Sustainable financing for vaccination towards advancing universal health coverage in the WHO African region: The strategic role of national health insurance.

There is a growing political interest in health reforms in Africa, and many countries are choosing national health insurance as their main financing mechanism for universal health coverage. Although vaccination is an essential health service that can influence progress toward universal health coverage, it is not often prioritized by these national health insurance systems. This paper highlights the potential gains of integrating vaccination into the package of health services that is provided through national health insurance and recommends practical policy actions that can enable countries to harness these benefits at population level.

Factors inhibiting and enabling performance-based financing in health care delivery across low and middle-income countries: a scoping review

Background: Emerging financing strategies in the health sector have been developed to improve the impact of investments and enhance healthcare outcomes. One promising approach is Results-based Financing, which establishes a connection between financial incentives and pre-established performance targets. This innovative approach holds the potential to strengthenhealthcare delivery and strengthen overall healthcare systems.Aim:The scoping review endeavored to systematically delineate the body of evidence pertaining tofacilitators and barriers to the implementation of performance-based financing within the realm of healthcare provision in low-and middle-income nations.Methods:The review used Preferred Reporting Items for Systematic Reviews and a Meta-Analysis extension for Scoping Reviews checklist to select, appraise, and report the findings. We searched PubMed, Web of Science, and Google Scholar databases and grey literature published between January 2000 and March 2022. We conducted the abstract screening with two independent reviewers. We also performed full-article screening. We used the six methodological frameworks proposed by Arksey and O'Malley. The results were thematically analyzed.Results:Of the 1071 searched studies, 34 met the eligibility criteria. 41% of the studies were descriptive, 26% cross-sectional, 18% trial, and 15% cohort studies. The enabling and inhibiting factors of performance-based financing in healthcaredelivery have been identified. Moreover, the review revealed that performance-based financing's influence on service delivery is context-specific.Conclusion:The facilitators and impediments to the effectiveness of performance-based financing in enhancing service delivery are contingent upon a holistic comprehension of the contextual factors, meticulous design, and efficient execution. Factors such as the level of care facilities, presence of community-based initiatives, stakeholder involvement, and participatory design emerge as key facilitators. Conversely, barriers such as communication obstacles, inadequacies in the PBF models, and deficiencies in the healthcare workforce are recognized as inhibitors. By harnessing the insights derived from a multitude of evidence incorporated in this scrutiny, stakeholders can deftly navigate the intricacies of performance-based financing, while also considering the prospective areas for further exploration and research

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.

Impact of federalization for health financing and workforce in Nepal.

The adoption of its 2015 constitution has converted Nepal to a federal government while simultaneously resulted in significant reforms of the health system in Nepal in terms of both structure and commitment. In this commentary, we review evidence ranging from health financing to health workforce development to show that the impact of federalization on Nepal's health system and its efforts to achieve equitable and affordable universal health care have been mixed. On the one hand, careful efforts of the federal government to support subnational governments during the transition appears to have avoided serious disruption, subnational governments have successfully taken on the financial burden of the health system, and increase subnational control has allowed more flexible adaptation to changing needs than might have otherwise been possible. On the other hand, financing resource and ability disparities across subnational governments contributes to significant disparities in workforce development, and subnational authorities appear to have underestimated significant health issues (e.g. NCDs) in their budgets. We then provide three recommendations to improve the success of the Nepalese system: (1) to assess whether the services covered by health financing and insurance schemes like the National Health Insurance Program adequately address the needs of the rising burden of NCDs in Nepal, (2) to set clear minimum requirements on key metrics for subnational health systems, and (3) to extend grant programs to address resource disparities.

Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective".

Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a National Health Insurance Scheme (NHIS). This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda's experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up NHISs.

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.

Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence.

Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF "works"-that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank's repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region-either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.

Strategic Health Purchasing in Nigeria: Investigating Governance and Institutional Capacities within Federal Tax-Funded Health Schemes and the Formal Sector Social Health Insurance Programme.

For Nigeria to make progress on its commitment to universal health coverage, additional public funding will be required. But more resources alone will not be enough. Government health spending must be more efficient and effective, through more strategic purchasing-a critical policy tool. Studies on health purchasing in Nigeria's health financing schemes are limited, however. This study examines the purchasing arrangements in schemes funded by the federal budget and in the Formal Sector Social Health Insurance Programme (FSSHIP) within the National Health Insurance Scheme. We adopted a qualitative, descriptive case-study approach and collected data through document reviews and key informant interviews based on the Strategic Health Purchasing Progress Tracking Framework. Our analysis used a thematic framework approach. Our findings reveal that legal frameworks and governance structures for strategic purchasing are in place for both schemes. Steps toward strategic purchasing are more advanced in FSSHIP, particularly in the design of benefit packages, accreditation and monitoring of health maintenance organizations (HMOs) and providers, and provider payment mechanisms. The limited share of health funding flowing through these mechanisms, and further fragmentation of that funding, impede strategic purchasing. Strategic purchasing is also hampered by weak regulation and monitoring of providers and purchasers, delays in provider payment, and corrupt practices by HMOs. Improving strategic purchasing in Nigeria will require a concerted effort to reduce fragmentation of health spending, significant investment in human resources, technical know-how, and information systems of purchasing institutions, and actions to improve the accountability of all actors in the system.

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.

Global collective action in mental health financing: Allocation of development assistance for mental health in 142 countries, 2000-2015.

Collective action between international donors is central to the mobilisation of global solidarity in global health. This is especially important in mental health where resources remain extremely limited. In this paper I investigate global collective action in mental health financing, looking at the responsiveness of international donors to mental health needs in low- and middle-income countries (LMICs). I analyse factors at the level of recipient countries (needs, interests, policy environment) associated with allocation of development assistance for mental health (DAMH) using a two-part regression model applied to a time series cross-sectional dataset of 142 LMICs between 2000 and 2015. Findings reveal that international donors' disbursements are not well aligned with mental health needs of recipient countries, and, moreover, contextual factors might be playing more prominent roles in resource allocation. Countries are more likely to receive DAMH if they experience significant outbreaks of infectious diseases or have lower gross domestic product (GDP) per capita and lower market openness. Selected recipient countries are more likely to receive higher DAMH amounts per capita if they have lower GDP per capita, higher government health expenditure, or higher mortality rates due to conflicts or natural disasters. Past DAMH recipients are more likely to be selected and, when selected, to receive higher DAMH amounts per capita. My results demonstrate that more holistic collective action amongst international donors is required to address mental health needs in LMICs. Investments should better reflect needs, particularly during and after emergencies such as COVID-19, and could be amplified by leveraging synergies across other health conditions and sectors.

Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives.

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing policies to expand health insurance coverage and achieve better access to quality healthcare for all. Recent reforms have included improved community health funds (iCHFs), and others are underway to implement a mandatory national health insurance scheme in order to expand access to services and improve financial risk protection. Governance is a crucial structural determinant for the successful implementation of health financing reforms, however there is little understanding of the governance elements that hinder the implementation of health financing reforms such as the iCHF in Tanzania. Therefore, this study used the perspectives of health sector stakeholders to explore governance factors that influence the implementation of health financing reforms in Tanzania. We interviewed 36 stakeholders including implementers of health financing reforms, policymakers and health insurance beneficiaries in the regions of Dodoma, Dar es Salaam and Kilimanjaro. Normalisation process theory and governance elements guided the structure of the in-depth interviews and analysis. Governance factors that emerged from participants as facilitators included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of iCHF enrolment due to digitisation of registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from community level and limited resources due to iCHF design. If stakeholders do not address the governance factors that hinder the implementation of health financing reforms, then current efforts to expand health insurance coverage are unlikely to succeed on their own.

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.

Variations in funding for treatment of obstructive sleep apnoea in England.

OBJECTIVES: This study aimed to review the funding policies of clinical commissioning groups for treatment of obstructive sleep apnoea in England. METHODS: Published policies from a randomly selected sample of 60 out of 190 clinical commissioning groups were reviewed. RESULTS: Continuous positive airway pressure was funded based on a clinical assessment or according to criteria that were in line with national guidelines in most clinical commissioning groups (49 of 60), with 11 clinical commissioning groups offering no policy. Mandibular advancement devices, tonsillectomy and nasal surgery were funded based on a clinical assessment or certain criteria in 16, 25 and 16 clinical commissioning groups, respectively. In contrast, only one clinical commissioning group provided funding for soft palate, tongue base or mandibular surgery. Hypoglossal nerve stimulation was not mentioned in any clinical commissioning group's policy. CONCLUSION: Although most clinical commissioning groups provide funding for the use of continuous positive airway pressure, the availability of funding for other obstructive sleep apnoea treatment modalities is heterogeneous, leaving continuous positive airway pressure intolerant patients with limited therapeutic options in some regions.

Crowdfunding Campaigns and COVID-19 Misinformation.

Objectives. To understand whether and how crowdfunding campaigns are a source of COVID-19-related misinformation.Methods. We searched the GoFundMe crowdfunding platform using 172 terms associated with medical misinformation about COVID-19 prophylaxes and treatments. We screened resulting campaigns for those making statements about the ability of these searched-for or related terms to prevent or treat COVID-19.Results. There were 208 campaigns worldwide that requested $21 475 568, raised $324 305 from 4367 donors, and were shared 24 158 times. The most discussed interventions were dietary supplements and purported immune system boosters (n = 231), followed by other forms of complementary and alternative medicine (n = 24), and unproven medical interventions (n = 15). Most (82.2%) of the campaigns made definitive efficacy claims.Conclusions. Campaigners focused their efforts on dietary supplements and immune system boosters. Campaigns for purported COVID-19 treatments are particularly concerning, but purported prophylaxes could also distract from known effective preventative approaches. GoFundMe should join other online and social media platforms to actively restrict campaigns that spread misinformation about COVID-19 or seek to better inform campaigners about evidence-based prophylaxes and treatments.

What was lost, missing, sought and hoped for: Qualitatively exploring medical crowdfunding campaign narratives for Lyme disease.

Lyme disease remains a contested illness in Canada, thereby making the diagnostic and treatment journeys difficult for some people. One outcome of this is that increasing numbers of people are turning to medical crowdfunding to support access to alternative therapies, non-local health care providers and assist with managing the costs of everyday life. In this analysis, we qualitatively explore the narratives shared in Canadians' crowdfunding campaigns to support Lyme disease treatment or diagnosis to identify whether or not any common elements shared in these narratives exist, and if so, what they are. We identified 238 campaigns for inclusion from three prominent crowdfunding platforms. Thematic analysis of the campaign narratives shows four consistent themes shared in these campaigns: what is lost (e.g. bodily ability), what is missing (e.g. local care options), what is sought (e.g. funds to cover treatment abroad) and what is hoped for (e.g. return to wellbeing). These themes demonstrate the highly personal and emotional nature of medical crowdfunding, particularly in the context of a contested illness that may lead some to question the legitimacy of one's financial need. This analysis contributes valuable new insights to the nascent scholarship on medical crowdfunding, and particularly to our understanding of how people communicate about their health and bodily needs on this public platform. It also identifies important directions for future research, including the potential for crowdfunding narratives to be used for advocacy.

Health and well-being and the 2030 agenda for sustainable development in the WHO European region: an analysis of policy development and implementation. Report of the first survey to assess Member States’ activities in relation to the WHO European region roadmap to implement the 2030 agenda for sustainable development

This report presents an analysis of policy, governance and implementation arrangements to achieve health and well-being for all at all ages and the Sustainable Development Goals (SDGs) in Member States of the WHO European Region. The analysis was based on a survey in 2019 that was completed by 29 Member States. Results show that Member States have prioritized implementation of the 2030 Agenda for Sustainable Development and integration of the SDGs into relevant planning frameworks. Integration has been facilitated through the creation or adaptation of institutional arrangements with leadership from high levels of government and participation of all sectors of society. More action is required to advance governance and leadership for health and well-being through a more holistic lens that encompasses a life-course approach, considers the determinants of health and invests in preparedness, prevention and resilience. Mechanisms were identified that facilitated intersectoral collaboration and improved accountability. The findings can be used by health stakeholders to identify solutions that can be adapted to the specific contexts of their institution, community or country to support achievement of the health and well-being goals and ultimately the SDGs. Findings can also be used by multilateral organizations and development partners to inform their role in fostering change and creating an enabling environment for the achievement of the SDGs.

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.

Empirical Investigation of Ethical Challenges Related to the Use of Biological Therapies.

The aim of this study was to investigate the ethical dilemma of prioritising financial resources to expensive biological therapies. For this purpose, the four principles of biomedical ethics formulated by ethicists Tom Beauchamp and James Childress were used as a theoretical framework. Based on arguments of justice, Beauchamp and Childress advocate for a health care system organised in line with the Danish system. Notably, our study was carried out in a Danish setting.