Ensuring that data collected through national health information systems are of sufficient quality for meaningful interpretation is a challenge in many resource-limited countries. An assessment was conducted to identify strengths and weaknesses of the health data management and reporting systems that capture and transfer routine monitoring and evaluation (M&E) data in Botswana.
This was a descriptive, qualitative assessment. In-depth interviews were conducted at the national (n = 27), district (n = 31), and facility/community (n = 71) levels to assess i) M&E structures, functions, and capabilities; ii) indicator definitions and reporting guidelines; iii) data collection forms and tools; iv) data management processes; and v) links with the national reporting system. A framework analysis was conducted using ATLAS.ti v6.1.
Health programs generally had standardized data collection and reporting tools and defined personnel for M&E responsibilities at the national and district levels. Best practices unique to individual health programs were identified and included a variety of relatively low-resource initiatives such as attention to staffing patterns, making health data more accessible for evidence-based decision-making, developing a single source of information related to indicator definitions, data collection tools, and management processes, and utilization of supportive supervision visits to districts and facilities. Weakness included limited ownership of M&E-related duties within facilities, a lack of tertiary training programs to build M&E skills, few standard practices related to confidentiality and document storage, limited dissemination of indicator definitions, and limited functionality of electronic data management systems.
Addressing fundamental M&E system issues, further standardization of M&E practices, and increasing health services management responsiveness to time-sensitive information are critical to sustain progress related to health service delivery in Botswana. In addition to high-resource initiatives, such as investments in electronic medical record systems and tertiary training programs, there are a variety of low-resource initiatives, such as regular data quality checks, that can strengthen national health information systems. Applying best practices that are effective within one health program to data management and reporting systems of other programs is a practical approach for strengthening health informatics and improving data quality.
Data quality; Health information system; Monitoring and evaluation
Networks are increasingly regarded as essential in health research aimed at influencing practice and policies. Less research has focused on the role networking can play in researchers’ careers and its broader impacts on capacity strengthening in health research. We used the Canadian Coalition for Global Health Research (CCGHR) annual Summer Institute for New Global Health Researchers (SIs) as an opportunity to explore networking among new global health researchers.
A mixed-methods exploratory study was conducted among SI alumni and facilitators who had participated in at least one SI between 2004 and 2010. Alumni and facilitators completed an online short questionnaire, and a subset participated in an in-depth interview. Thematic analysis of the qualitative data was triangulated with quantitative results and CCGHR reports on SIs. Synthesis occurred through the development of a process model relevant to networking through the SIs.
Through networking at the SIs, participants experienced decreased isolation and strengthened working relationships. Participants accessed new knowledge, opportunities, and resources through networking during the SI. Post-SI, participants reported ongoing contact and collaboration, although most participants desired more opportunities for interaction. They made suggestions for structural supports to networking among new global health researchers.
Networking at the SI contributed positively to opportunities for individuals, and contributed to the formation of a network of global health researchers. Intentional inclusion of networking in health research capacity strengthening initiatives, with supportive resources and infrastructure could create dynamic, sustainable networks accessible to global health researchers around the world.
Collaboration; Continuing education; Developing countries; Knowledge translation; Mixed methods; Networks
Bibliometric studies are increasingly being used for research assessment by involving the application of statistical methods to scientific publications to obtain the bibliographics for each country. The main objective of this study was to analyse the research productivity originating from 13 Middle Eastern Arab (MEA) countries with articles published in toxicology journals.
Data from January 1, 2003 till December 31, 2012 were searched for documents with specific words in the toxicology field as a “source title” in any one of the 13 MEA countries. Research productivity was evaluated based on a methodology developed and used in other bibliometric studies. Research productivity was adjusted to the national population and nominal gross domestic product (GDP) per capita.
Documents (n = 1,240) were retrieved from 73 international peer-reviewed toxicology journals. The h-index of the retrieved documents was 39. Of the 73 journal titles, 52 (69.9%) have their IF listed in the ISI Journal Citation Reports 2012; 198 documents (16.0%) were published in journals that had no official IF. After adjusting for economy and population power, Egypt (193.6), Palestine (18.1), Kingdom of Saudi Arabia (KSA) (13.0), and Jordan (11.5) had the highest research productivity. Countries with large economies, such as the Kuwait, United Arab Emirates (UAE), and Oman, tended to rank relatively low after adjustment of GDP. The total number of citations at the time of data analysis (August 4, 2013) was 10,991, with a median (interquartile range) of 4 (1–11). MEA collaborated more with countries in the MEA regions (16.7%), especially KSA, Egypt, and UAE, followed by Europe (14.4%), especially with the United Kingdom and Germany.
