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Dale E, Peacocke EF, Movik E, Voorhoeve A, Ottersen T, Kurowski C, Evans DB, Norheim OF, Gopinathan U. Criteria for the procedural fairness of health financing decisions: a scoping review. Health Policy Plan 2023; 38:i13-i35. [PMID: 37963078 PMCID: PMC10645052 DOI: 10.1093/heapol/czad066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/19/2023] [Accepted: 08/02/2023] [Indexed: 11/16/2023] Open
Abstract
Due to constraints on institutional capacity and financial resources, the road to universal health coverage (UHC) involves difficult policy choices. To assist with these choices, scholars and policy makers have done extensive work on criteria to assess the substantive fairness of health financing policies: their impact on the distribution of rights, duties, benefits and burdens on the path towards UHC. However, less attention has been paid to the procedural fairness of health financing decisions. The Accountability for Reasonableness Framework (A4R), which is widely applied to assess procedural fairness, has primarily been used in priority-setting for purchasing decisions, with revenue mobilization and pooling receiving limited attention. Furthermore, the sufficiency of the A4R framework's four criteria (publicity, relevance, revisions and appeals, and enforcement) has been questioned. Moreover, research in political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing has examined the key features of procedural fairness, but these insights have not been synthesized into a comprehensive set of criteria for fair decision-making processes in health financing. A systematic study of how these criteria have been applied in decision-making situations related to health financing and in other areas is also lacking. This paper addresses these gaps through a scoping review. It argues that the literature across many disciplines can be synthesized into 10 core criteria with common philosophical foundations. These go beyond A4R and encompass equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. These criteria can be used to evaluate and guide decision-making processes for financing UHC across different country income levels and health financing arrangements. The review also presents examples of how these criteria have been applied to decisions in health financing and other sectors.
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Affiliation(s)
- Elina Dale
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | | | - Espen Movik
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Alex Voorhoeve
- Philosophy, Logic and Scientific Method, London School of Economics and Political Science (LSE), Houghton Street, London WC2A 2AE, UK
| | - Trygve Ottersen
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Christoph Kurowski
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - David B Evans
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - Ole Frithjof Norheim
- Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Årstadveien 21, Bergen 5018, Norway
| | - Unni Gopinathan
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
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Kaiser AH, Rotigliano N, Flessa S, Ekman B, Sundewall J. Extending universal health coverage to informal workers: A systematic review of health financing schemes in low- and middle-income countries in Southeast Asia. PLoS One 2023; 18:e0288269. [PMID: 37432943 DOI: 10.1371/journal.pone.0288269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/23/2023] [Indexed: 07/13/2023] Open
Abstract
Achieving universal health coverage (UHC) is a priority of most low- and middle-income countries, reflecting governments' commitments to improved population health. However, high levels of informal employment in many countries create challenges to progress toward UHC, with governments struggling to extend access and financial protection to informal workers. One region characterized by a high prevalence of informal employment is Southeast Asia. Focusing on this region, we systematically reviewed and synthesized published evidence of health financing schemes implemented to extend UHC to informal workers. Following PRISMA guidelines, we systematically searched for both peer-reviewed articles and reports in the grey literature. We appraised study quality using the Joanna Briggs Institute checklists for systematic reviews. We synthesized extracted data using thematic analysis based on a common conceptual framework for analyzing health financing schemes, and we categorized the effect of these schemes on progress towards UHC along the dimensions of financial protection, population coverage, and service access. Findings suggest that countries have taken a variety of approaches to extend UHC to informal workers and implemented schemes with different revenue raising, pooling, and purchasing provisions. Population coverage rates differed across health financing schemes; those with explicit political commitments toward UHC that adopted universalist approaches reached the highest coverage of informal workers. Results for financial protection indicators were mixed, though indicated overall downward trends in out-of-pocket expenditures, catastrophic health expenditure, and impoverishment. Publications generally reported increased utilization rates through the introduced health financing schemes. Overall, this review supports the existing evidence base that predominant reliance on general revenues with full subsidies for and mandatory coverage of informal workers are promising directions for reform. Importantly, the paper extends existing research by offering countries committed to progressively realizing UHC around the world a relevant updated resource, mapping evidence-informed approaches toward accelerated progress on the UHC goals.
