The rationale for South Africa to prioritise mental health care as a critical aspect of overall health care.

BACKGROUND: The publication of South Africa's National Mental Health Policy Framework and Strategic Plan 2023-2030 and the proposed National Health Insurance (NHI) make it timely to review that state of mental health services in the country, and to emphasize the importance of prioritising mental health as a pivotal component of holistic healthcare. METHOD: We searched the published literature on mental health using Google Scholar, Pubmed, and Bing Chat, focusing on these words: epidemiology of mental health disorders, depression and anxiety disorders, mental health services, mental health facilities, human resources, financing and impact of COVID-19 on mental health in South Africa and beyond. We also searched the grey literature on mental health policy that is publicly available on Google. RESULTS: We provided information on the epidemiology and economic impact of mental health disorders, the availability of mental health services, enabling policies, human resources, financing, and the infrastructure for mental health service delivery in South Africa. We detail the high lifetime prevalence rates of common mental disorders, as well as the profound impact of socioeconomic determinants such as poverty, unemployment, and trauma on mental health disorders. We note the exacerbating effect of the COVID-19 pandemic, and emphasize the pressing need for a robust mental health care system. CONCLUSION: In addition to outlining the challenges, such as limited mental health service availability, a shortage of mental health professionals, and financial constraints, the review proposes potential solutions, including task-sharing, telehealth, and increasing the production of mental health professionals. The paper underscores the necessity of crafting a comprehensive NHI package of mental health services tailored to the local context. This envisioned package would focus on evidence-based interventions, early identification, and community-based care. By prioritising mental health and addressing its multifaceted challenges, South Africa can aspire to render accessible and equitable mental health services for all its citizens within the framework of the National Health Insurance.

Governing Integrated Health and Social Care: An Analysis of Experiences in Three European Countries.

Purpose: Achieving greater health and social care integration is a policy priority in many countries, but challenges remain. We focused on governance and accountability for integrated care and explored arrangements that shape more integrated delivery models or systems in Italy, the Netherlands and Scotland. We also examined how the COVID-19 pandemic affected existing governance arrangements. Design/methodology/approach: A case study approach involving document review and semi-structured interviews with 35 stakeholders in 10 study sites between February 2021 and April 2022. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to guide our analytical enquiry. Findings: Study sites ranged from bottom-up voluntary agreements in the Netherlands to top-down mandated integration in Scotland. Interviews identified seven themes that were seen to have helped or hindered integration efforts locally. Participants described a disconnect between what national or regional governments aspire to achieve and their own efforts to implement this vision. This resulted in blurred, and sometimes contradictory, lines of accountability between the centre and local sites. Flexibility and time to allow for national policies to be adapted to local contexts, and engaged local leaders, were seen to be key to delivering the integration agenda. Health care, and in particular acute hospital care, was reported to dominate social care in terms of policies, resource allocation and national monitoring systems, thereby undermining better collaboration locally. The pandemic highlighted and exacerbated existing strengths and weaknesses but was not seen as a major disruptor to the overall vision for the health and social care system. Research limitations: We included a relatively small number of interviews per study site, limiting our ability to explore complexities within sites. Originality: This study highlights that governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration.

Developing the improved Community Health Fund in Tanzania: was it a fair process?

Tanzania developed its 2016-26 health financing strategy to address existing inequities and inefficiencies in its health financing architecture. The strategy suggested the introduction of mandatory national health insurance, which requires long-term legal, interministerial and parliamentary procedures. In 2017/18, improved Community Health Fund (iCHF) was introduced to make short-term improvements in coverage and financial risk protection for the informal sector. Improvements involved purchaser-provider split, portability of services, uniformity in premium and risk pooling at the regional level. Using qualitative methods and drawing on the policy analysis triangle framework (context, content, actors and process) and criteria for procedural fairness, we examined the decision-making process around iCHF and the extent to which it met the criteria for a fair process. Data collection involved a document review and key informant interviews (n = 12). The iCHF reform was exempt from following the mandatory legislative procedures, including processes for involving the public, for policy reforms in Tanzania. The Ministry of Health, leading the process, formed a technical taskforce to review evidence, draw lessons from pilots and develop plans for implementing iCHF. The taskforce included representatives from ministries, civil society organizations and CHF implementing partners with experience in running iCHF pilots. However, beneficiaries and providers were not included in these processes. iCHF was largely informed by the evidence from pilots and literature, but the evidence to reduce administrative cost by changing the oversight role to the National Health Insurance Fund was not taken into account. Moreover, the iCHF process lacked transparency beyond its key stakeholders. The iCHF reform provided a partial solution to fragmentation in the health financing system in Tanzania by expanding the pool from the district to regional level. However, its decision-making process underscores the significance of giving greater consideration to procedural fairness in reforms guided by technical institutions, which can enhance responsiveness, legitimacy and implementation.