The present data show a promising rise and a good start for toxicology research activity in toxicology journals in the Arab world. Research output is low in some countries, which can be improved by investing in more international and national collaborative research projects in the field of toxicology.
Bibliometric; Impact factor; Middle Eastern Arab; Scopus; Toxicology
The key to universal coverage in tuberculosis (TB) management lies in community participation and empowerment of the population. Social infrastructure development generates social capital and addresses the crucial social determinants of TB, thereby improving program performance. Recently, there has been renewed interest in the concept of social infrastructure development for TB control in developing countries. This study aims to revive this concept and highlight the fact that documentation on ways to operationalize urban TB control is required from a holistic development perspective. Further, it explains how development of social infrastructure impacts health and development outcomes, especially with respect to TB in urban settings.
A wide range of published Government records pertaining to social development parameters and TB program surveillance, between 2001 and 2011 in Delhi, were studied. Social infrastructure development parameters like human development index along with other indicators reflecting patient profile and habitation in urban settings were selected as social determinants of TB. These include adult literacy rates, per capita income, net migration rates, percentage growth in slum population, and percentage of urban population living in one-room dwelling units. The impact of the Revised National Tuberculosis Control Program on TB incidence was assessed as an annual decline in new TB cases notified under the program. Univariate linear regression was employed to examine the interrelationship between social development parameters and TB program outcomes.
The decade saw a significant growth in most of the social development parameters in the State. TB program performance showed 46% increment in lives saved among all types of TB cases per 100,000 population. The 7% reduction in new TB case notifications from the year 2001 to 2011, translates to a logarithmic decline of 5.4 new TB cases per 100,000 population. Except per capita income, literacy, and net migration rates, other social determinants showed significant correlation with decline in new TB cases per 100,000 population.
Social infrastructure development leads to social capital generation which engenders positive growth in TB program outcomes. Strategies which promote social infrastructure development should find adequate weightage in the overall policy framework for urban TB control in developing countries.
Decline in new TB cases; Social capital; Social determinants; Social infrastructure; Tuberculosis; Universal coverage; Urban TB
Knowledge translation platforms (KTPs), which are partnerships between policymakers, stakeholders, and researchers, are being established in low- and middle-income countries (LMICs) to enhance evidence-informed health policymaking (EIHP). This study aims to gain a better understanding of the i) activities conducted by KTPs, ii) the way in which KTP leaders, policymakers, and stakeholders perceive these activities and their outputs, iii) facilitators that support KTP work and challenges, and the lessons learned for overcoming such challenges, and iv) factors that can help to ensure the sustainability of KTPs.
This paper triangulated qualitative data from: i) 17 semi-structured interviews with 47 key informants including KTP leaders, policymakers, and stakeholders from 10 KTPs; ii) document reviews, and iii) observation of deliberations at the International Forum on EIHP in LMICs held in Addis Ababa in August 2012. Purposive sampling was used and data were analyzed using thematic analysis.
Deliberative dialogues informed by evidence briefs were identified as the most commendable tools by interviewees for enhancing EIHP. KTPs reported that they have contributed to increased awareness of the importance of EIHP and strengthened relationships among policymakers, stakeholders, and researchers. Support from policymakers and international funders facilitated KTP activities, while the lack of skilled human resources to conduct EIHP activities impeded KTPs. Ensuring the sustainability of EIHP initiatives after the end of funding was a major challenge for KTPs. KTPs reported that institutionalization within the government has helped to retain human resources and secure funding, whereas KTPs hosted by universities highlighted the advantage of autonomy from political interests.
The establishment of KTPs is a promising development in supporting EIHP. Real-time lesson drawing from the experiences of KTPs can support improvements in the functioning of KTPs in the short term, while making the case for sustaining their work in the long term. Lessons learned can help to promote similar EIHP initiatives in other countries.
