Kerala's progress towards universal health coverage: the road travelled and beyond.

BACKGROUND: Kerala has initiated many Universal Health Coverage (UHC) reforms in the last decade. The Aardram Mission launched in 2017 stands out owing to its scope, objectives, and commitments for strengthening Primary Health Care (PHC) in the State. The current study proposes to explore access and financial protection through the lens of equity in Kerala especially in the context of major UHC reforms carried out during the last decade. This paper will also highlight the key lessons from Kerala's approach towards UHC and health systems strengthening through a political economy approach. METHODS: Data from the Kerala state sample of 75th Round (2017-18) National Sample Survey is used for this study. Comparison is also drawn from the 71st Round Sample Survey, 2014, to measure the state's progress in terms of access and financial protection. Logistic regression was used for the calculation. The findings were further explored through a political economy approach. RESULTS: The share of public facilities for outpatient care is 47.5%, which is a significant increase from 34.0% (in 2014) in the state. The share of public sector for out-patient care has increased for the lower socio-economic population in the state. The share of public sector for in-patient care has also increased to 37.3% in 2017-18 from 33.9% in 2014, but not to the extent as the increase shown in outpatient care. The average out-of-pocket-expenditure during hospitalization has increased more in private facilities as compared to public for both outpatient care and hospitalization. CONCLUSIONS: Overall increase in the share of public facilities for both outpatient care and hospitalization is indicative of the enhanced trust among the people at large of the public healthcare delivery system in Kerala, post the launch of UHC reforms in the State. The insurance linked UHC reforms would be insufficient for the State to progress further towards UHC. Kerala with a long and successful history in 'public provisioning' should focus more on strengthening PHC through Aardram Mission in its journey towards pursuit of UHC.

Study on Universal Health Coverage Scheme in India - The Stumper to Private Hospitals.

BACKGROUND: Many governments have introduced health insurance schemes for the poor sections of society to save them from catastrophic health expenditure. Private hospitals play a key role in India, as they are in significant number in secondary and tertiary care services. Private hospitals have to fund their infrastructure, staff salaries from the revenue of previous year. In this study, we compared money received by a private medical college hospital bed through government insurance scheme patient and private paying patient. METHODS: Observational study, comparing money reimbursed for top ten procedures treated in private medical college hospitals by Ayushman Bharat (AB) fund and the price offered by a paying patient in similar bed. RESULTS: On average 600 patients received medical care through the AB scheme per month at our tertiary care super-specialty hospital. Highest numbers were seen in specialties like cardiovascular, and cancer treatments and infectious diseases under general medicine specialty. The costs considered were surgeon's cost, medicines, devices, and hospitalization costs. The laparoscopic procedures were incurring a loss of 130%, knee replacements about 50%, coronary bypass grafting thankfully due to controlling of prices by central government is incurring a loss of 10%. The package amount offered accounts to 26-52% only of the costs incurred by the private hospitals. CONCLUSION: The private academic hospitals need 25% to 50% more than current prices offered, across various procedures.

Universal health coverage and equal access in Sweden: a century-long perspective on macro-level policy.

BACKGROUND: When today's efforts to achieve universal health coverage are mainly directed towards low-income settings, it is perhaps easy to forget that countries considered to have universal, comprehensive and high-performing health systems have also undergone this journey. In this article, the aim is to provide a century-long perspective to illustrate Sweden's long and ongoing journey towards universal health coverage and equal access to healthcare. METHODS: The focus is on macro-level policy. A document analysis is divided into three broad eras (1919-1955; 1955-1989; 1989-) and synthesises seven points in time when policies relevant to overarching goals and regulation of universal health coverage and equal access were proposed and/or implemented. The development is analysed and concluded in relation to two egalitarian goals in the context of health: equality of access and equal treatment for equal need. RESULTS: Over the past century, macro-level policy evolved from the concept of creating access for the neediest and those reliant on wages for their survival to a mandatory insurance with equal right to healthcare for all. However, universal health coverage was not achieved until 1955, and individuals had to rely on their personal financial resources to cover the cost at the time of care utilization until the 1970s. It was not until 1983 that legislation explicitly stated that access to healthcare should be equal for the entire population (horizontal equity), while a vertical equity-principle was not added until 1997. Subsequently, ideas of free choice and privatization have gained significance. For instance, they aim to increase service access, addressing the Swedish health system's Achilles' heel in this regard. However, the principle of equal access for all is now being challenged by the emergence of private health insurance, which offers quicker access to services. It can be concluded that there is no perpetual Swedish healthcare model and various dimensions of access have been the focus of policy discussion. The discussion on access barriers has shifted from financial to personal and organizational ones. Today, Sweden still ranks high in terms of affordability and equity in international comparisons: although not as well as a decade ago. Whether this marks the beginning of a new trend intertwined with a decline in Sweden's welfare 'exceptionalism', or is a temporary decline remains to be assessed in the future.

