lead-lag relationships. In particular, health care prepayment tended to lead government willingness during the 2006 to 2012 period since the increase of health subsidies and expenditures strengthened government responsibility over the health sector, and there existed a persistent mutual stimulation between economic growth and health care prepayment level across all frequency bands along with the reform.

Effects of private and public health expenditure on health outcomes among countries with different health care systems: 2000 and 2014.

Background: In the recent decades, most studies have paid more attention to community expenditures in health sector and health outcomes. This study provides econometric evidence linking countries’ health expenditures to 3 health outcomes: (1) infant mortality, (2) under 5 mortality and (3) life expectancy within 4 different health care systems. Methods: In this study, we used the econometric method to estimate the effect of health expenditure on health status. Panel data were collected and grouped for 25 countries according to the health care system over 15 years (2000-2015). The random effects model was selected over the fixed effects model based on the Hausman test to assess the effect of different factors on the 3 mentioned health outcomes. Results: A significant relationship was found between health expenditures and health indicators. The effect of private health expenditures on health outcomes in countries with mixed health financing system and traditional sickness fund insurance was higher than public expenditures. Also, after comparing the results between different health care systems, we found that the effect of health expenditure on the health outcome in countries with national health system (NHS) was more than other health care systems. Conclusion: To improve health status, health policymakers should focus on the factors that lie inside the health care system. Therefore, since private and public health expenditures have different effects on health outcomes in each health care system, countries should choose an optimal combination of private and public health expenditures.

Health and Social Care influences on Long Hospital Length of Stay (LOS): A Critical Realist Study in a large metropolitan hospital

Introduction: Theory-driven design of integrated care interventions requires that research first be undertaken of the pre-existing system performance and factors that might be amendable to improvement. One indicator of health and social care system performance is hospital length of stay (LOS). LOS is one of the single most important indicators of hospital performance and health care delivery. LOS is an important measure of resource utilization with strong associations between LOS and hospital costs. The cost of long LOS has a significant impact on individual hospital budgets as well as being an overall burden on health systems. Consequently studies of LOS are essential for management and financing of hospitals and health systems. Patient pre-existing comorbidities, socioeconomic situation and base-line care-demands all have significant impacts on length of stay. Thus LOS not only evaluates bed management and the efficiency of hospital internal systems, but also the performance of pre-admission and post-discharge community-based health and social care systems. The study of long hospital LOS should therefore also examine the impact, and potential for modification, of complex health and social care, service, policy and system factors. The aim of this study is to determine the underlying internal and external health and social care factors that impact on the phenomenon of long length of stay in a major metropolitan hospital. Theory/Methods: Critical realism will provide the methodological underpinning for this mixed method study. Critical realism seeks to understand the underlying mechanisms and structures that are generating the observed phenomenon. The study will use a concurrent triangulated design that will contribute to explanatory theory building and subsequent design of interventions. The quantitative study will use longitudinal administrative data from the study hospital and supporting health district electronic medical records. Study variables will include: LOS, diagnosis and procedures, patient demographics, and various referral and discharge parameters. Statistical analysis will use exploratory data analysis, regression and time-trend methods. The qualitative study will use critical realist interview methods, purposeful selection of key staff and patients, and realist grounded theory approaches to analysis and development of realist theoretical propositions. Results: Quantitative data collection has commenced. Quantitative analysis will be used to concurrently to inform the qualitative interview questions. Interviews are expected to commence in early February 2018. Preliminary findings will be presented. We will identify underlying structures and mechanisms contributing to long LOS and develop realist MCO theoretical propositions in the form mechanism (M), context (C), Outcome (O). Discussions: We will demonstrate the use of critical realist research methods to study health and social care factors impacting on hospital LOS. The findings will be used to develop realist theoretical propositions that can be used to design service, policy and system-wide interventions. Conclusions: We anticipate that we will demonstrate that system-wide health and social care factors impact on the phenomenon of long hospital LOS. We will be able to propose interventions that will include the development of integrated care approaches in both the health and social care sectors.

Policy Recommendations to Address Financial Toxicity Following Cancer in Low- and Middle-Income Countries: One Size Does Not Fit All

Background: Evidence to guide cancer policy-making is scarce in low- and middle-income countries (LMIC). Furthermore, most economic studies in cancer have been conducted from the provider's or payer's perspective. Aim: The ASEAN Costs in Oncology Study (ACTION) was conducted to provide the essential intelligence for national policymakers and official development assistance donors to construct economically sound national cancer control plans. Methods: In the ACTION study, 9513 newly diagnosed cancer patients from eight LMIC in southeast Asia were prospectively followed-up for adverse economic outcomes up to one year after diagnosis, through serial interviews and use of cost diaries. Results: Country-specific analysis of the ACTION Study data had revealed that just within a year of diagnosis, 1 in 2 Malaysian cancer survivors had reported spending more than 30% of their annual household income for cancer related expenditures (FC: financial catastrophe). Strikingly, Malaysia, albeit being a higher income nation, appeared to have fared worse than Thailand, where only 1 in 3 cancer survivors reported FC. Nonetheless, in contrast to finding of the regional study that medical payments (drugs, hospitalization, consultation), largely explained the incidence of FC following cancer, only half of the reported catastrophic expenditures in Malaysia were attributed to medical expenditures suggesting that nonmedical payments related to cancer (e.g., travel, accommodation, childcare) was an important contributor to adverse financial outcomes. Furthermore, marked institutional variations in levels of catastrophic expenditures were observed in Malaysia, even within the public healthcare system. Proportion of patients experiencing FC in the general government hospitals was only 33% compared with 65% in the public academic hospitals. Although late stage at cancer diagnosis largely explained the increased risk of adverse economic outcomes and death, patients from low-income households remained vulnerable even when diagnosed with earlier stages. Conclusion: The findings of the ACTION Study importantly highlight the need for LMIC to undertake their own studies examining the financial impact of cancer in the population, to take affirmative actions to reduce financial loss and premature deaths associated with cancer. From the Malaysian perspective, there appears to be an urgent need to improve social support for cancer in the country, be it through government-led programs such as disability insurance and short term credit or multisectoral collaboration with civil societies, private industries, and philanthropic organizations. Key policy changes should also include prioritization of programs which would allow early detection of cancer, re-examination of the national health financing system to ensure that public funds are channeled to those who need them the most, and addressing disparities in funding between public hospitals.