In 2006, the first edition of a monitoring tool for the performance of the Dutch health care system was released: the Dutch Health Care Performance Report (DHCPR). The Netherlands was among the first countries in the world developing such a comprehensive tool for reporting performance on quality, access, and affordability of health care. The tool contains 125 performance indicators; the choice for specific indicators resulted from a dialogue between researchers and policy makers. In the ‘policy cycle’, the DHCPR can rationally be placed between evaluation (accountability) and agenda-setting (for strategic decision making). In this paper, we reflect on important lessons learned after seven years of health care system performance assessment. These lessons entail the importance of a good conceptual framework for health system performance assessment, the importance of repeated measurement, the strength of combining multiple perspectives (e.g., patient, professional, objective, subjective) on the same issue, the importance of a central role for the patients’ perspective in performance assessment, how to deal with the absence of data in relevant domains, the value of international benchmarking and the continuous exchange between researchers and policy makers.
Health care; Health system performance assessment; Performance indicators
The World Health Report 2013 provides a major boost to the health research community and, in particular, to those who believe that health research will make its greatest impact on improving health when it is organised through a systems approach. The World Health Report 2013, Research for Universal Health Coverage, starts with three key messages. Firstly, that universal health coverage, with full access to high-quality services, needs research evidence if it is to be achieved; second, all nations should conduct and use research; and finally, the report states that systems are needed to develop national research agendas, to raise funds, to strengthen research capacity, and to make effective use of research findings. Each of these themes is elaborated in the report and supported by extensive references.
In this editorial, we first outline the key messages from the World Health Report 2013 and highlight the contributions made by papers from our journal, Health Research Policy and Systems. In addition, we discuss very recent papers that advance some issues even further. In particular, we consider new evidence both on how to achieve financial protection for those who use health services, and on whether healthcare professionals and organisations who engage in research provide an improved healthcare performance. Finally, we propose additional perspectives that add to the impressive body of evidence and analyses presented in the report. Specifically, we suggest that considering the needs of various stakeholders, as attempted in the UK, in parallel with analysing how to fulfil essential functions, should boost the prospects of successfully building and strengthening health research systems. This is important because research is vital for achieving universal health coverage, and consequently for improving the health of millions of people.
Health research capacity strengthening (RCS) projects are often complex and hard to evaluate. In order to inform health RCS evaluation efforts, we aimed to describe and compare key characteristics of existing health RCS evaluation frameworks: their process of development, purpose, target users, structure, content and coverage of important evaluation issues. A secondary objective was to explore what use had been made of the ESSENCE framework, which attempts to address one such issue: harmonising the evaluation requirements of different funders.
We identified and analysed health RCS evaluation frameworks published by seven funding agencies between 2004 and 2012, using a mixed methods approach involving structured qualitative analyses of documents, a stakeholder survey and consultations with key contacts in health RCS funding agencies.
The frameworks were intended for use predominantly by the organisations themselves, and most were oriented primarily towards funders’ internal organisational performance requirements. The frameworks made limited reference to theories that specifically concern RCS. Generic devices, such as logical frameworks, were typically used to document activities, outputs and outcomes, but with little emphasis on exploring underlying assumptions or contextual constraints. Usage of the ESSENCE framework appeared limited.
We believe that there is scope for improving frameworks through the incorporation of more accessible information about how to do evaluation in practice; greater involvement of stakeholders, following evaluation capacity building principles; greater emphasis on explaining underlying rationales of frameworks; and structuring frameworks so that they separate generic and project-specific aspects of health RCS evaluation. The third and fourth of these improvements might assist harmonisation.
Capacity strengthening; Evaluation; Frameworks; Health research
The present study focuses on the program “Medical Insurance for the Poor (MIP)” in Georgia. Under this program, the government purchased coverage from private insurance companies for vulnerable households identified through a means testing system, targeting up to 23% of the total population. The benefit package included outpatient and inpatient services with no co-payments, but had only limited outpatient drug benefits. This paper presents the results of the study on the impact of MIP on access to health services and financial protection of the MIP-targeted and general population.
With a holistic case study design, the study employed a range of quantitative and qualitative methods. The methods included document review and secondary analysis of the data obtained through the nationwide household health expenditure and utilisation surveys 2007–2010 using the difference-in-differences method.
The study findings showed that MIP had a positive impact in terms of reduced expenditure for inpatient services and total household health care costs, and there was a higher probability of receiving free outpatient benefits among the MIP-insured. However, MIP insurance had almost no effect on health services utilisation and the households’ expenditure on outpatient drugs, including for those with MIP insurance, due to limited drug benefits in the package and a low claims ratio. In summary, the extended MIP coverage and increased financial access provided by the program, most likely due to the exclusion of outpatient drug coverage from the benefit package and possibly due to improper utilisation management by private insurance companies, were not able to reverse adverse effects of economic slow-down and escalating health expenditure. MIP has only cushioned the negative impact for the poorest by decreasing the poor/rich gradient in the rates of catastrophic health expenditure.