Progress toward universal health coverage in Vietnam: Evidence on dispensing trends of diabetes medications from 2015 to 2021.

AIMS: This study aims to investigate the trends in treatment coverage through dispensing diabetes medications in Vietnam from 2015 to 2021. The findings will serve to inform health policies to mitigate the health burden of Type 2 diabetes mellitus (T2DM). METHODS: We collected information on major antidiabetic medicines from General Department of Vietnam Customs and payments for antidiabetics via the National Health Insurance Program. We applied ordinary least squares models, accounting for economic and health outcome characteristics, to estimate the association between the annual mass of medications and related factors. RESULTS: Nationally, the total mass/doses of all antidiabetic drugs increased rapidly from 2015 to 2021, based on both databases. Metformin was the most frequently prescribed medicine, with the total mass increasing nearly threefold over the study period. Gliclazide, a Sulfonylureas drug, ranked second. In the multivariate regression analysis, a one-unit increase in adults with diabetes (in 1,000 s) was associated with 0.11 % (95 %CI = 0.0005; 0.0076) and 0.13 % (95%CI = 0.0007; 0.0242) higher mass of Metformin and Glimepiride, respectively. CONCLUSION: Our data suggested that policies changes were related to significant increase in antidiabetic medication dispenses in Vietnam. The high treatment coverage indicates impressive progress in achieving universal health coverage in Vietnam, meeting the UN Sustainable Development Goal (SDG).

Institutionalizing Health Technology Assessment and Priority Setting in South Korea's Universal Health Coverage Journey.

This study charts the chronological developments of the three institutions that were established in South Korea for priority setting in health. In 2007, the Evidence-based Medicine Team and the Center for New Health Technology Assessment (CnHTA) were established and nested in the Health Insurance Review and Assessment Service (HIRA). In December 2008, the National Evidence-based Healthcare Collaborating Agency (NECA) was launched, to which the CnHTA was transferred in 2010. Since then, non-drug technologies have been reviewed by NECA and drugs have been reviewed by HIRA. Political debates about how to embrace expensive but important health technologies that were not on the benefits list led to the creation of the Participatory Priority Setting Committee (PPSC) in 2012. The PPSC, led by the general public, has played a key role in advancing the path toward universal health coverage by revitalizing the list of essential, yet previously overlooked, medical technologies. PPSC offers these technologies a second chance at coverage. HIRA and NECA served to strengthen evidence-based and efficiency-based decision-making in the health system via CnHTA, and PPSC served to strengthen social value-based decision making via priority setting in Korea. The reassessment by PPSC may be relevant in countries where the economy is growing and citizens want to rapidly expand the benefits list.

Harnessing Health Technology Assessment in Latin America and the Caribbean: Keeping the Region on Course.

Latin America and the Caribbean has made significant progress toward universal health coverage (UHC), but health spending efficiency, equity, and sustainability remain major challenges-and progress is hindered by the difficult macroeconomic context. Health technology assessment (HTA) can make resource allocation more efficient and equitable when systematically used to inform coverage decisions. We highlight five considerations that need to be taken into account to realize the full potential of HTA in the LAC region: i) explicitly link HTA to decision-making and anchor it in legal frameworks, ii) systematically incorporate the opportunity cost as a core principle into HTA activities informing coverage decisions, iii) make the internationally available evidence more fit for purpose for low- and middle-income countries (LMICs), iv) incorporate pragmatism as a key principle of HTA activities in the region, and v) institutionalize the monitoring of HTA processes and results.

Establishing a Health Technology Assessment Evidence Ecosystem in India's Pradhan Mantri Jan Arogya Yojana.

The introduction of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) scheme in India was a significant step toward universal health coverage. The PM-JAY scheme has made notable progress since its inception, including increasing the number of people covered and expanding the range of services provided under the health benefit package (HBP). The creation of the Health Financing and Technology Assessment (HeFTA) unit within the National Health Authority (NHA) further enhanced evidence-based decision-making processes. We outline the journey of HeFTA and highlight significant cost savings to the PM-JAY as a result of health technology assessment (HTA). Our paper also discusses the application of HTA evidence for decisions related to inclusions or exclusions in HBP, framing standard treatment guidelines as well as other policies. We recommend that future financing reforms for strategic purchasing should strengthen strategic purchasing arrangements and adopt value-based pricing (VBP). Integrating HTA and VBP is a progressive approach toward health care financing reforms for large government-funded schemes like the PM-JAY.