The value of maternity care in Queensland, 2012-18, based on an analysis of administrative data: a retrospective observational study.

OBJECTIVE: To quantify the value of maternity health care - the relationship of outcomes to costs - in Queensland during 2012-18. STUDY DESIGN: Retrospective observational study; analysis of Queensland Perinatal Data Collection data linked with the Queensland Health Admitted Patient, Non-Admitted Patient, and Emergency Data Collections, and with the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) databases. SETTING, PARTICIPANTS: All births in Queensland during 1 July 2012 - 30 June 2018. MAIN OUTCOME MEASURES: Maternity care costs per birth (reported in 2021-22 Australian dollars), both overall and by funder type (public hospital funders, MBS, PBS, private health insurers, out-of-pocket costs); value of care, defined as total cost per positive birth outcome (composite measure). RESULTS: The mean cost per birth (all funders) increased from $20 471 (standard deviation [SD], $17 513) during the second half of 2012 to $30 000 (SD, $22 323) during the first half of 2018; the annual total costs for all births increased from $1.31 billion to $1.84 billion, despite a slight decline in the total number of births. In a mixed effects linear analysis adjusted for demographic, clinical, and birth characteristics, the mean total cost per birth in the second half of 2018 was $9493 higher (99.9% confidence interval, $8930-10 056) than during the first half of 2012. The proportion of births that did not satisfy our criteria for a positive birth outcome increased from 27.1% (8404 births) during the second half of 2012 to 30.5% (9041 births) during the first half of 2018. CONCLUSION: The costs of maternity care have increased in Queensland, and many adverse birth outcomes have become more frequent. Broad clinical collaboration, effective prevention and treatment strategies, as well as maternal health services focused on all dimensions of value, are needed to ensure the quality and viability of maternity care in Australia.

The political economy of financing traditional vaccines and vitamin A supplements in six African countries.

Vaccines and vitamin A supplementation (VAS) are financed by donors in several countries, indicating that challenges remain with achieving sustainable government financing of these critical health commodities. This qualitative study aimed to explore political economy variables of actors' interests, roles, power and commitment to ensure government financing of vaccines and VAS. A total of 77 interviews were conducted in Burundi, Comoros, Ethiopia, Madagascar, Malawi and Zimbabwe. Governments and development partners had similar interests. Donor commitment to vaccines and VAS was sometimes dependent on the priorities and political situation of the donor country. Governments' commitment to financing vaccines was demonstrated through policy measures, such as enactment of immunization laws. Explicit government financial commitment to VAS was absent in all six countries. Some development partners were able to influence governments directly via allocation of health funding while others influenced indirectly through coordination, consolidation and networks. Government power was exercised through multiple systemic and individual processes, including hierarchy, bureaucracy in governance and budgetary process, proactiveness of Ministry of Health officials in engaging with Ministry of Finance, and control over resources. Enablers that were likely to increase government commitment to financing vaccines and VAS included emerging reforms, attention to the voice of citizens and improvements in the domestic economy that in turn increased government revenues. Barriers identified were political instability, health sector inefficiencies, overly complicated bureaucracy, frequent changes of health sector leadership and non-health competing needs. Country governments were aware of their role in financing vaccines, but only a few had made tangible efforts to increase government financing. Discussions on government financing of VAS were absent. Development partners continue to influence government health commodity financing decisions. The political economy environment and contextual factors work together to facilitate or impede domestic financing.

Challenges for Medicare and universal health care in Australia since 2000.

OBJECTIVES: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening. STUDY DESIGN: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded. DATA SOURCES: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites. RESULTS: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system. CONCLUSIONS: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

Willingness to pay for a National Health Insurance Scheme in The Gambia: a contingent valuation study.

