Health system governance
As is well known, the current state of public health in India is attributed to a large extent to poor governance of both the public and private health sectors. How the UHC debate addresses this issue is critical for retaining momentum and achieving its goal. Though the increasingly diverse private sector cannot be ignored and needs to be roped in to achieve this shared goal, it is important to work out effective mechanisms for an ideal mix of both public and private participation with well-defined accountability mechanisms and processes. A much more informed debate on what would work best in terms of practical mechanisms of public-private mix is required. What have been the experiences so far in the Public-Private Partnerships experiments? How are lessons from such experiments fed into the UHC debates? How could regulation and accountability be enhanced in the private sector considering that mainstream approaches to regulate private sector don’t work? What could be alternative innovative mechanisms to regulate and govern the private sector? What have been the experiences of different states on private sector regulations? We need to understand the differences between public and private health sectors and the power dynamics within the private sector taking into account the huge diversity that is typical of this sector. However within these frameworks of difference, what fruitful partnerships can be created and how can they help each other? These questions need to be explored in a
The main objectives of this paper are to analyses the economic implications of fiscal sustainability on India’s recently proposed UniversalHealthCoverage policy (UHCP) above by answering the following research questions. What are the health expenditure requirements for implementation of a proposed UHC policy? How can such expenditures be projected in future? What are fiscal options to financing a UHC policy above? If a proposed UHC policy is entirely pubic-funded, non-means tested and non-contributory, can it be sustained by current fiscal policies? If not, what are additional conditions required to attain fiscal sustainability under the proposed UHCP? To answer these questions, this paper calculates a new measure of age specific consumption of UHC by combining the age profile of public and private health consumption by using the National Transfer Accounts methodology [Mason and Lee, 2011; United Nations, 2013a)]. Fiscal sustainability of UHCP is evaluated by the Generational Accounting methodology [Auerbach and Kotlikoff, 1999], which determines fiscal policy initiatives on the “net tax burden” (tax payments net of benefit transfers) on current and future generations by using the concept and measure of Generational balance [or what a fiscal policy initiative that is
The government, at both the national and state levels, was identified as the dominant user of HTA. This find- ing is similar to the reported global use of HTA, wherein ministries of health or national health insurance bodies have been identified as the main initiators of HTAs [26, 27]. However, unlike in several countries where HTA is applied, the government is not a large player in the health sector, contributing to only a third of overall health spending in the country . Further, the govern- ance system for healthcare is complex given the federal structure of the country and multiple stakeholders that operate therein ; while the central government is re- sponsible for supporting medical education, managing regulatory bodies and supporting states among other ac- tivities, health policies are decided and implemented at the state level. This has implications for linking HTA to policy; at the national and state levels, HTA may be used to define the benefits package of insurance schemes such as the Rashtriya Swasthya Bima Yojana, to be subsumed under the Ayushman Bharat – Pradhan Mantri Jan Aar- ogya Yojana scheme, that covers families below the pov- erty line as well as those working in the unorganised sector [28, 29] or the various insurance schemes at the state level [30, 31]. Additionally, vertical programmes on AIDS or Tuberculosis or the National Health Mission, which supports states to improve or maintain key health indicators, may be other users of HTA to enhance deliv- ery of care. In addition to the government, the pharma- ceutical industry, insurance companies and healthcare providers have been identified as relevant stakeholders in the process .
Finally, panel discussants recognised opportunities and the importance of mutual learning between India and African nations. Health systems in India and Africa are different from those in more mature economies. While the current UHC agendas tend to be set by donors, these agendas are unlikely to be sustainable or successful in the Indian and African contexts. In both contexts, process-oriented innovations were seen to be as important as technology innovations. This points to the importance of logistics, infrastructure, and user experiences in achieving UHC. In addition, it was noted that innovations from Indian and African markets can feed into developed economies, as well. Innovations in low-resource settings are by necessity designed for value – the consideration of quality over cost –, which is not necessarily the case in more developed and expensive health systems like the United States (US). The US healthcare system has only recently started to shift towards value-based care as costs skyrocket and nearly one in four federal dollars is spent on healthcare. Elegant and affordable innovations developed in India and Africa could have a large market to serve in the US and beyond. Multinational companies (e.g. GE, Philips, etc.) may have these platforms for learning across countries as they operate in multiple settings.