Health Insurance Deductibles and Health Care-Seeking Behaviors in a Consumer-Driven Health Care System With Universal Coverage.

Importance: Characteristics of a health care system can facilitate forgoing of health care owing to economic reasons and can influence population health. Whether health insurance deductibles are associated with forgoing of health care in a consumer-driven health care system with universal coverage, such as the Swiss health system, remains to be determined. Objective: To assess the association between insurance plan deductibles and forgoing of health care with consideration of socioeconomic factors. Design, Setting, and Participants: This cross-sectional study was conducted in Geneva, Switzerland, using data collected from January 1, 2007, to December 31, 2019. Population-based samples were obtained yearly through random stratified sampling by age and sex of the general population aged 20 to 74 years. Participants were invited to an appointment at 1 of the 3 study sites in Geneva, where they completed a sociodemographic and health questionnaire. Exposures: Insurance plan deductible level. Main Outcomes and Measures: The main outcome was forgoing of health care owing to economic reasons. Unadjusted and multivariable Poisson models were used to assess the association between deductible level and forgoing of health care. Differences in forgoing health care across the range of health insurance deductibles or household income levels were quantified using the relative index of inequality (RII). Results: The study group included 11 872 participants (5974 [50.3%] male; median age, 48.1 years [interquartile range, 38.7-59.1 years]); 1146 (9.7%) reported forgoing health care. Participants with high-deductible plans reported forgoing health care more frequently than those with low-deductible plans (331 [13.5%] vs 591 [8.7%]). In adjusted analysis, higher-deductible plans were associated with a greater likelihood of forgoing health care (RII, 2.2; 95% CI, 1.7-3.0; P < .001) independently of socioeconomic status, known comorbidities, and cardiovascular risk factors. Deductible level was associated with forgoing of health care among participants younger than 40 years (RII, 2.5; 95% CI, 1.6-4.0; P < .001) and those aged 40 to 64 years (RII, 1.9; 95% CI, 1.3-2.9; P = .002) but not among those older than 65 years (RII, 2.9; 95% CI, 0.8-10.4; P = .11). Conclusions and Relevance: In this cross-sectional study, high insurance plan deductibles were associated with forgoing of health care independent of socioeconomic status and preexisting conditions in a universal consumer-driven health care system with good population outcomes in Switzerland. Uncovering health care system design features that could lead to suboptimal population care may help decision makers improve their current health care system design to achieve better outcomes.

Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19.

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries.

Realizing the right to health in Latin America, equitably.

This special issue "Realizing the Right to Health in Latin America and the Caribbean" provides an overview of one of the most challenging objectives of health systems: equity and the realization of the right to health. In particular, it concentrates on the issues associated with such a challenge in countries suffering of deep inequity. The experience in Latin America and the Caribbean demonstrates that the efforts of health systems to achieve Universal Health Coverage are necessary but not sufficient to achieve an equitable realization of the right to health for all. The inequitable realization of all other human rights also determines the realization of the right to health.

Revision of the Ethiopian Essential Health Service Package: An Explication of the Process and Methods Used.

To make progress toward universal health coverage, countries should define the type and mix of health services that respond to their populations' needs. Ethiopia revised its essential health services package (EHSP) in 2019. This paper describes the process, methodology and key features of the new EHSP. A total of 35 consultative workshops were convened with experts and the public to define the scope of the revision, develop a list of health interventions, agree on the prioritization criteria, gather evidence and compare health interventions. Seven prioritization criteria were employed: disease burden, cost effectiveness, equity, financial risk protection, budget impact, public acceptability and political acceptability. In the first phase, 1,749 interventions were identified, including existing and new interventions, which were regrouped and reorganized to identify 1,442 interventions as relevant. The second phase removed interventions that did not match the burden of disease or were not relevant in the Ethiopian setting, reducing the number of interventions to 1,018. These were evaluated further and ranked by the other criteria. Finally, 594 interventions were classified as high priority (58%), 213 as medium priorities (21%) and 211 as low priority interventions (21%). The current policy is to provide 570 interventions (56%) free of charge while guaranteeing the availability of the remaining services with cost-sharing (38%) and cost-recovery (6%) mechanisms in place. In conclusion, the revision of Ethiopia's EHSP followed a participatory, inclusive and evidence-based prioritization process. The interventions included in the EHSP were comprehensive and were assigned to health care delivery platforms and linked to financing mechanisms.

Networks of Care in Rural Madagascar for Achieving Universal Health Coverage in Ifanadiana District.