In pursuit of universal health coverage, many low- and middle-income countries are reforming their health financing systems and introducing health insurance schemes. As part of these reforms, lawmakers in The Gambia enacted 'The National Health Insurance Bill, 2021'. The Act will establish a National Health Insurance Scheme (NHIS) that pays for the cost of healthcare services for its members. This study assessed Gambians' willingness to pay (WTP) for a NHIS. Using multistage sampling design with no replacement, head/co-head of households were presented with a hypothetical health insurance scheme from July to August 2020. Their WTP and factors influencing WTP were elicited using a contingent valuation method. Descriptive statistics were used to describe sample characteristics. Lopez-Feldman's modified ordered probit model and linear regression were applied to estimate respondents' WTP as well as identify factors that influence their WTP. More than 90% of the respondents-677 (94.4%) were willing to join and pay for the scheme. Half of these respondents-398 (58.8%) agreed to pay the first bid of US dollars (US$) 20.78 or Gambian dalasi (GMD) 1000. The average WTP was estimated at US$23.27 (GMD1119.82), whereas average maximum amount to pay was US$26.01 (GMD1251.16). Results of the two models together showed that gender, level of education and household income were statistically significant, with the latter showing negative influence on WTP. The study found that Gambians were largely receptive to the scheme and have stated their willingness to contribute. Our findings can inform policymakers in The Gambia and other sub-Saharan countries when establishing contribution rates and exemption criteria during social health insurance scheme implementation.

Progressivity of out-of-pocket costs under Australia's universal health care system: A national linked data study.

BACKGROUND: In line with affordability and equity principles, Medicare-Australia's universal health care program-has measures to contain out-of-pocket (OOP) costs, particularly for lower income households. This study examined the distribution of OOP costs for Medicare-subsidised out-of-hospital services and prescription medicines in Australian households, according to their ability to pay. METHODS: OOP costs for out-of-hospital services and medicines in 2017-18 were estimated for each household, using 2016 Australian Census data linked to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefit Scheme (PBS) claims. We derived household disposable income by combining income information from the Census linked to income tax and social security data. We quantified OOP costs as a proportion of equivalised household disposable income and calculated Kakwani progressivity indices (K). RESULTS: Using data from 82% (n = 6,830,365) of all Census private households, OOP costs as a percentage of equivalised household disposable income decreased from 1.16% in the poorest decile to 0.63% in the richest decile for MBS services, and from 1.35% to 0.35% for PBS medicines. The regressive trend was less pronounced for MBS services (K = -0.06), with percentage OOP cost relatively stable between the 2nd and 9th income deciles; while percentage OOP cost decreased with increasing income for PBS medicines (K = -0.24). CONCLUSION: OOP costs for out-of-hospital Medicare services were mildly regressive while those for prescription medicines were distinctly regressive. Actions to reduce inequity in OOP costs, particularly for medicines, should be considered.

National health insurance contribution to family planning program funding in Indonesia: A fund flow analysis.

Background: Launched in 2014, Indonesia's national health insurance system (JKN) aimed to provide universal health coverage, including contraceptive services, to its population. We aim to evaluate the contribution of JKN to the overall spending for the family planning program in Indonesia. Methods: Data from the Indonesian Demographic Health Survey, Survey on Financial Flows for Family Planning, Indonesia Motion Tracker Matrix, World Population Prospect, and Indonesian ministries' budget accountability reports were entered into the CastCost Contraceptive Projection Tool to define budgetary allocation and spending for the family planning program at the national level in 2019. Results: Indonesia's family planning program in 2019 was financed mostly by the national budget (64.0%) and out-of-pocket payments (34.6%). There were three main ministries responsible for family planning financing: the National Population and Family Planning Board (BKKBN) (35.8%), the Ministry of Finance (26.2%), and the Ministry of Health (2.0%). Overall, JKN contributed less than 0.4% of the funding for family planning services in Indonesia in 2019. The majority of family planning spending was by public facilities (57.3%) as opposed to private facilities (28.6%). Conclusion: JKN's contribution to funding Indonesia's family planning programs in 2019 was low and highlights a huge opportunity to expand these contributions. A coordinated effort should be conducted to identify possible opportunities to realign BKKBN and JKN roles in the family planning programs and lift barriers to accessing family planning services in public and private facilities. This includes a concerted effort to improve integration of private family planning providers into the JKN program.

