Health System Financing and Resource Allocation in Humanitarian Settings: Toward a Collaborative Policy Research Agenda in the Eastern Mediterranean Region.

This article discusses key policy questions around health system financing in humanitarian settings, with specific reference to the Eastern Mediterranean region. We discuss key financing functions in the context of different challenges and the potential policy options for addressing these effectively. We also identify areas of collaborative research between academics, policy- and decision-makers and other stakeholders to inform appropriate policy choices that are aligned to universal health coverage in such challenging contexts.

Cost-effectiveness of One Health interventions for rabies elimination: a systematic review.

The 'One Health' (OH) approach is the most promising idea in realising the global goal of eliminating canine-mediated human rabies by 2030. However, taking an OH approach to rabies elimination can mean many different things to different people. We conducted a systematic review scrutinizing economic evaluations (EEs) retrieved from MEDLINE OVID, Embase OVID, Global Health OVID, CINAHL EBSCO and ECONLIT EBSCO that used the OH approach with the intent of identifying cost-effective sets of interventions that can be combined to implement an optimal OH-based rabies elimination program and highlight key gaps in the knowledge base. Our review suggests that an optimal OH program to tackle rabies should incorporate mass dog vaccination and integrated bite case management in combination with efficient use of post-exposure prophylaxis along with a shift to a 1-week abbreviated intradermal rabies vaccine regimen in humans. We recommend that future EEs of OH interventions for rabies elimination should be performed alongside implementation research to ensure proposed interventions are feasible and adopt a wider societal perspective taking into account costs and outcomes across both the human health and animal welfare sectors. The systematic review has been registered with PROSPERO.

The redistributive effect of the public health system: the case of Sierra Leone.

Universal health coverage (UHC), health equity and reduction of income inequalities are key objectives for the Sierra Leone government. While investing in health systems may drive economic growth, it is less clear whether investing in health systems reduces income inequality. Therefore, a crucial issue is to what extent the Sierra Leone public healthcare system reduces income inequality, and finances and provides healthcare services equitably. We use data from the Sierra Leone Integrated Household Survey 2018 to complete a financing and benefit incidence analysis of the Sierra Leone public healthcare system. We extend these analyses by assessing the redistributive effect of the public healthcare system (i.e. fiscal incidence analysis). We compute the redistributive effect as the change in Gini index induced by the payments for, and provision of, public healthcare services. The financing incidence of the Sierra Leone public healthcare system is marginally progressive (i.e. Kakwani index: 0.011*, P-value <0.1). With regard to public healthcare benefits, while primary healthcare (PHC) benefits are pro-poor, secondary/tertiary benefits are pro-rich. The result is that overall public healthcare benefits are equally distributed (concentration index (CI): 0.008, not statistically different from zero). However, needs are concentrated among the poor, so benefits are pro-rich when needs are considered. We find that the public healthcare system redistributes resources from better-off quintiles to worse-off quintiles (Gini coefficient reduction induced by public healthcare system = 0.5%). PHC receives less financing than secondary/tertiary care but delivers a larger reduction in income inequality. The Sierra Leone public healthcare system redistributes resources and reduces income inequality. However, the redistributive effect occurs largely thanks to PHC services being markedly pro-poor, and the Sierra Leone health system could be more equitable. Policy-makers interested in improving Sierra Leone public health system equity and reducing income inequalities should prioritize PHC investments.

The effect of health financing systems on health system outcomes: A cross-country panel analysis.

Several low- and middle-income countries are considering health financing system reforms to accelerate progress toward universal health coverage (UHC). However, empirical evidence of the effect of health financing systems on health system outcomes is scarce, partly because it is difficult to quantitatively capture the 'health financing system'. We assign country-year observations to one of three health financing systems (i.e., predominantly out-of-pocket, social health insurance (SHI) or government-financed), using clustering based on out-of-pocket, contributory SHI and non-contributory government expenditure, as a percentage of total health expenditures. We then estimate the effect of these different systems on health system outcomes, using fixed effects regressions. We find that transitions from OOP-dominant to government-financed systems improved most outcomes more than did transitions to SHI systems. Transitions to government financing increases life expectancy (+1.3 years, p < 0.05) and reduces under-5 mortality (-8.7%, p < 0.05) and catastrophic health expenditure incidence (-3.3 percentage points, p < 0.05). Results are robust to several sensitivity tests. It is more likely that increases in non-contributory government financing rather than SHI financing improve health system outcomes. Notable reasons include SHI's higher implementation costs and more limited coverage. These results may raise a warning for policymakers considering SHI reforms to reach UHC.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries.