The recent governmental decision on major expansion of MIP coverage and inclusion of additional drug benefit will most likely significantly enhance the overall MIP impact and its potential as a viable policy instrument for achieving universal coverage. The Georgian experience presented in this paper may be useful for other low- and middle-income countries that are contemplating ways to ensure universal coverage for their populations.
Catastrophic expenditure; Financial protection; Health insurance for the poor; Service utilisation; Targeting the poor; Universal coverage
Undertaking HIV research in the culturally diverse Pacific nation of Papua New Guinea (PNG) requires careful consideration of social, cultural and religious beliefs and practices. Here, we share a detailed description of culturally informed research processes and lessons learned from the first ever study undertaken on male circumcision for HIV prevention at a faith-based university in PNG.
Male and female staff and students at Pacific Adventist University were invited to complete an anonymous self-administered questionnaire, and/or participate in a semi-structured interview or focus group discussion. Male participants were invited for clinical examination. Results were collated and disseminated to the university community in gender segregated sessions. The study deliberately partnered with student leaders and centralised social, cultural, and religious paradigms. Student leaders were interviewed about their experience of partnering in sensitive health research.
The student leaders reported that pre-existing relationships, cultural ties, gendered sensitivity and regular communication reinforced trust between researchers, student leaders and participants, and helped the success of the study. The amount of time, complex logistics and social and cultural relationships between single and married staff and students were highlighted as challenges.
Partnering with regional student leaders to plan and implement the study gave a legitimate and immediate mechanism for involving PNG staff and students in this sensitive health research. Gendered research processes utilised established social and cultural structures and ensured the safety of participants; all of these factors contributed to the acceptability of the study. Capacity was strengthened in PNG and Australian researchers to undertake sensitive HIV research in PNG. The study demonstrated that it is possible to conduct sensitive sexual health research at a faith-based university in PNG.
Culture; Faith-based; HIV prevention; Male circumcision; Research process; Pacific Islander; Papua New Guinea
The aim of this study was to assess the status of knowledge translation (KT) in Iranian medical science universities in order to assess the strengths and weaknesses of the most important organizations responsible for producing knowledge in the country.
The KT activities were assessed qualitatively and quantitatively in nine universities using the Self-Assessment Tool for Research Institutes.
The strengths and weaknesses of universities were determined using seven main themes: priority setting; research quality and timeliness; researchers’ KT capacities; interaction with research users; the facilities and prerequisites of KT; the processes and regulations supporting KT; and promoting and evaluating the use of evidence.
The quantitative and qualitative results showed that the Iranian universities did not have an appropriate context for KT. There were significant shortcomings in supportive regulations, facilities for KT activities, and the level of interaction between the researchers and research users.
The shortcomings in KT were mostly in the area of stewardship and policymaking (macro level), followed by planning and implementation at the universities. In order to strengthen KT in Iran, it should occupy a prominent and focused role in the strategies of the country’s health research system.
Building research capacity in Indigenous health has been recognised as integral in efforts to reduce the significant health disparities between Indigenous and other Australian populations. The past few decades have seen substantial changes in funding policy for Australian Indigenous health research, including increases in overall expenditure and a greater focus on collaborative and priority-driven research. However, whether these policy shifts have resulted in any change to the structure of the research workforce in this field is unclear. We examine research publications in Australian Indigenous health from 1995–2008 to explore trends in publication output, key themes investigated, and research collaborations.
A comprehensive literature search was undertaken to identify research publications about Australian Indigenous health from 1995–2008. Abstracts of all publications identified were reviewed by two investigators for relevance. Eligible publications were classified according to key themes. Social network analyses of co-authorship patterns were used to examine collaboration in the periods 1995–1999, 2000–2004 and 2005–2008.
Nine hundred and fifty three publications were identified. Over time, the number of publications per year increased, particularly after 2005, and there was a substantial increase in assessment of health service-related issues. Network analyses revealed a highly collaborative core group of authors responsible for the majority of outputs, in addition to a series of smaller separate groups. In the first two periods there was a small increase in the overall network size (from n = 583 to n = 642 authors) due to growth in collaborations around the core. In the last period, the network size increased considerably (n = 1,083), largely due to an increase in the number and size of separate groups. The general size of collaborations also increased in this period.