Health care is most effective when a patient's basic primary care needs are met as close to home as possible, with advanced care accessible when needed. In Ifanadiana District, Madagascar, a collaboration between the Ministry of Public Health (MoPH) and PIVOT, a non-governmental organization (NGO), fosters Networks of Care (NOC) to support high-quality, patient-centered care. The district's health system has three levels of care: community, health center, district hospital; a regional hospital is available for tertiary care services. We explore the MoPH/PIVOT collaboration through a case study which focuses on noteworthy elements of the collaboration across the four NOC domains: (I) agreement and enabling environment, (II) operational standards, (III) quality, efficiency, and responsibility, (IV) learning and adaptation. Under Domain I, we describe formal agreements between the MoPH and PIVOT and the process for engaging communities in creating effective NOC. Domain II discusses patient referral across levels of the health system and improvements to facility readiness and service availability. Under Domain III the collaboration prioritizes communication and supervision to support clinical quality, and social support for patients. Domain IV focuses on evaluation, research, and the use of data to modify programs to better meet community needs. The case study, organized by the domains of the NOC framework, demonstrates that a collaboration between the MoPH and an NGO can create effective NOC in a remote district with limited accessibility and advance the country's agenda to achieve universal health coverage.

A Tale of Transition: Trends of Catastrophic Health Expenditure and Impoverishment in Urban China, 1986-2009.

From 1986 to 2009, China's health system reform first adopted a market-oriented approach and later reemphasized the role of the government starting from 2002. China's oscillating health care financing policies present us a unique opportunity to examine the consequences of government-led financing and market-oriented financing measures. This study uses the Urban Household Survey, a diary data in China that covers the period of 1986 to 2009, to examine the long-run trends in the incidence and intensity of catastrophic health expenditure and medical impoverishment. Four major findings emerge. First, the incidence and intensity of catastrophic health expenditure in urban Chinese households increased rapidly between 1986 and 2002, whereas they stabilized after 2002. Second, the incidence of medical impoverishment and its depth in the poverty gap remained stable before 2002 and decreased rapidly after 2002. Third, income and regional inequality in measures of catastrophic health expenditure widened from 1986 to 2002. They narrowed in the 2000s but remain wide. Fourth, income and regional inequality in medical impoverishment remained unchanged between 1986 and 2002 and narrowed substantially after 2002. All these results suggest that China's two cycles of health care reform generated significantly different outcomes in financial protection, holding lessons for the ongoing health care reform in China and other countries.

Access to reperfusion therapy and mortality outcomes in patients with ST-segment elevation myocardial infarction under universal health coverage in Thailand.

BACKGROUND: Evidence on access to reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI) and associated mortality in developing countries is scarce. This study determined time trends in the nationally aggregated reperfusion and mortality, examined distribution of percutaneous coronary intervention (PCI) utilization across provinces, and assessed the reperfusion-mortality association in Thailand that achieved universal health coverage in 2002. METHODS: Data on hospitalization with STEMI in 2011-2017 of 69,031 Universal Coverage Scheme (UCS) beneficiaries were used for estimating changes in the national aggregates of % reperfusion and mortality by a time-series analysis. Geographic distribution of PCI-capable hospitals and PCI recipients was illustrated per provinces. The reperfusion-mortality association was determined using the propensity-score matching of individual patients and panel data analysis at the hospital level. The exposure is a presence of PCI or thrombolysis. Outcomes are all-cause mortality within 30 and 180 days after an index hospitalization. RESULTS: In 2011-2017, the PCI recipients increased annually 5.7 percentage (%) points and thrombolysis-only recipients decreased 2.2% points. The 30-day and 180-day mortalities respectively decreased annually 0.20 and 0.27% points among the PCI recipients, and they increased 0.79 and 0.59% points among the patients receiving no reperfusion over the same period. Outside Bangkok, the provinces with more than half of the patients receiving PCI increased from 4 provinces of PCI-capable hospitals in 2011 to 37 provinces, which included the neighboring provinces of the PCI-capable hospitals in 2017. Patients undergoing reperfusion had lower 30-day and 180-day mortalities respectively by 19.6 and 21.1% points for PCI, and by 14.1 and 15.1% points for thrombolysis only as compared with no reperfusion. The use of PCI was associated with decreases in 30-day and 180-day mortalities similarly by 5.4-5.5% points as compared with thrombolysis only. A hospital with 1% higher in the recipients of PCI had lower mortalities within 30 and 180 days by approximately 0.21 and 0.20%, respectively. CONCLUSIONS: Patients with STEMI in Thailand experienced increasing PCI access and the use of PCI was associated with lower mortality compared with thrombolysis only. This is an evidence of progress toward a universal coverage of high-cost and effective health care.