The Landscape of Strategic Health Purchasing for Universal Health Coverage in Burkina Faso: Insights from Five Major Health Financing Schemes.

Strategic health purchasing is a key strategy in Burkina Faso to spur progress toward universal health coverage (UHC). However, a comprehensive analysis of existing health financing arrangements and their purchasing functions has not been undertaken to date. This article provides an in-depth analysis of five key health financing schemes in Burkina Faso: Gratuité (a national free health care program for women and children under age 5), crédits délégués (delegated credits), crédits transférés (transfers to municipalities), community-based health insurance, and occupation-based health insurance. This study involved a document review and complementary key informant interviews using the Strategic Health Purchasing Progress Tracking Framework developed by the Strategic Purchasing Africa Resource Center (SPARC). Data were collected using the framework's accompanying Microsoft Excel-based tool. We analyzed the data manually to examine and identify the strengths and weaknesses of governance arrangements and purchasing functions and capacities. The study provides insight into areas that are working well from a strategic purchasing perspective and, more importantly, areas that need more attention. Areas for improvement include low financial and managerial autonomy for some schemes, weak accountability measures, lack of explicit quality standards for contracting and for service delivery, budget overruns and late provider payment, provider payment that is not linked to provider performance, fragmented health information systems, and information generated is not linked to purchasing decisions. Improvements in purchasing functions are required to address shortcomings while consolidating achievements. This study will inform next steps for Burkina Faso to improve purchasing and advance progress toward UHC.

The influence of the National Health Insurance scheme of the Lao People's Democratic Republic on healthcare access and catastrophic health expenditures for patients with chronic renal disease, and the possibility of integrating organ transplantation into the health financing system.

Citizens of the Lao People's Democratic Republic have difficulties in obtaining proper health services compared to more developed countries, due to the lack of available health facilities and health financing programmes. Haemodialysis (HD) is currently included under the coverage of the National Health Insurance (NHI) scheme. However, there are several technical barriers related to health service utilization. This study aims to analyse the effects of the Lao NHI on issues of accessibility and the possibility of encountering catastrophic health expenditures for patients with chronic kidney disease. In addition, the study provides policy recommendations for policy-makers regarding the provision of organ transplantation under NHI in the future. Savannakhet Province was purposively selected as a study site, where 342 respondents participated in the study. Two logistic regression models are used to assess the effectiveness of the NHI in terms of accessibility and financial protection against catastrophic health expenditures. The Andersen behavioural model is applied as a guideline to identify factors that affect accessibility and economic catastrophe. NHI is found to improve accessibility to health service utilization for household members with chronic kidney disease. However, due to the limited HD services, there are barriers to accessing health services and a risk of financial hardship due to nonmedical expenditures. Chronic conditions, in addition to kidney issues, dramatically increase the chances of suffering catastrophic health expenditures. In the short run, collaboration with neighbouring countries' hospitals through copayment programmes is strongly recommended for NHI's policy-makers. For long-term policy guidelines, the government should move forward to include kidney transplantation in the NHI healthcare system.

Health Coverage and Financial Protection in Uganda: A Political Economy Perspective.

BACKGROUND: As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. METHODS: The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector. RESULTS: We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. CONCLUSION: By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

Implementation bottlenecks of the National Health Insurance program in Nepal: Paving the path towards Universal Health Coverage: A qualitative study.

Most low and low-middle income countries adopting National Health Insurance (NHI) programs to achieve Universal Health Coverage are struggling to implement the program due to underlying problems at implementation. However, there is a lack of research that focuses on these problems. The Nepal NHI program initiated in 2016 has experienced numerous implementation challenges. This qualitative study delves into the NHI program's inputs and throughputs/implementation bottlenecks. The study based in Nepal's four districts included 28 in-depth interviews, six focus group discussions, and identified 12 themes that pointed to the NHI program's inadequate inputs causing bottlenecks. The analysis employed the Grounded Theory. The main challenges identified were insufficiently defined NHI implementations guidelines, conflicting Act clauses, a lack of HIB organizational guidelines, and inadequate human resources. The major throughput bottlenecks were difficulty enrolling the insurees, the inability to select the health providers competitively and to act as a prudent purchaser of the services. These inadequate inputs and throughput bottlenecks led to negative outputs such as insurees' high dropouts, and low coverage of poor households. The NHI program's sustainability might be at stake if the identified problems persist, further exacerbated by the plummeting economic situation in the country due to COVID-19.

