Universal Health Coverage Policy Research Articles

Fragmentation by design: Universal health coverage policies as governmentality in Senegal.

There is increasing international consensus that countries need to reduce health system fragmentation in order to achieve universal health coverage (UHC). Yet there is little agreement on what drives fragmentation, in particular the extent to which fragmentation has a political purpose. This study analyses a highly fragmented health financing system through a UHC policy that aims to remove user fees for people aged 60 and over in Senegal. 53 semi-structured interviews (SSIs) and focus group discussions with the target population were conducted in four regions in Senegal over a period of six months during 2012. A further 46 SSIs were conducted with key informants at the national level and in each of the four regions. By analysing explanations of the successes and failures of policies, an understanding of power relations in state institutions, communities and individuals is gained. The concept of governmentality is used to interpret the results. The interviewees' main concern was to implement or resist various techniques of control over the conduct of bureaucrats, health workers, patients and the wider population. These techniques included numeracy and calculation, referral letters, ID cards, data collection, new prudentialism, active citizenship and ethical self-formation through affinities of the community. The techniques sought to make two types of subjects; citizens subjects of rights and obligations; and autonomous subjects of choice and self-identity. A key implication is that in Senegal, and perhaps elsewhere, fragmentation of the health system plays a key role in the formation and control of subjects, in the name of "freedom". As such, fragmentation may be an inherent feature of UHC. Interventions that aim to reduce fragmentation based on evidence of its inefficiency, inequity and ineffectiveness in reducing poverty and ill health may be missing this point.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

BackgroundAccess to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.MethodsThe data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations.ResultsThe odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p < .001).ConclusionIn Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

Varying universal health coverage policy implementation states: exploring the process and lessons learned from a national health insurance pilot site

Background Worldwide efforts have increased to understand what works in policy implementation, for whom and under what circumstances (context) are health policies useful and effective. All countries are striving towards Universal Health Coverage (UHC). Reforms are being implemented to ensure no-one is left behind. Methods We draw on our experiences of tracking implementation of policies aimed at achieving UHC in a national health insurance (NHI) pilot district (universal coverage in Tanzania and South Africa). Policies aimed at achieving UHC were tracked from 2011-2015 to understand why there are varying UHC policy implementation states and outcomes among facilities in the same district? Results Lessons learned in the process include: i) to adopt or adapt policy is a process – actors at the front-line seem to engage with policy, carry out a policy-context audit, try to engage with superiors if there are discrepancies between policy and context and eventually take a decision to adopt or adapt policy; ii) local facility contexts matter and vary – decision to implement policy is influenced by the conditions on the ground, hence implementation states can vary from one facility to the other despite being in the same district; iii) implementation states range from full policy adoption and implementation, policy adaptation and partial implementation, delayed implementation to non-implementation; iv) a resource audit before policy is implemented could go a long way in reducing policy-practice gaps; and v) Policy implementation states are dynamic subject to change – for example, when equipment breaks down and is not replaced immediately. Conclusion There seems to be inherent respect among implementing actors, for the department of health and people above them. They are however concerned with the fact that they are removed from the ground, could have lost touch with realities on the ground, hence the policy directives sent from the top, are often not congruent with ground conditions. Actors revealed how they engage with the policy, assess what they are being asked to do and compare that with the existing resources. To adopt or adapt policy in a UHC context: there seems to be a series of steps actors take.

Erratum: Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy

Cambodia's healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012-14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of -0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.

Knowledge, perception, and attitudes of Universal Health Coverage policies among Alfaisal University students in Saudi Arabia.