Table 1 provides a summary of key health financing pol- icy developments in Kenya. Following independence in 1963, the Kenyan post-colonial government made uni- versal health care a major policy goal. Two years after independence, the post-colonial government abolished user fees that were implemented by the colonialist. Health services were funded primarily through general tax up to 1988, when the Kenyan government yielded to pressure from the World Bank and International Mone- tary Fund to introduce user fees and other major reforms in the health sector. Poor economic perfor- mance, inadequate financial resources and declining budgets were some of the reasons given to justify the introduction of user fees . In the post colonial period, user fees were first introduced in 1989, but were sus- pended in 1990 and reintroduced in phases in 1991 . Reasons for the failure of the 1989 implementation were attributed to various factors including: hurried imple- mentation; massive declines in utilisation of health ser- vices; lack of quality improvements; and poor revenue collection [9-12]. Following the reintroduction in 1991, user fees were charged for individual services like drugs, injections, and laboratory services, instead of consulta- tion as was previously the case. Revenue collected was returned to the district level to cater for public health needs within the district and facilities developed detailed plans for spending 75% of the revenue. A waiving policy to protect the poor was put in place, and children below five years were exempted from all charges, but in reality waiving mechanisms hardly existed .
While primary care should be given priority, he added, some secondary and tertiary care also is essential. He too emphasized the need to develop an adequate
multilayered health workforce with sufficient numbers of nurses and community health workers as well as doctors, and ensure it operates where it is needed most. While India likely has the resources to address coverage expansion, it could use technical assistance from the international community. “Particularly when you are at the very beginning of designing a universalhealthcoverage program there are likely to be mistakes made which, if not corrected in design at an early stage, can cost us very dear as we move along,” Reddy said.
Each source of health financing has implications for expanding UHC, achieving equity (i.e. the regressive/progressive nature of resource mobilization), and economic growth. Most global health practitioners are focused on the first two benefits of UHC and see these investments in health as beneficial for improving economic productivity and growth. But the expansion of UHC potentially creates a disincentive for workers to participate in the formal sector. Instead, workers can opt for the informal sector because a UHC expansion allows them to access health benefits without making payroll tax payments. As a result, a reduced formal sector can potentially lead to reduced long term economic growth (Loayza 2011). This chapter seeks to provide insight into the impact of UHC on labor markets by looking at how the change in the payroll tax and expansion of coverage under Indonesia’s health insurance reform affects the labor market. Specifically, this chapter asks did Indonesia’s 2014 Social Health Insurance reform increase informal sector employment. Unlike the previous chapter, this chapter uses labor force participation data to analyze the working formal and informal sector population. Because of the data used, the term informal sector refers specifically to those who work in the informal sector, irrespective of insurance or income status. A statistical definition provided in the methodology section goes into greater detail about the employment categories used to classify the informal sector.
Services not covered by Kisiizi Hospital Health Insur- ance scheme included: dentures; spectacles/optical appli- ances; self-inflicted injuries such as complications of failed suicide attempt, criminal abortion and fights under influence of alcohol and other substance abuse; chronic diseases such as diabetes, high blood pressure, asthma, epilepsy and other mental illnesses; fertility treatment and procedures; food and food supplements; police forms; routine medical checkup for jobs or school; semen analysis; culture and sensitivity; glycated haemo- globin test; international normalized ratio assays evaluat- ing the extrinsic pathway of coagulation; hormonal tests (prostate surface antigen test and thyroid-stimulating Table 3 Co-payments
Similarly, there would be also gaps for the government to provide health workforces. In this case, this paper examines the ratio of doctors and nurses (per 1,000 people). Table 3 shows the results of gap analysis on health human resources. There would be many gaps (all the values are minus) in all scenarios to fulfill the proper standard. The limited budget allocations could be one of the reasons. In addition, the inequalities in providing health workforces of local government might also be other reasons. After Indonesia transformed to decentralization system in 2001 21 , there are a lot of problems regarding to health human resources distribution.