Strategic Health Purchasing Progress Mapping in Cameroon: A Scoping Review.

Many low- and middle-income countries are adopting far-reaching health financing policies using strategic health purchasing (SHP) approaches to address their health sector challenges. However, limited efforts have been directed toward analyzing the SHP activities nationwide. Our objective was to explore the scope and development of SHP in Cameroon. We conducted a scoping review applying the framework developed by Arksey and O'Malley and modified by Levac et al. to identify and extract data from relevant SHP studies and documents published between 2000 and 2019, which focused on Cameroon. Among the existing 30 health financing schemes, 5 present the elements of SHP: (1) national health insurance (NHI), (2) performance-based financing (PBF), (3) voucher system, (4) private health insurance, and (5) mutual health organizations. The findings suggest that the governance function of purchasing is very challenging due to the multiple purchaser markets and the resulting fragmentation of the health financing system. In addition, the misalignment of the different benefit packages across schemes leads to considerable gaps and overlaps in the population coverage. The issue of multiple highly fragmented payment systems also remains a big concern across the different schemes, with tentative harmonization observed with NHI and PBF. Achieving the full potential of SHP in Cameroon will require (1) a defragmentation of the multiple schemes, (2) an effective oversight arrangement, and (3) an alignment of provider payment method to a coherent set of incentives across the system, with the ultimate aim of promoting equity, efficiency and quality.

Harnessing the Power of Networks of Care for Universal Health Coverage.

On the global health agenda, Universal Health Coverage has been displaced by the COVID-19 pandemic while disparities in COVID-19 outcomes have exposed stark gaps in quality, access, equity, and financial risk protection. These disparities highlight the importance of the core goals of Universal Health Coverage and the need for innovative approaches to working toward them. The newly codified concept of "Networks of Care" offers a promising option for implementation. The articles in this special issue present the Networks of Care lexicon and framework and demonstrate the development of leadership, responsibility, intra- and inter-facility cooperation, and dynamic cycles of quality improvement. These elements are associated with better access to services and better health outcomes, the ultimate goals of Universal Health Coverage. Increases in poverty, food insecurity, and deleterious impact on the status of women secondary to the COVID-19 pandemic add urgency to Universal Health Coverage, while the economic impact of pandemic mitigation may reduce availability of resources for years to come. The need for Universal Health Coverage and efficiency and flexibility in health spending, including the ability to contract directly, has become even more important. Countries where Universal Health Coverage efforts have yet to carry through to provision of good quality, accessible and equitable service delivery could potentially benefit from concurrent Networks of Care implementation. Documentation of Networks of Care in the context of Universal Health Coverage should be prioritized to understand how Networks of Care can be used to help realize the goals of Universal Health Coverage around the world.

Universal health coverage in India: Newer innovations and the role of public health.

The realization of Universal Health Coverage requires adequate healthcare financing and human resources to provide financial protection to the economically disadvantaged population by covering their medicine, diagnostics, and service costs. Conventionally, inadequate public healthcare financing and the lack of skilled human resources are considered as the major barriers towards achieving UHC in India. To strengthen the Indian healthcare system, there has been significant increase budgetary allocation towards healthcare, a national health protection scheme targeting low-income households, upgrading of primary health-care and expansion of the health work-force. Nevertheless, an evolving paradigm for improving holistic health, sanitation, nutrition, gender equity, drug accessibility and affordability, innovative initiatives in national health programs for reduction of maternal deaths, tuberculosis and HIV burden and the utilization of information technology in healthcare provision of the underserved and the marginalized is gaining rapid acceleration. These represent a genuine innovation towards fulfillment of UHC goals for India.

The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of cancer treatment.