BACKGROUND:Saudi Arabia aims to achieve Universal Health Coverage (UHC) by a combination of free public healthcare and mandatory cooperative health insurance. To ensure the effectiveness of UHC policies, every individual should have a strong knowledge of their health-care rights and the system that guarantees it.OBJECTIVES:The aim of this study is to measure the knowledge of Alfaisal students and record their perceptions and attitudes about Saudi Arabia's basic health-care coverage structure and UHC policies.MATERIALS AND METHODS:A cross-sectional survey was developed with 22 items measuring knowledge and 7 items evaluating perception and attitudes and distributed through E-mail with a consecutive sampling method at Alfaisal University to achieve the required calculated sample size for March–April of 2020. The accumulated data were organized, tabulated, and statistically analyzed using SPSS software. Comparison between two groups and more was made using the Chi-square test.RESULTS:Students’ self-reported knowledge on the three main knowledge questions ranged from 30.6% to 57.7%, with medical students admitting to similar or worse knowledge compared to their colleagues from other colleges. About 57.3% of our respondents believe the Saudi system provides effective and sufficient healthcare to all, but only 42.7% believe that the system provides financial protection to all.CONCLUSION:The study showed a low level of knowledge about Saudi Arabia's UHC policies among Alfaisal students, especially among medical students, with a generally positive perception and attitudes toward them, although with some serious misconceptions that should be addressed.

Institutionalizing Evidence-Informed Priority Setting for Universal Health Coverage: Lessons From Indonesia.

Planning and administering Universal Health Coverage (UHC) policies involve complex and critical decisions, especially in resource-scarce and densely populated settings such as Indonesia. Increasing investments alone do not ensure success and sustainability of UHC, and defining priorities is imperative. In 2013, Indonesia formally embarked on its journey of institutionalizing priority setting with technical assistance from the International Decision Support Initiative (iDSI), which is a global network of organizations in pursuit of evidence-based priority setting. This article provides a perspective for countries in pursuit of institutionalization of evidence-informed policy setting systems and sheds light on the factors conducive to the development of health technology assessment (HTA). It explores the main actors and the context of priority setting in Indonesia and articulates strategies and key outcomes and impact using the theory of change (ToC).

How is equity approached in universal health coverage? An analysis of global and country policy documents in Benin and Senegal

BackgroundEquity seems inherent to the pursuance of universal health coverage (UHC), but it is not a natural consequence of it. We explore how the multidimensional concept of equity has been approached in key global UHC policy documents, as well as in country-level UHC policies.MethodsWe analysed a purposeful sample of UHC reports and policy documents both at global level and in two Western African countries (Benin and Senegal). We manually searched each document for its use and discussion of equity and related terms. The content was summarised and thematically analysed, in order to comprehend how these concepts were understood in the documents. We distinguished between the level at which inequity takes place and the origin or types of inequities.ResultsMost of the documents analysed do not define equity in the first place, and speak about “health inequities” in the broad sense, without mentioning the dimension or type of inequity considered. Some dimensions of equity are ambiguous – especially coverage and financing. Many documents assimilate equity to an overall objective or guiding principle closely associated to UHC. The concept of equity is also often linked to other concepts and values (social justice, inclusion, solidarity, human rights – but also to efficiency and sustainability). Regarding the levels of equity most often considered, access (availability, coverage, provision) is the most often quoted dimension, followed by financial protection. Regarding the types of equity considered, those most referred to are socio-economic, geographic, and gender-based disparities. In Benin and Senegal, geographic inequities are mostly pinpointed by UHC policy documents, but concrete interventions mostly target the poor. Overall, the UHC policy of both countries are quite similar in terms of their approach to equity.ConclusionsWhile equity is widely referred to in global and country-specific UHC policy documents, its multiple dimensions results in a rather rhetorical utilisation of the concept. Whereas equity covers various levels and types, many global UHC documents fail to define it properly and to comprehend the breadth of the concept. Consequently, perhaps, country-specific policy documents also use equity as a rhetoric principle, without sufficient consideration for concrete ways for implementation.

Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy.

Cambodia’s healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012–14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of −0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.

Open Source HMIS Enabled Evaluation of Financial Burden of Disease and Patient Coverage in Three University Hospitals in Great Lakes Africa.