BACKGROUND: The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs. METHODS: This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs. RESULTS: We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality. CONCLUSIONS: Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

Economics of healthcare access in low-income and middle-income countries: a protocol for a scoping review of the economic impacts of seeking healthcare on slum-dwellers compared with other city residents.

INTRODUCTION: People living in slums face several challenges to access healthcare. Scarce and low-quality public health facilities are common problems in these communities. Costs and prevalence of catastrophic health expenditures (CHE) have also been reported as high in studies conducted in slums in developing countries and those suffering from chronic conditions and the poorest households seem to be more vulnerable to financial hardship. The COVID-19 pandemic may be aggravating the economic impact on the extremely vulnerable population living in slums due to the long-term consequences of the disease. The objective of this review is to report the economic impact of seeking healthcare on slum-dwellers in terms of costs and CHE. We will compare the economic impact on slum-dwellers with other city residents. METHODS AND ANALYSIS: This scoping review adopts the framework suggested by Arksey and O'Malley. The review is part of the accountability and responsiveness of slum-dwellers (ARISE) research consortium, which aims to enhance accountability to improve the health and well-being of marginalised populations living in slums in India, Bangladesh, Sierra Leone and Kenya. Costs of accessing healthcare will be updated to 2020 prices using the inflation rates reported by the International Monetary Fund. Costs will be presented in International Dollars by using purchase power parity. The prevalence of CHE will also be reported. ETHICS AND DISSEMINATION: Ethical approval is not required for scoping reviews. We will disseminate our results alongside the events organised by the ARISE consortium and international conferences. The final manuscript will be submitted to an open-access international journal. Registration number at the Research Registry: reviewregistry947.

Socioeconomic inequality in life expectancy in India.

INTRODUCTION: Concern for health inequalities is an important driver of health policy in India; however, much of the empirical evidence regarding health inequalities in the country is piecemeal focusing only on specific diseases or on access to particular treatments. This study estimates inequalities in health across the whole life course for the entire Indian population. These estimates are used to calculate the socioeconomic disparities in life expectancy at birth in the population. METHODS: Population mortality data from the Indian Sample Registration System were combined with data on mortality rates by wealth quintile from the National Family Health Survey to calculate wealth quintile specific mortality rates. Results were calculated separately for males and females as well as for urban and rural populations. Life tables were constructed for each subpopulation and used to calculate distributions of life expectancy at birth by wealth quintile. Absolute gap and relative gap indices of inequality were used to quantify the health disparity in terms of life expectancy at birth between the richest and poorest fifths of households. RESULTS: Life expectancy at birth was 65.1 years for the poorest fifth of households in India as compared with 72.7 years for the richest fifth of households. This constituted an absolute gap of 7.6 years and a relative gap of 11.7 %. Women had both higher life expectancy at birth and narrower wealth-related disparities in life expectancy than men. Life expectancy at birth was higher across the wealth distribution in urban households as compared with rural households with inequalities in life expectancy widest for men living in urban areas and narrowest for women living in urban areas. CONCLUSION: As India progresses towards Universal Health Coverage, the baseline social distributions of health estimated in this study will allow policy makers to target and monitor the health equity impacts of health policies introduced.

Financial incentives in health: New evidence from India's Janani Suraksha Yojana.

This paper studies the health effects of one of the world's largest demand-side financial incentive programmes--India's Janani Suraksha Yojana. Our difference-in-difference estimates exploit heterogeneity in the implementation of the financial incentive programme across districts. We find that cash incentives to women were associated with increased uptake of maternity services but there is no strong evidence that the JSY was associated with a reduction in neonatal or early neonatal mortality. The positive effects on utilisation are larger for less educated and poorer women, and in places where the cash payment was most generous. We also find evidence of unintended consequences. The financial incentive programme was associated with a substitution away from private health providers, an increase in breastfeeding and more pregnancies. These findings demonstrate the potential for financial incentives to have unanticipated effects that may, in the case of fertility, undermine the programme's own objective of reducing mortality.

Heterogeneity in self-assessed health status among the elderly in India.

The authors examine the observed heterogeneity in self-assessed health (SAH) among the aged in India using data on health and living conditions of the elderly in India from the 60th Round of National Sample Survey (2004-2005). Results indicate that almost one fourth of the old in India rate their health as poor, and there exists considerable interstate variations in SAH ratings. Based on hypotheses framed on the basis of preliminary evidence, the article uses ordered probit models to find that probabilities of reporting poor health are increasingly clustered and more likely among the poor, single, lower-educated, and economically inactive groups among the elderly, with those states with a higher proportion of older people reporting poor subjective health status. Physical mobility appears to have a strong and direct bearing on SAH. The authors also identify unobserved heterogeneity among the states and also among the health rating categories.