In the past few decades there has been substantial development of the research workforce in Indigenous health, characterised by an increase in authors and outputs, a greater focus on some identified priority areas and sustained growth in collaborations. This has occurred in conjunction with significant changes to funding policy for Indigenous health research, suggesting that both productivity and collaboration may be sensitive to reform, including the provision of dedicated funding.
Aborigines; Australian; Cooperative behaviour; Research personnel
Sichuan is a province in China with an extensive history of earthquakes. Recent earthquakes, including the Lushan earthquake in 2013, have resulted in thousands of people losing their homes and their families. However, there is a research gap on the efficiency of government support policies. Therefore, this study develops a new perspective to study the health of earthquake survivors, based on the effect of post-earthquake rescue policies on health-related quality of life (HRQOL) of survivors of the Sichuan earthquake.
This study uses data from a survey conducted in five hard-hit counties (Wenchuan, Qingchuan, Mianzhu, Lushan, and Dujiangyan) in Sichuan in 2013. A total of 2,000 questionnaires were distributed, and 1,672 were returned; the response rate was 83.6%.
Results of the rescue policies scale and Medical Outcomes Study Short Form 36 (SF-36) scale passed the reliability test. The confirmatory factor analysis model showed that the physical component summary (PCS) directly affected the mental component summary (MCS). The results of structural equation model regarding the effects of rescue policies on HRQOL showed that the path coefficients of six policies (education, orphans, employment, poverty, legal, and social rescue policies) to the PCS of survivors were all positive and passed the test of significance. Finally, although only the path coefficient of the educational rescue policy to the MCS of survivors was positive and passed the test of significance, the other five policies affected the MCS indirectly through the PCS.
The general HRQOL of survivors is not ideal; the survivors showed a low satisfaction with the post-earthquake rescue policies. Further, the six post-earthquake rescue policies significantly improved the HRQOL of survivors and directly affected the promotion of the PCS of survivors. Aside from the educational rescue policy, all other policies affected the MCS indirectly through the PCS. This finding indicates relatively large differences in the effects of different post-earthquake rescue policies on the HRQOL of survivors.
Health-related quality of life; Post-earthquake rescue policies; SEM; SF-36; Survivors
Communities of Practice (CoPs) are groups of people that interact regularly to deepen their knowledge on a specific topic. Thanks to information and communication technologies, CoPs can involve experts distributed across countries and adopt a ‘transnational’ membership. This has allowed the strategy to be applied to domains of knowledge such as health policy with a global perspective. CoPs represent a potentially valuable tool for producing and sharing explicit knowledge, as well as tacit knowledge and implementation practices. They may also be effective in creating links among the different ‘knowledge holders’ contributing to health policy (e.g., researchers, policymakers, technical assistants, practitioners, etc.).
CoPs in global health are growing in number and activities. As a result, there is an increasing need to document their progress and evaluate their effectiveness. This paper represents a first step towards such empirical research as it aims to provide a conceptual framework for the analysis and assessment of transnational CoPs in health policy.
The framework is developed based on the findings of a literature review as well as on our experience, and reflects the specific features and challenges of transnational CoPs in health policy. It organizes the key elements of CoPs into a logical flow that links available resources and the capacity to mobilize them, with knowledge management activities and the expansion of knowledge, with changes in policy and practice and, ultimately, with an improvement in health outcomes. Additionally, the paper addresses the challenges in the operationalization and empirical application of the framework.
Communities of practice; Evaluation; Health policy; Knowledge management; Knowledge translation
Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities.
Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated.
The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages.
Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.
Challenges; Maternal health; Opportunities; Output-based approach; Public sector engagement; Reproductive health; Vouchers
To identify priority policy issues in access to medicines (ATM) relevant for low- and middle-income countries, to identify research questions that would help address these policy issues, and to prioritize these research questions in a health policy and systems research (HPSR) agenda.
The study involved i) country- and regional-level priority-setting exercises performed in 17 countries across five regions, with a desk review of relevant grey and published literature combined with mapping and interviews of national and regional stakeholders; ii) interviews with global-level stakeholders; iii) a scoping of published literature; and iv) a consensus building exercise with global stakeholders which resulted in the formulation and ranking of HPSR questions in the field of ATM.
A list of 18 priority policy issues was established following analysis of country-, regional-, and global-level exercises. Eighteen research questions were formulated during the global stakeholders’ meeting and ranked according to four ranking criteria (innovation, impact on health and health systems, equity, and lack of research). The top three research questions were: i) In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of medicines, sustainability of the insurance system, and financial impact on the insured? ii) How can stakeholders use the information available in the system, e.g., price, availability, quality, utilization, registration, procurement, in a transparent way towards improving access and use of medicines? and iii) How do policies and other interventions into private markets, such as information, subsidies, price controls, donation, regulatory mechanisms, promotion practices, etc., impact on access to and appropriate use of medicines?
Our HPSR agenda adopts a health systems perspective and will guide relevant, innovative research, likely to bear an impact on health, health systems and equity.
Access to medicines; Health systems; Health systems research; Priority setting
Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.
These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.
The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.
This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC.
Financial protection; Low- and middle-income countries; Policy analysis; Pooling; Purchasing; Revenue collection; Universal health coverage
In many countries, the responsibility for planning and delivery of health services is devolved to the subnational level. Health programs, however, often fall short of efficient use of data to inform decisions. As a result, programs are not as effective as they can be at meeting the health needs of the populations they serve. In Kenya, a decision-support tool, the District Health Profile (DHP) tool was developed to integrate data from health programs, primarily HIV, at the district level and to enable district health management teams to review and monitor program progress for specific health issues to make informed service delivery decisions.
Thirteen in-depth interviews were conducted with ten tool users and three non-users in six districts to qualitatively assess the process of implementing the tool and its effect on data-informed decision making at the district level. The factors that affected use or non-use of the tool were also investigated. Respondents were selected via convenience sample from among those that had been trained to use the DHP tool except for one user who was self-taught to use the tool. Selection criteria also included respondents from urban districts with significant resources as well as respondents from more remote, under-resourced districts.
Findings from the in-depth interviews suggest that among those who used it, the DHP tool had a positive effect on data analysis, review, interpretation, and sharing at the district level. The automated function of the tool allowed for faster data sharing and immediate observation of trends that facilitated data-informed decision making. All respondents stated that the DHP tool assisted them to better target existing services in need of improvement and to plan future services, thus positively influencing program improvement.
This paper stresses the central role that a targeted decision-support tool can play in making data aggregation, analysis, and presentation easier and faster. The visual synthesis of data facilitates the use of information in health decision making at the district level of a health system and promotes program improvement. The experience in Kenya can be applied to other countries that face challenges making district-level, data-informed decisions with data from fragmented information systems.
Data-informed decision making; Data dashboards; Data use; Decision-support tools; District level; Health information systems; Health systems strengthening
In Panama, the health research system has been strengthened during recent years by the development of new financing opportunities, promotion of scientific and technological activities, and initiation of human capital training to ultimately improve competitiveness. However, aligning this system with the population’s health needs is a significant challenge. This study was designed to characterize the National Health Research System in Panama, aiming to understand it within a local context to facilitate policymaking.
The study was based on the analysis of operative and functional components of the National Health Research System, characterized by four specific components: stewardship, financing, creation and maintenance of resources, and production and use of research results. The analysis was based on official documents from key local institutions in the areas of science, technology and innovation management, and health and health research, as well as bibliographic databases.
Panama’s National Health Research System is characterized by the presence of only two biomedical research institutes and reduced research activity in hospitals and universities, ambivalent governance, a low critical mass of researchers, reduced capacity to recruit new researchers, poor scientific production, and insufficient investment in science and technology.
The present study illustrates an approach to the context of the Panamanian Health Research System which characterizes the system as insufficient to accomplish its operative role of generating knowledge for new health interventions and input for innovations. In turn, this analysis emphasizes the need to develop a National Health Research Policy, which should include longer-term plans and a strategy to overcome the asymmetries and gaps between the different actors and components of the current system.
Health research policy; Health research system; Panama
Policymakers and stakeholders need immediate access to many types of research evidence to make informed decisions about the full range of questions that may arise regarding health systems.
We examined all types of research evidence about governance, financial and delivery arrangements, and implementation strategies within health systems contained in Health Systems Evidence (HSE) (http://www.healthsystemsevidence.org). The research evidence types include evidence briefs for policy, overviews of systematic reviews, systematic reviews of effects, systematic reviews addressing other questions, systematic reviews in progress, systematic reviews being planned, economic evaluations, and health reform and health system descriptions. Specifically, we describe their distribution across health system topics and domains, trends in their production over time, availability of supplemental content in various languages, and the extent to which they focus on low- and middle-income countries (LMICs), as well as (for systematic reviews) their methodological quality and the availability of user-friendly summaries.
As of July 2013, HSE contained 2,629 systematic reviews of effects (of which 501 are Cochrane reviews), 614 systematic reviews addressing other questions, 283 systematic reviews in progress, 186 systematic reviews being planned, 140 review-derived products (evidence briefs and overviews of systematic reviews), 1,669 economic evaluations, 1,092 health reform descriptions, and 209 health system descriptions. Most systematic reviews address topics related to delivery arrangements (n = 2,663) or implementation strategies (n = 1,653) with far fewer addressing financial (n = 241) or governance arrangements (n = 231). In addition, 2,928 systematic reviews have been quality appraised with moderate AMSTAR ratings found for reviews addressing governance (5.6/11), financial (5.9/11), and delivery (6.3/11) arrangements and implementation strategies (6.5/11); 1,075 systematic reviews have no independently produced user-friendly summary and only 737 systematic reviews have an LMIC focus. Literature searches for half of the systematic reviews (n = 1,584, 49%) were conducted within the last five years.
Greater effort needs to focus on assessing whether the current distribution of systematic reviews corresponds to policymakers’ and stakeholders’ priorities, updating systematic reviews, increasing the quality of systematic reviews, and focusing on LMICs.
This paper explores the implementation and sustenance of universal health coverage (UHC) in Costa Rica, discussing the development of a social security scheme that covered 5% of the population in 1940, to one that finances and provides comprehensive healthcare to the whole population today. The scheme is financed by mandatory, tri-partite social insurance contributions complemented by tax funding to cover the poor.
The analysis takes a historical perspective and explores the policy process including the key actors and their relative influence in decision-making. Data were collected using qualitative research instruments, including a review of literature, institutional and other documents, and in-depth interviews with key informants.
Key lessons to be learned are: i) population health was high on the political agenda in Costa Rica, in particular before the 1980s when UHC was enacted and the transfer of hospitals to the social security institution took place. Opposition to UHC could therefore be contained through negotiation and implemented incrementally despite the absence of real consensus among the policy elite; ii) since the 1960s, the social security institution has been responsible for UHC in Costa Rica. This institution enjoys financial and managerial autonomy relative to the general government, which has also facilitated the UHC policy implementation process; iii) UHC was simultaneously constructed on three pillars that reciprocally strengthened each other: increasing population coverage, increasing availability of financial resources based on solidarity financing mechanisms, and increasing service coverage, ultimately offering comprehensive health services and the same benefits to every resident in the country; iv) particularly before the 1980s, the fruits of economic growth were structurally invested in health and other universal social policies, in particular education and sanitation. The social security institution became a flagship of Costa Rica’s national development strategy which reinforced its political importance and contributed to its longer-term sustainability and that of UHC.
UHC has been achieved in Costa Rica because it was supported at the highest political level within a favourable socio-economic and political context. Once achieved, UHC became an entitlement for the population and now enjoys broad public support.
Health policy; Social protection; Universal health coverage
India’s health expenditure is met mostly by households through out-of-pocket (OOP) payments at the time of illness. To protect poor families, the Indian government launched a national health insurance scheme (RSBY). Those below the national poverty line (BPL) are eligible to join the RSBY. The premium is heavily subsidised by the government. The enrolled members receive a card and can avail of free hospitalisation care up to a maximum of US$ 600 per family per year. The hospitals are reimbursed by the insurance companies. The objective of our study was to analyse the extent to which RSBY contributes to universal health coverage by protecting families from making OOP payments.
A two-stage stratified sampling technique was used to identify eligible BPL families in Patan district of Gujarat, India. Initially, all 517 villages were listed and 78 were selected randomly. From each of these villages, 40 BPL households were randomly selected and a structured questionnaire was administered. Interviews and discussions were also conducted among key stakeholders.
Our sample contained 2,920 households who had enrolled in the RSBY; most were from the poorer sections of society. The average hospital admission rate for the period 2010–2011 was 40/1,000 enrolled. Women, elderly and those belonging to the lowest caste had a higher hospitalisation rate. Forty four per cent of patients who had enrolled in RSBY and had used the RSBY card still faced OOP payments at the time of hospitalisation. The median OOP payment for the above patients was US$ 80 (interquartile range, $16–$200) and was similar in both government and private hospitals. Patients incurred OOP payments mainly because they were asked to purchase medicines and diagnostics, though the same were included in the benefit package.