Since the eighties, case mix evaluation methods based on diagnosis-related groups (DRG) were gradually introduced in developed countries. These methods of assessing the costs of diseases to measure the productivity of the hospital have been introduced in management softwares that are not accessible to low-income countries. In this study, the authors applied these methods to an open source hospital management information system (HMIS) implemented in three university hospitals in Great Lakes Africa. A comparative study of the financial burden of five major diseases, monitored as part of a universal health coverage (UHC) analysis, was carried out. The level of coverage of patients in the hospitals was evaluated and the impact of UHC policies demonstrated. Although the financial protection of patients treated in the three hospitals had improved, HIV and tuberculosis treatments that ought to be free, remained a considerable financial burden for the patient.

Does Universal Health Coverage at Early Age Reduced Medical Needs at Later Age? Evidence from Vietnam

This study examines the impacts of exposure to a universal health coverage policy at early age on utilization of health services at later age. Our empirical strategy identifies the effects of the program by exploiting cross-cohort variation in exposure, generated by the age eligibility of the policy, and cross-province variation in the policy's intensity, generated by differences in provincial geographic characteristics. We find that exposure to the program at early age reduces probability of visit for treatment, mainly hospitalization, but does not affect preventive care and outpatient treatment at later age. Our results are robust to various controls for cohort-varying factors and ongoing poverty-reduction policies. We document larger impacts among individuals from low-income and low-education households, and those living in areas with higher risks from natural disasters. These results imply that the program benefited the most vulnerable population. Exploring potential mechanisms, we find no substantial change in household's financial well-being and household's labor market decisions associated with exposure at early age. Combining with results from previous studies, these findings suggest that the main mechanism is through increases in utilization at early age.

The integration of the global HIV/AIDS response into universal health coverage: desirable, perhaps possible, but far from easy

BackgroundThe international community’s health focus is shifting from achieving disease-specific targets towards aiming for universal health coverage. Integrating the global HIV/AIDS response into universal health coverage may be inevitable to secure its achievements in the long run, and for expanding these achievements beyond addressing a single disease. However, this integration comes at a time when international financial support for the global HIV/AIDS response is declining, while political support for universal health coverage is not translated into financial support. To assess the risks, challenges and opportunities of the integration of the global HIV/AIDS response into national universal health coverage plans, we carried out assessments in Indonesia, Kenya, Uganda and Ukraine, based on key informant interviews with civil society, policy-makers and development partners, as well as on a review of grey and academic literature.ResultsIn the absence of international financial support, governments are turning towards national health insurance schemes to finance universal health coverage, making access to healthcare contingent on regular financial contributions. It is not clear how AIDS treatment will be fit in. While the global HIV/AIDS response accords special attention to exclusion due to sexual orientation and gender identity, sex work or drug use, efforts to achieve universal health coverage focus on exclusion due to poverty, gender and geographical inequalities. Policies aiming for universal health coverage try to include private healthcare providers in the health system, which could create a sustainable framework for civil society organisations providing HIV/AIDS-related services. While the global HIV/AIDS response insisted on the inclusion of civil society in decision-making policies, that is not (yet) the case for policies aiming for universal health coverage.DiscussionWhile there are many obstacles to successful integration of the global HIV/AIDS response into universal health coverage policies, integration seems inevitable and is happening. Successful integration will require expanding the principle of ‘shared responsibility’ which emerged with the global HIV/AIDS response to universal health coverage, rather than relying solely on domestic efforts for universal health coverage. The preference for national health insurance as the best way to achieve universal health coverage should be reconsidered. An alliance between HIV/AIDS advocates and proponents of universal health coverage requires mutual condemnation of discrimination based on sexual orientation and gender identity, sex work or drug use, as well as addressing of exclusion based on poverty and other factors. The fulfilment of the promise to include civil society in decision-making processes about universal health coverage is long overdue.