"Financial toxicity" has now become a familiar term used in the discussion of cancer drugs, and it is gaining traction in the literature given the high price of newer classes of therapies. However, as a phenomenon in the contemporary treatment and care of people with cancer, financial toxicity is not fully understood, with the discussion on mitigation mainly geared toward interventions at the health system level. Although important, health policy prescriptions take time before their intended results manifest, if they are implemented at all. They require corresponding strategies at the individual patient level. In this review, the authors discuss the nature of financial toxicity, defined as the objective financial burden and subjective financial distress of patients with cancer, as a result of treatments using innovative drugs and concomitant health services. They discuss coping with financial toxicity by patients and how maladaptive coping leads to poor health and nonhealth outcomes. They cover management strategies for oncologists, including having the difficult and urgent conversation about the cost and value of cancer treatment, availability of and access to resources, and assessment of financial toxicity as part of supportive care in the provision of comprehensive cancer care. CA Cancer J Clin 2018;68:153-165. © 2018 American Cancer Society.

Ability to Pay for Future National Health Financing Scheme among Malaysian Households.

BACKGROUND: Malaysia is no exception to the challenging health care financing phenomenon of globalization. OBJECTIVES: The objective of the present study was to assess the ability to pay among Malaysian households as preparation for a future national health financing scheme. METHODS: This was a cross-sectional study involving representative samples of 774 households in Peninsular Malaysia. FINDINGS: A majority of households were found to have the ability to pay for their health care. Household expenditure on health care per month was between MYR1 and MYR2000 with a mean (standard deviation [SD]) of 73.54 (142.66), or in a percentage of per-month income between 0.05% and 50% with mean (SD) 2.74 (5.20). The final analysis indicated that ability to pay was significantly higher among younger and higher-income households. CONCLUSIONS: Sociodemographic and socioeconomic statuses are important eligibility factors to be considered in planning the proposed national health care financing scheme to shield the needed group from catastrophic health expenditures.

The imperative for systems thinking to promote access to medicines, efficient delivery, and cost-effectiveness when implementing health financing reforms: a qualitative study.

BACKGROUND: Health systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. Expansion of health insurance coverage offers promise in the quest for sustainable healthcare financing for many of the health systems in the region. However, the broader policy implications of expanding health insurance coverage have not been fully investigated and contextualized to many African health systems. METHODS: We interviewed 37 key informants drawn from public, private and civil society organizations involved in health service delivery in Botswana. The objective was to determine the potential health system impacts that would result from expanding the health insurance scheme covering public sector employees. Study participants were selected through purposeful sampling, stakeholder mapping, and snowballing. We thematically synthesized their views, focusing on the key health system areas of access to medicines, efficiency and cost-effectiveness, as intermediate milestones towards universal health coverage. RESULTS: Participants suggested that expansion of health insurance would be characterized by increased financial resources for health and catalyze an upsurge in utilization of health services particularly among those with health insurance cover. As a result, the health system, particularly within the private sector, would be expected to see higher demand for medicines and other health technologies. However, majority of the respondents cautioned that, realizing the full benefits of improved population health, equitable distribution and financial risk protection, would be wholly dependent on having sound policies, regulations and functional accountability systems in place. It was recommended that, health system stewards should embrace efficient and cost-effective delivery, in order to make progress towards universal health coverage. CONCLUSION: Despite the prospects of increasing financial resources available for health service delivery, expansion of health insurance also comes with many challenges. Decision-makers keen to achieve universal health coverage, must view health financing reform through the holistic lens of the health system and its interactions with the population, in order to anticipate its potential benefits and risks. Failure to embrace this comprehensive approach, would potentially lead to counterproductive results.

Sub-national health care financing reforms in Indonesia.

Indonesia has seen an emergence of local health care financing schemes over the last decade, implemented and operated by district governments. Often motivated by the local political context and characterized by a large degree of heterogeneity in scope and design, the common objective of the district schemes is to address the coverage gaps for the informal sector left by national social health insurance programs. This paper investigates the effect of these local health care financing schemes on access to health care and financial protection. Using data from a unique survey among District Health Offices, combined with data from the annual National Socioeconomic Surveys, the study is based on a fixed effects analysis for a panel of 262 districts over the period 2004-10, exploiting variation in local health financing reforms across districts in terms of type of reform and timing of implementation. Although the schemes had a modest impact on average, they do seem to have provided some contribution to closing the coverage gap, by increasing outpatient utilization for households in the middle quintiles that tend to fall just outside the target population of the national subsidized programs. However, there seems to be little effect on hospitalization or financial protection, indicating the limitations of local health care financing policies. In addition, we see effect heterogeneity across districts due to differences in design features.