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Affiliation(s)
- Andrea Hannah Kaiser
- Department of Clinical Sciences Malmö, Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Improving Social Protection and Health Project, Phnom Penh, Cambodia
| | - Niccolò Rotigliano
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Improving Social Protection and Health Project, Phnom Penh, Cambodia
| | - Steffen Flessa
- Department of Health Care Management, University of Greifswald, Greifswald, Germany
| | - Björn Ekman
- Department of Clinical Sciences Malmö, Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
| | - Jesper Sundewall
- Department of Clinical Sciences Malmö, Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
- HEARD, University of KwaZulu-Natal, Durban, South Africa
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Ashuntantang G, Miljeteig I, Luyckx VA. Bedside rationing and moral distress in nephrologists in sub- Saharan Africa. BMC Nephrol 2022; 23:196. [PMID: 35614418 PMCID: PMC9131991 DOI: 10.1186/s12882-022-02827-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/11/2022] [Indexed: 11/11/2022] Open
Abstract
Background Kidney diseases constitute an important proportion of the non-communicable disease (NCD) burden in Sub-Saharan Africa (SSA), though prevention, diagnosis and treatment of kidney diseases are less prioritized in public health budgets than other high-burden NCDs. Dialysis is not considered cost-effective, and for those patients accessing the limited service available, high out-of-pocket expenses are common and few continue care over time. This study assessed challenges faced by nephrologists in SSA who manage patients needing dialysis. The specific focus was to investigate if and how physicians respond to bedside rationing situations. Methods A survey was conducted among a randomly selected group of nephrologists from SSA. The questionnaire was based on a previously validated survey instrument. A descriptive and narrative approach was used for analysis. Results Among 40 respondents, the majority saw patients weekly with acute kidney injury (AKI) or end-stage kidney failure (ESKF) in need of dialysis whom they could not dialyze. When dialysis was provided, clinical compromises were common, and 66% of nephrologists reported lack of basic diagnostics and medication and > 80% reported high out-of-pocket expenses for patients. Several patient-, disease- and institutional factors influenced who got access to dialysis. Patients’ financial constraints and poor chances of survival limited the likelihood of receiving dialysis (reported by 79 and 78% of nephrologists respectively), while a patient’s being the family bread-winner increased the likelihood (reported by 56%). Patient and institutional constraints resulted in most nephrologists (88%) frequently having to make difficult choices, sometimes having to choose between patients. Few reported existence of priority setting guidelines. Most nephrologists (74%) always, often or sometimes felt burdened by ethical dilemmas and worried about patients out of hospital hours. As a consequence, almost 46% of nephrologists reported frequently regretting their choice of profession and 26% had considered leaving the country. Conclusion Nephrologists in SSA face harsh priority setting at the bedside without available guidance. The moral distress is high. While publicly funded dialysis treatment might not be prioritized in essential health care packages on the path to universal health coverage, the suffering of the patients, families and the providers must be acknowledged and addressed to increase fairness in these decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02827-2.
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Affiliation(s)
- Gloria Ashuntantang
- Yaoundé General Hospital Faculty of Medicine & Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Faculty of Health Sciences, The University of Bamenda, Bamenda, Cameroon
| | - Ingrid Miljeteig
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,Department of Research and Development, Helse Bergen Health Trust, Bergen, Norway.