Universal health coverage and primary care, Thailand.

Thailand’s policy on universal health coverage (UHC) has made good progress since its inception in 2002. Every Thai citizen is now entitled to essential preventive, curative and palliative health services at all life stages. Like its counterparts elsewhere, however, the policy faces challenges. A predominantly tax-financed system in a nation with a high proportion of people living in poverty will always strive to contain rising costs. Disparities exist among the different health insurance schemes that provide coverage for Thai citizens. National health expenditure is heavily borne by the government, primarily to reduce financial barriers to access for the poor. The population is ageing and the disease profiles of the population are changing alongside the modernization of Thai people’s lifestyles. Thailand is now aiming to enhance and sustain its UHC policy. We examine the merits of different policy options and aim to identify the most promising and feasible way to enhance and sustain UHC. We argue that developing the existing primary care system in Thailand has the greatest potential to provide more self-sustaining, efficient, equitable and effective UHC. Primary care needs to move from its traditional role of providing basic disease-based care, to being the first point of contact in an integrated, coordinated, community-oriented and person-focused care system, for which the national health budget should be prioritized.

Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions.

Catastrophic health expenditure forces 5.7 million Bangladeshis into poverty. Inequity is present in most of health indicators across social, economic, and demographic parameters. This study explores the existing health policy environment and current activities to further the progress towards Universal Health Coverage (UHC) and the challenges faced in these endeavors. This qualitative study involved document reviews (n=22) and key informant interviews (KII, n=15). Thematic analysis of texts (themes: activities around UHC, implementation barriers, suggestions) was done using the manual coding technique. We found that Bangladesh has a comprehensive set of policies for UHC, e.g., a health-financing strategy and staged recommendations for pooling of funds to create a national health insurance scheme and expand financial protection for health. Progress has been made in a number of areas including the roll out of the essential package of health services for all, expansion of access to primary health care services (support by donors), and the piloting of health insurance which has been piloted in three sub districts. Political commitment for these areas is strong. However, there are barriers pertaining to the larger policy level which includes a rigid public financing structure dating from the colonial era. While others pertain to the health sector’s implementation shortfalls including issues of human resources, political interference, monitoring, and supervision, most key informants discussed demand-side barriers too, such as sociocultural disinclination, historical mistrust, and lack of empowerment. To overcome these, several policies have been recommended, e.g., redesigning the public finance structure, improving governance and regulatory mechanism, specifying code of conduct for service providers, introducing health-financing reform, and collaborating with different sectors. To address the implementation barriers, recommendations include improving service quality, strengthening overall health systems, improving health service management, and improving monitoring and supervision. Addressing demand-side barriers, such as patient education and community empowerment, is also needed. Research and advocacy are required to address crosscutting barriers such as the lack of common understanding of UHC.

The place of learning in a universal health coverage health policy process: the case of the RAMED policy in Morocco

BackgroundTo progress towards universal health coverage (UHC), each country will have to develop its systemic learning capacity. This study aims at documenting how, across time, learning can feed into a UHC policy process, and how the latter can itself strengthen (or not) the learning capacity of the health system. It specifically focuses on the development of a major health financing policy aligned with the UHC goal in Morocco, the RAMED, a health financing scheme covering hospital costs for the poorest segment of the population.MethodsWe conducted a retrospective analysis of the RAMED policy for the period between 1997 and 2018, along with a case study design. For the data collection and analysis, we developed a framework combining Garvin’s learning organisation framework and the heuristic health policy analysis framework. We gathered data from key informants and document reviews.ResultsThe study confirmed the importance of learning during the different stages of the RAMED policy process. There is evidence of a leadership encouraging learning, the introduction and adoption of knowledge management processes, and the start of a transformation of the administrative culture. Yet, our study also showed some major shortcomings, especially the lack of structure of the learning, and insufficient effort to systemise and sustain a transformation of practices within the health administration. Our study also confirms that the learning changes in nature across the different stages of the policy process.ConclusionThe policy decisions and the implementation strategy create a learning dynamic, though not structured in all cases. Despite the positive interaction between learning and the RAMED policy, the opportunity to push forward a more structural transformation towards a learning system has not been fully seized. Hierarchical logics still largely prevail in the Moroccan health administration. The impact of future health policies for both the target beneficiaries and the health system will be bigger if their design integrates purposeful and structured actions in favour of organisational learning. This recommendation probably applies beyond Morocco.

