Understanding the impacts of NPM and proposed solutions to the healthcare system reforms in Indonesia: the case of BPJS

The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review

BACKGROUND

Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals.

METHODS

We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively.

RESULTS

Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members.

CONCLUSION

We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.

Health financing challenges in Southeast Asian countries for universal health coverage: a systematic review

BACKGROUND

Universal Health Coverage (UHC) has received much attention and many countries are striving to achieve it. The Southeast Asian region, in particular, comprises many developing countries with limited resources, exacerbating challenges around attaining UHC. This paper aims to specifically explore the health financing challenges these countries face in achieving UHC via a systematic review approach and formulate recommendations that will be useful for policymakers.

METHODS

The systematic review followed the guidelines as recommended by PRISMA. The narrative synthesis approach was used for data synthesis, followed by identifying common themes.

RESULTS

The initial search returned 160 articles, and 32 articles were included after the screening process. The identified challenges in health financing towards achieving UHC in the Southeast Asian region are categorised into six main themes, namely (1) Unsustainability of revenue-raising methods, (2) Fragmented health insurance schemes, (3) Incongruity between insurance benefits and people's needs, (4) Political and legislative indifference, (5) Intractable and rapidly rising healthcare cost, (6) Morally reprehensible behaviours.

CONCLUSIONS

The challenges identified are diverse and therefore require a multifaceted approach. Regional collaborative efforts between countries will play an essential role in the progress towards UHC and in narrowing the inequity gap. At the national level, individual countries must work towards sustainable health financing strategies by leveraging innovative digital technologies and constantly adapting to dynamic health trends.

REGISTRATION

This study is registered with PROSPERO, under registration number CRD42022336624.

Healthcare services gap analysis: a supply capture and demand forecast modelling, Dubai 2018-2030

BACKGROUND

Health systems aim to provide a range of services to meet the growing demand of Dubai's heathcare system aims to provide a range of services to meet the growing demand of its population health needs and to ensure that standards of easy access, quality, equity and responsiveness are maintained. Dubai Health Authority (DHA) uses health services planning tools to assess the health needs of its population and sets priorities and effective regulatory strategies to achieve equilibrium of supply and demand of healthcare services and ensure adequate healthcare services are available, in terms of both quality and quantity. This study aims to measure the gap between demand and supply in health care services in Dubai at the baseline and to forecast the gap size and type (according to medical specialty, key medical planning units and geographical area) till 2030. The specific consequential aim includes identification of appropriate strategic directions for regulation, licensing, policies, insurance.

METHODOLOGY

The supply of healthcare services, professionals and medical equipment is captured through a census of all healthcare facilities licensed for practice in the Emirate of Dubai. The demand is estimated using a need based approach, where demand for episodes of medical care are estimated by age and gender and aligned to the internationally defined diagnosis related groups (IR-DGRs). The estimated episodes are then forecasted into the future, until 2030, using three scenarios of population growth (high, medium and low) for the emirate of Dubai. The captured supply and forecasted demand has been categorized into eight key health-planning units (KPUs) to allow for understanding of the population healthcare service needs by main service categories. Using a software for health services planning, a gap analysis between supply and demand is conducted till year 2030.

RESULTS

The results revealed a current and expected undersupply and oversupply for some healthcare services by medical specialty and geographical area of the Emirate. By 2030, the largest gaps exists in acute beds, which would require 1,590 additional beds, for acute-same day beds, an additional 1575 beds, for outpatient consultation rooms, an additional 2,160 consultation rooms, for emergency department, an additional 107 emergency bays, and for long-term care and rehabilitation beds, an additional 675 beds. The top specialty needs for these categories include cardiology, orthopedics, rheumatology, psychiatry, pediatric medicine & surgery, gastroenterology, hematology & oncology, renal medicine, primary care, respiratory medicine, endocrinology, rehabilitation and long-term care.

CONCLUSIONS

There is an existing and growing requirement to support the healthcare services capacity needs for the top service lines and geographical areas with the largest gaps. Future licensing is required to ensure that new facilities are geographically distributed in a balanced way, and requests for licensing that create or augment oversupply should be avoided.

Transparency in Healthcare Reporting: The Case of External Contractors and Consultants in New Zealand's Healthcare System

This study investigates the quality of reporting around the spending related to the use of external consultant and contractors in New Zealand's 20 District Health Boards (DHBs). We make use of the publicly available annual reviews conducted by the New Zealand Parliament Health Select Committee (HSC) as well as DHB data which were retrieved using Official Information Act (OIA) requests. The quality of reporting was judged on the differences and discrepancies observed in the HSC reports each year as well as the DHB internal data. Perhaps, unsurprisingly, total spending on external consultants and contractors has been increasing over the years while the quality of reporting has been decreasing. Our analysis highlighted a number of quality issues-mistakes, discrepancies and an overall lack of standardised reporting in almost all of the DHBs. Some of these discrepancies included failure to provide information required by the HSC, differences in yearly total amounts in consecutive reports and differences between information provided to the HSC and to the authors of this article. It is hoped that this research and the prospective areas for improvement highlighted here are used as a guide to improve the quality of healthcare financial reporting.

Experience of Indonesian medical students of ethical issues during their clinical clerkship in a rural setting

Although ethics is an essential part of medical education, little attention has been paid to ethics education during the clerkship phase, where medical students observe how physicians make decisions regarding various ethical problems. Specific nuances and cultural contexts such as working in a rural setting can determine ethical issues raised. This phenomenology study aimed to explore ethical issues experienced by Indonesian students during clinical clerkship in a rural setting. In-depth interviews were used to explore students’ experiences. Participants were ten students, selected on gender and clerkship year variations. Data saturation was reached after eight interviews, followed by two additional interviews. Thematic analysis was used in this study, and trustworthiness was ensured through data and investigator triangulation, member checking, and audit trail.

Three main themes found in this study were limited facilities and resources, healthcare financing and consent issues, as well as unprofessional behavior of healthcare providers. Many ethical issues related to substandard care were associated to limited resources and complexities within the healthcare system in the rural setting. Early exposure to recurrent ethical problems in healthcare can help students prepare for their future career as a physician in a rural setting.