While the RSBY has managed to include the poor under its umbrella, it has provided only partial financial coverage. Nearly 60% of insured and admitted patients made OOP payments. We plea for better monitoring of the scheme and speculate that it is possible to enhance effective financial coverage of the RSBY if the nodal agency at state level would strengthen its stewardship and oversight functions.
Financial protection; Health insurance; India; National health insurance scheme; Out-of-pocket payments; RSBY; Universal health coverage
Public-private collaborations are increasingly being utilized to universalize health care. In Malawi, the Ministry of Health contracts selected health facilities owned by the main faith-based provider, the Christian Health Association of Malawi (CHAM), to deliver care at no fee to the most vulnerable and underserved populations in the country through Service Level Agreements (SLAs). This study examined the features of SLAs and their effectiveness in expanding universal coverage. The study involved a policy analysis focusing on key stakeholders around SLAs as well as a case study approach to analyse how design and implementation of SLAs affect efficiency, equity and sustainability of services delivered by SLAs.
The study employed both qualitative and quantitative research methods to address the research questions and was conducted in five CHAM health facilities: Mulanje Mission, Holy Family, and Mtengowanthenga Hospitals, and Mabiri and Nkope Health Centres. National and district level decision makers were interviewed while providers and clients associated with the health facilities were surveyed on their experiences. A total of 155 clients from an expected 175 were recruited in the study.
The study findings revealed key aspects of how SLAs were operating, the extent to which their objectives were being attained and why. In general, the findings demonstrated that SLAs had the potential to improve health and universal health care coverage, particularly for the vulnerable and underserved populations. However, the findings show that the performance of SLAs in Malawi were affected by various factors including lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate human and material resources, and lack of systems to monitor performance of SLAs, amongst others.
There was strong consensus and shared interest between the government and CHAM regarding SLAs. It was clear that free services provided by SLAs had a great impact on the impoverished locals that used the facilities. However, lack of supporting systems, inadequate infrastructure and shortage of health care providers affected SLA performance. The paper provides recommendations to policy makers for the replication and strengthening of SLA implementation in the roll-out of universalization policy.
Health policy; Financial risk protection; Policy analysis; Universal coverage
Non-communicable diseases (NCDs) were previously considered to only affect high-income countries. However, they now account for a very large burden in terms of both mortality and morbidity in low- and middle-income countries (LMICs), although little is known about the impact these diseases have on households in these countries. In this paper, we present a literature review on the costs imposed by NCDs on households in LMICs. We examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. In particular, in the treatment of diabetes, insulin – when required – represents an important source of spending for patients and their families. These financial costs deter many people suffering from NCDs from seeking the care they need. The limited health insurance coverage for NCDs is reflected in the low proportions of patients claiming reimbursement and the low reimbursement rates in existing insurance schemes. The costs associated with lost income-earning opportunities are also significant for many households. Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. In this paper, we identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.
Financial burden; Low- and middle-income countries; Non-communicable diseases; Review
Attention is increasingly directed to bridging the gap between the production of knowledge and its use for health decision-making in low- and middle-income countries (LMICs). An important and underdeveloped area of health policy and systems research (HPSR) is the organization of this process. Drawing from an interdisciplinary conception of embeddedness, a literature review was conducted to identify examples of embedded HPSR used to inform decision-making in LMICs. The results of the literature review were organized according to the World Health Organization’s Building Blocks Framework. Next, a conceptual model was created to illustrate the arrangement of organizations that produce embedded HPSR and the characteristics that facilitate its uptake into the arena of decision-making. We found that multiple forces converge to create context-specific pathways through which evidence enters into decision-making. Depending on the decision under consideration, the literature indicates that decision-makers may call upon an intricate combination of actors for sourcing HPSR. While proximity to decision-making does have advantages, it is not the position of the organization within the network, but rather the qualities the organization possesses, that enable it to be embedded. Our findings suggest that four qualities influence embeddedness: reputation, capacity, quality of connections to decision-makers, and quantity of connections to decision-makers and others. In addition to this, the policy environment (e.g. the presence of legislation governing the use of HPSR, presence of strong civil society, etc.) strongly influences uptake. Through this conceptual model, we can understand which conditions are likely to enhance uptake of HPSR in LMIC health systems. This raises several important considerations for decision-makers and researchers about the arrangement and interaction of evidence-generating organizations in health systems.
Embeddedness; Evidence-informed policy-making; Health policy and systems research; Low- and middle-income countries