Use of medicine pricing and reimbursement policies for universal health coverage in Indonesia.

ObjectivesThis study aimed to define the problems of the current use of the e-Catalogue and the national formulary (NF)—two elements of medicine pricing and reimbursement policies in Indonesia for achieving universal health coverage (UHC)—by examining the knowledge and attitudes of stakeholders. Specifically, to investigate (1) the perceived challenges involved in the further implementation of the e-Catalogue and the NF, (2) reasons of prescribing medicines not listed in the NF, and (3) possible improvements in the acceptance and use of the e-Catalogue and the NF.MethodsSemi-structured interviews were conducted with stakeholders (policymakers, healthcare providers, a pharmaceutical industry representative, and experienced patients) to collect the qualitative data. The data was analysed using directed content analysis, following the guidelines of the COnsolidated criteria for REporting Qualitative studies (COREQ) in reporting the findings.ResultsInterestingly, 20 of 45 participants decided to withdraw from the interview due to their lack of knowledge of the e-Catalogue and the NF. All 25 stakeholders who fully participated in this research were in favor of the e-Catalogue and the NF. However, interviewees identified a range of challenges. A major challenge was the lack of harmonization between the lists of medicines in the e-Catalogue and the NF. Several system and personal reasons for prescribing medicines not listed in the NF were identified. Important reasons were a lack of incentives for physicians as well as a lack of transparent and evidence-based methods of selection for the medicines to be listed in the NF.ConclusionsThe e-Catalogue and the NF have not been fully utilized for achieving UHC in Indonesia. Some possible improvements suggested were harmonization of medicines listed in the e-Catalogue and the NF, restructuring incentive programs for prescribing NF medicines, and increasing the transparency and evidence-based approach for selection of medicines listed in the e-Catalogue and the NF.

Analysis of strategies to attract and retain rural health workers in Cambodia, China, and Vietnam and context influencing their outcomes

BackgroundMany Asia-Pacific countries are experiencing rapid changes in socio-economic and health system development. This study aims to describe the strategies supporting rural health worker attraction and retention in Cambodia, China, and Vietnam and explore the context influencing their outcomes.MethodsThis paper is a policy analysis based on key informant interviews with stakeholders about a rural province of Cambodia, China, and Vietnam, coupled with a broad review of the literature.ResultsCambodia, China, and Vietnam have implemented medical education, provided financial incentives, and provided personal and professional support to attract and retain rural health workers. More socio-economic development was related to a wider range of interventions and their scope. The health system context influenced the outcomes. Increased autonomy of public hospitals attracted more health workers from rural primary health facilities in China and Vietnam. Health financing policies for universal health coverage in China and Vietnam have increased the utilization of health services. Subsidies for poor people to access health services in Cambodia have provided financial incentives to retain rural health workers. However, the dismantling of the referral system in China and Vietnam has resulted in a high rate of health workers moving from primary health facilities to higher-level hospitals while clear definition of primary healthcare package in Cambodia guided its planning of primary health workforce. The prosperous private health sector in Cambodia and Vietnam attracted more health workers from rural primary health facilities, impeded implementation and determined effectiveness of financial incentives.ConclusionsSocio-economic and health system reforms including health financing, public hospital autonomy, abolition of referral system and prosperous private sector have both positive and negative impacts on the design, implementation, and effectiveness of interventions to attract and retain rural health workers. Interventions to attract and retain health workers in rural and remote areas need to be considered within overall health system reform.