Consumption expenditure as a measure of ability to pay however is not without problem. The main weakness of the measure is the implied assumption that healthcare expenditure does not affect saving decision. The use of consumption expenditure as a measure of welfare or ability to pay assumes that households with higher abil- ity to pay have higher consumption expenditure than those with lower ability to pay. The measure then does not take into account the fact that households may have to borrow in order to increase consumption expenditure . Besides the ability to pay of households that are able to produce their own foodstuff would be underesti- mated. An increase in consumption expenditure for a household could also be due to debt repayment and hence may not imply an increase in goods and services con- sumed but a fall or no change in welfare. To minimize the negative effects consumption expenditure as a measure of welfare is computed as gross household expenditures on food and non-food items including taxes, social security, as well as all out of pocket expenditures on healthcare . Since the interest in the current study is in the distri- butional impact of the premium, the gross expenditure of households on food and all other household needs includ- ing health care expenditure was used as an indicator of ability to pay.
difficulties of incorporating a large informal sector into a UHC scheme. In a country such as India, where individuals working in the informal sector make up a significant portion of the population, the government will need to develop an effective strategy for collecting adequate contributions from this group. Even if India adopts a tax-based rather than a premium-based health care system, accounting for a large informal sector is crucial for any government-run universalhealth care scheme to be sustainable in the long term. These 16 international country case studies additionally show that a well-functioning UHC system must align the economic incentives of health care providers with the goals of the system. Both China and Taiwan demonstrate how misaligned economic incentives can encourage behaviors that threaten a high quality of care. In China, government block grants often do not fully cover the actual operating costs of local health institutions. Because those institutions are encouraged to make up the marginal difference, physician-induced demand for unnecessary services and other profit-seeking behaviors have became huge concerns. In Taiwan and the Philippines, fee-for- service mechanisms also encourage supplier-induced demand for services that may not be medically needed. Because Taiwan permits hospitals to sell drugs for prices beyond their acquisition cost, the profitability of prescribing drugs gives providers yet another economic incentive to over-medicate patients. It is crucial for any UHC scheme to incorporate economic incentives and provider payment mechanisms that encourage principles of quality, efficiency, cost- effectiveness and safety.
It has been estimated that about 150 million people suffer from financial crippling as a result of health payments annually and 100 million people are pushed below the poverty line simply because they must seek health care services and pay directly out-of-pocket (WHO, 2013) a significant proportion of these statistics must be from poor and middle income countries where health system performance is very poor with poor health outcomes. For instance, the National Population Commission NPC (2013) in Nigeria reported that just about 38% of women deliver under the supervision of qualified attendants, 36% of women delivered in health facility. This was far lower in three states of Jigawa (7.6%), Kano (13.7%), and Bauchi (16.3%). This implies that for these states over 80% of pregnant women delivers outside the health facility either at home or with traditional care givers. Generally, about 25% of the under-five are fully immunized. Nationally the proportion of fully immunized children aged 12 to 23 months ranges from 4.7% in the North-West zone to 40.7 % in the South West zone. Coverage in rural areas is 13.4% compared with 32.6% in the urban areas, malaria contributes 30% to childhood mortality (WHO Country Co-operation Strategy, 2014). It was also observed by the WHO (2014). A weak health system such as Nigeria needs assessment of the level of UHC and financial protection with equity implications.
such as the publication of Standard Treatment Guidelines, mandatory display of rates for services, and the standardisation of rates. In addition, this act created the multi-stakeholder Clinical Establishment Council to agree to both rules and generalised standards in the sector. However, the CEA of 2010 was not sufficiently comprehensive. For example, it did not mention the Charter of Patients’ Rights, nor did it offer a grievance redressal mechanism. Furthermore, it created an over-centralisation of standard-setting procedures (Phadke 2010). Given this context, JAA demanded that the state government of Maharashtra should enact its own state-specific CEA by incorporating positive features of the national act, while adding key provisions to protect patients’ rights, including grievance redressal mechanisms, and removing certain impractical provisions which would be unfair to doctors. To press for this demand, JAA organised mass demonstrations during Legislative Assembly sessions in 2012 and 2013 (The Times of India 2012),
Our study findings provide a base for key policy conclusions as the magnitude of the catastrophic health expenditure is an indicator of the effectiveness of the current health financing arrangements. Although the level of catastrophic health care expenditure varies depending on the approach and threshold used, the problem of catastrophic expenditures in Myanmar cannot be denied. The government of Myanmar needs to scale up the current SSS or establish a new financial protec- tion mechanism for the population. Vulnerable groups, such as households with a low educated household head, house- holds with children under the age of 5 years or disabled per- sons, and low-income households should be a priority in the improvement of access to essential health care. The inci- dence of catastrophic expenditures that we captured in our study, might only be the tip of the iceberg as our data only represent subnational trends. Additionally, the uneven distri- bution of catastrophic expenditures across wealth quintiles may also show another major problem: individuals not seek- ing needed care because of OOPPs. This problem is not vis- ible in catastrophic health care expenditure research and requires a separate investigation.
Health care facilities of U S A are largely owned and operated by private sector businesses. According to United States Census Bureau (2012), out of entire population only 32.6% is availing benefits provided by Public HealthCoverage, Private HealthCoverage is 63.9%, and uninsured people are 15.4 %. Public programs provide the primary source of coverage for most seniors and low-income children. Families covered under Medicare are 15.7%, Medicaid are 16.4% and Military Health Insurance are 4.4%. Private insurance for non-elderly working population form major part of healthcoverage in United States which involves Consumer Driven, Managed Care and Health saving Account. Due to costly health services in America, people cannot able to afford it and hence Obama care or Patient Protection and Affordable Care Act (PPACA) came into picture with the goals of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage, and reducing the costs of healthcare for individuals and the government. The basic idea of capitalism is seen even in healthcare were in the system encourages generation of money and has followed principles of revenue generation through business. In US the healthcare is dominated by the private insurance agencies who have inflated the cost of healthcare for earning maximum profits. In such capitalistic dominated health care system the patient is seen as a customer with adequate money.
A few years after the NRHM, the Rashtriya Swasthya Bima Yojna (RSBY) scheme run by the Ministry of Labour & Employment aims to provide financial risk protection for in-patient care (mainly) to the population living below poverty line. It uses an insurance mechanism and currently covers 80 million beneficiaries (in contrast, the NRHM is tax-based). Along with the comprehensive union-funded insurance schemes (Employee State Insurance Scheme, with 60 million beneficiaries and the Central Government Health Scheme covering three million), some 143 million people are now covered in India.
Objective: to examine advanced practice nursing (APN) roles internationally to inform role development in Latin America and the Caribbean to support universalhealthcoverage and universal access to health. Method: we examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universalhealthcoverage and access to health. Results: given evidence of their effectiveness in many countries, APN roles are ideally suited as part of a primary health care workforce strategy in Latin America to enhance universalhealthcoverage and access to health. Brazil, Chile, Colombia, and Mexico are well positioned to build this workforce. Role implementation barriers include lack of role clarity, legislation/regulation, education, funding, and physician resistance. Strong nursing leadership to align APN roles with policy priorities, and to work in partnership with primary care providers and policy makers is needed for successful role implementation. Conclusions: given the diversity of contexts across nations, it is important to systematically assess country and population health needs to introduce the most appropriate complement and mix of APN roles and inform implementation. Successful APN role introduction in Latin America and the Caribbean could provide a roadmap for similar roles in other low/middle income countries.
Now ten years after the implementation of Brazil’s last ma- jor healthcare reform strategy, we have 97% facility delivery amongst the poorest quintile, and about 98%-99% among the rest of the population. We have virtually eradicated this massive difference between rich and poor, at least in access to facilities. Brazil has already met the MDG 1 indicator of underweight…. We’re going to meet MGD 4 next year…. Universalcoverage certainly played a role. We’re not so sure about MGD 5. Why? As part of Brazil’s universalcoverage, we have maternal audit committees in virtually every city in the country, and we’re measuring mortality more accu- rately than ever before, so it looks like [the mortality rate] is not falling, but I strongly believe that if we had the right measurement, we’d also be detecting a sizeable reduction in maternal mortality.
The approach taken to health care in the Rural Health Scheme was pioneering because the focus shifted from curative services provided by hospitals to maternal and child health services provided by primary care centres (Mahmud 2013). If these primary care centres detected illness requiring hospital care, the centres would act as feeders to urban hospitals that were already available. The stumbling block in the way of the success of the scheme, as is even the case today, is that there is a need to achieve a critical mass of trained personnel to make the system work and to ensure that there are sufficient human resources who are able and willing to work in the farthest rural reaches of the land. It was only in the 1970s that a sufficiently large civil service-based pool of health care workers became available through ample training facilities coupled with burgeoning inland roads that made it possible for urban- based staff to travel to rural areas to provide health care services.
We faced an additional problem because the right to health is, according to General Comment 14, “an inclu- sive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and ad- equate sanitation, an adequate supply of safe food, nutri- tion and housing, healthy occupational and environmental conditions, and access to health-related education and in- formation, including on sexual and reproductive health” , whereas UHC is focused on health care – including “prevention, promotion, treatment and rehabilitation”, as the 2012 WHO Discussion Paper clarifies , but focused on health care nonetheless. We therefore decided to limit the scope of our comparative normative analysis to the right to health care, although we acknowledge that the absence of broader health determinants within UHC does limit its ability to practically express the right to health in totality.