| | - Valerie A Luyckx
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,Renal Division, Brigham and Women's Hospital, Harvard medical School, Boston, MA, USA.,Department of Nephrology, University Children's Hospital, Zurich, Switzerland
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Simões Corrêa Galendi J, Caramori CA, Lemmen C, Müller D, Stock S. Expectations for the Development of Health Technology Assessment in Brazil. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11912. [PMID: 34831668 PMCID: PMC8625173 DOI: 10.3390/ijerph182211912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022]
Abstract
The implementation of health technology assessment (HTA) in emerging countries depends on the characteristics of the health care system and the needs of public health care. The objective of this survey was to investigate experts' expectations for the development of HTA in Brazil and to derive measures to strengthen the impact of HTA in Brazil on health care decisions. Based on a scoping literature review, a questionnaire was developed proposing eight theses for seven domains of HTA: (i) capacity building, (ii) public involvement, (iii) role of cost-effectiveness analysis (CEA), (iv) institutional framework, (v) scope of HTA studies, (vi) methodology of HTA, and (vii) HTA as the basis for jurisdiction. Thirty experts responded in full to the survey and agreed to five of the eight theses proposed. Experts suggested several measures to promote HTA within the scope of each domain, thus addressing capacity building related to HTA, availability, and reliability of population data, and legal endowment of the HTA system. Finally, HTA processes in Brazil should also address public health issues (e.g., appraisal of interventions directed at chronic diseases).
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Affiliation(s)
- Julia Simões Corrêa Galendi
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany; (C.L.); (D.M.); (S.S.)
| | - Carlos Antonio Caramori
- Department of Internal Medicine, Medical School, São Paulo State University (UNESP), 18618687 Botucatu, Brazil;
| | - Clarissa Lemmen
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany; (C.L.); (D.M.); (S.S.)
| | - Dirk Müller
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany; (C.L.); (D.M.); (S.S.)
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany; (C.L.); (D.M.); (S.S.)
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Luyckx VA, Harris DCH, Varghese C, Jha V. Bringing equity in access to quality dialysis. Lancet 2021; 398:10-11. [PMID: 33865498 DOI: 10.1016/s0140-6736(21)00732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia
| | | | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; School of Public Health, Imperial College London, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India.
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Luyckx VA, Moosa MR. Priority Setting as an Ethical Imperative in Managing Global Dialysis Access and Improving Kidney Care. Semin Nephrol 2021; 41:230-241. [PMID: 34330363 DOI: 10.1016/j.semnephrol.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Priority-setting dilemmas arise when trade-offs must be made regarding the kinds of services that should be provided and to whom, thereby withholding other services from individuals or groups that could benefit from them. Currently, it is practically impossible for lower-income countries to provide dialysis for all patients with kidney failure; however, the fundamental premise of the human right to health, while acknowledging the current resource constraints, is the progressive realization of access to care for all. In this article we outline the rationale for priority setting, starting with the global goal of achieving universal health coverage, the prerequisites for fair and transparent priority setting, and discuss how these may apply to expensive care such as dialysis. Priority is inherently a value-laden process, and cannot be whittled down to technical considerations of clinical or cost effectiveness alone. Fair and transparent priority setting should originate from population health needs, be based on evidence, and be associated with ethical values or principles. This requires effective engagement with relevant stakeholders. Once policies are developed and implemented, good oversight is crucial to ensure accountability and to provide iterative feedback such that the goals of universal health coverage may be progressively realized.
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Affiliation(s)
- Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Child Health and Pediatrics, University of Cape Town, Cape Town, South Africa.
| | - M Rafique Moosa
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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Kiendrébéogo JA, De Allegri M, Meessen B. Policy learning and Universal Health Coverage in low- and middle-income countries. Health Res Policy Syst 2020; 18:85. [PMID: 32693808 PMCID: PMC7374847 DOI: 10.1186/s12961-020-00591-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/18/2020] [Indexed: 01/18/2023] Open
Abstract
Learning is increasingly seen as an essential component to spur progress towards universal health coverage (UHC) in low- and middle-income countries (LMICs). However, learning remains an elusive concept, with different understandings and uses that vary from one person or organisation to another. Specifically, it appears that 'learning for UHC' is dominated by the teacher mode - notably scientists and experts as 'teachers' conveying to local decision/policy-makers as 'learners' what to do. This article shows that, to meet countries' needs, it is important to acknowledge that UHC learning situations are not restricted to the most visible epistemic learning approach practiced today. This article draws on an analytical framework proposed by Dunlop and Radaelli, whereby they identified four learning modes that can emerge according to the specific characteristics of the policy process: epistemic learning, learning in the shadow of hierarchy, learning through bargaining and reflexive learning. These learning modes look relevant to help widen the learning prospects that LMICs need to advance their UHC agenda. Actually, they open up new perspectives in a research field that, until now, has appeared scattered and relatively blurry.
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Affiliation(s)
- Joël Arthur Kiendrébéogo
- Department of Public Health, Health Sciences Training and Research Unit, University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso.
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany.
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Bruno Meessen
- Health Systems Governance and Financing, WHO, Geneva, Switzerland
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Chu A, Kwon S, Cowley P. Health Financing Reforms for Moving towards Universal Health Coverage in the Western Pacific Region. Health Syst Reform 2020; 5:32-47. [PMID: 30924747 DOI: 10.1080/23288604.2018.1544029] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
This article provides an overview of health financing reforms across countries in the Western Pacific Region as progress is made toward universal health coverage (UHC). Moving toward UHC requires a strong health system with sustainable financing, which countries strive to achieve through various approaches appropriate to their country contexts. Great efforts have been made by financing reforms through resource mobilization, risk pooling, resource allocation, and strategic purchasing. Overall governance of health financing systems has improved within the context of service delivery and budget reforms. But there are still challenges and ongoing needs to continue expanding health financing mechanisms equitably and efficiently, improving stewardship and accountability, strengthening the transition to domestic financing, and enabling evidence-informed priority setting and benefits design processes. Asian countries are rapidly developing and moving to more prepaid financing mechanisms with government subsidies to reduce relatively high out-of-pocket expenses, while facing implementation challenges in the governance and expansion of social health insurance. The Pacific island countries, on the other hand, face stagnating economic growth and rely on government financing, with some countries receiving significant external funding, making it important to have strong stewardship and public financing systems in place. The way forward calls for continuing to strengthen the evidence generation and monitoring function to assess country progress, reorienting primary health care as the foundation of the health sector to ensure that continuity of care is affordable and accountable, and leveraging the private sector to contribute to an equitable and efficient health system.
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Affiliation(s)
- Annie Chu
- a Health Policy and Financing Unit , WHO Regional Office of the Western Pacific , Manila , Philippines
| | - Soonman Kwon
- b Graduate School of Public Health , Seoul National University , Seoul , Republic of Korea
| | - Peter Cowley
- a Health Policy and Financing Unit , WHO Regional Office of the Western Pacific , Manila , Philippines
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Hemadeh R, Hammoud R, Kdouh O. Lebanon's essential health care benefit package: A gateway for universal health coverage. Int J Health Plann Manage 2019; 34:e1921-e1936. [PMID: 31271234 DOI: 10.1002/hpm.2850] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 11/10/2022] Open
Abstract
Recent years have demonstrated the resurgence of a global commitment toward universal health coverage (UHC). The first step toward developing a sustainable primary health care (PHC)-oriented UHC program is the creation and service delivery of an explicit essential health care benefit package (EHCP). This paper aims to describe the development, features, and progress of the EHCP in Lebanon, in addition to outlining barriers, facilitators, and next steps. Building on the investments made in the PHC network, the ministry of public health in Lebanon piloted an essential PHC package program in 2016 targeting vulnerable Lebanese and was able to enroll over 87% of targeted population to date. In order to scale up the EHCP to the national level and achieve UHC, modifications need to be made to the package entitlements, provider payment mechanisms, and implementation arrangements. The paper also notes that further advocacy and lobbying are needed in order to place UHC and the EHCP on the national agenda and stimulate public demand.
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Affiliation(s)
- Randa Hemadeh
- Primary Health Care Department, Ministry of Public Health, Beirut, Lebanon.,Global Health Team of Experts, Beirut, Lebanon
| | - Rawan Hammoud
- Primary Health Care Department, Ministry of Public Health, Beirut, Lebanon.,Global Health Team of Experts, Beirut, Lebanon
| | - Ola Kdouh
- Primary Health Care Department, Ministry of Public Health, Beirut, Lebanon.,Global Health Team of Experts, Beirut, Lebanon
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