Universal Health Coverage Policy and Practice Framework in India: A Review

Universal health coverage has recently been listed on top of the worldwide health agenda backed by multilateral and donor organizations. Unless and until the concept is clearly understood, “universal coverage” (or universal health coverage i.e. UHC) can be used to define practically any health financing reform or scheme. All countries are concerned to provide better equity in the use of health services, service quality and financial protection for their people. Hence, the achievement of UHC is relevant to every country. It is the duty of ever nation to provide free and universal access to quality health-care services to its citizens irrespective of causing any economic burden on them. India as a country continues to be among the countries of the world that have a high burden of diseases. In a developing country like India, 39 million people are being impoverished because of Out-of-pocket health expenditures each year and a major share of these expenditures are contributed by hospitalization. Out-of-pocket expenditures are huge even after the financial protection given by a number of health insurance programs. These pose challenges along with a global discourse to achieve universal health coverage (UHC) – increasing access to quality healthcare services at affordable cost, by all people; and in times of fast economic growth in India. The Indian people deserve and demand an efficient and equitable health system which can provide UHC. UHC in India could only be achieved by increasing spending on health sector, if the primary health care facilities receive a minimum of 70% of health spending, public spending on the purchase of medicines increase from 0.1% to 0.5% GDP, and all the health facilities in India are upgraded to match the Indian Public Health Standards. This paper unfolds all the aspects related to policy and practice of achieving Universal Health Coverage in India.

An evaluation of health systems equity in Indonesia: study protocol

BackgroundMany low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms.MethodsUsing a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken.DiscussionAs countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach – are not excluded. The results of this study will not only help track Indonesia’s progress to universalism but also reveal what the UHC-reforms mean to the poor.

How much does community-based targeting of the ultra-poor in the health sector cost? Novel evidence from Burkina Faso

BackgroundTargeting efforts aimed at increasing access to care for the poorest by reducing to a minimum or completely eliminating payments at point of use are increasingly being adopted across low and middle income countries, within the framework of Universal Health Coverage policies. No evidence, however, is available on the real cost of designing and implementing these efforts. Our study aimed to fill this gap in knowledge through the systematic assessment of both the financial and economic costs associated with designing and implementing a pro-poor community-based targeting intervention across eight districts in rural Burkina Faso.MethodsWe conducted a partial retrospective economic evaluation (i.e. estimating costs, but not benefits) associated with the abovementioned targeting intervention. We adopted a health system perspective, including all costs incurred by the government and its development partners as well as costs incurred by the community when working as volunteers on behalf of government structures. To trace both financial and economic costs, we combined Activity-Based Costing with Resource Consumption Accounting. To this purpose, we consulted and extracted information from all relevant design/implementation documents and conducted additional key informant structured interviews to assess the resource consumption that was not valued in the documents.ResultsFor the entire community-based targeting intervention, we estimated a financial cost of USD 587,510 and an economic cost of USD 1,213,447. The difference was driven primarily by the value of the time contributed by the community. Communities carried the main economic burden. With a total of 102,609 ultra-poor identified, the financial cost and the economic cost per ultra-poor person were respectively USD 5,73 and USD 11,83.ConclusionThe study is first of its kind to accurately trace the financial and economic costs of a community-based targeting intervention aiming to identify the ultra-poor. The financial costs amounted to USD 5,73 and the economic costs to USD 11,83 per ultra-poor person identified. The financial costs of almost USD 6 represents 21% of the per capita government expenditure on health.

Patients\u2019 perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

BackgroundA universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large-scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage.MethodsA qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach.ResultsTwenty-nine participants (mean age, 56.76 ± 16.65 years) participated in five FGDs and one IDI. The emerging themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare services, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common.ConclusionsThe factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are positive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients.