Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries.

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

Фазои буҷетӣ барои тандурустӣ дар Ҷумҳурии Тоҷикистон: имкониятҳои ҷалби захираҳои давлатии иловагӣ

Барномаи ислоҳоти соҳаи тандурустии Ҷумҳурии Тоҷикистон ҷиҳати ноил шудан ба фарогирии умумӣ бо хизматрасониҳои тандурустӣ (ФУХТ) аз беҳтар намудани дастрасии тамоми аҳолӣ ба хизматрасонии тиббии баландсифат ва истифодаи самараноки захираҳои давлатӣ иборат аст. Стратегияи миллии тандурустии ба наздикӣ қабулшуда (Стратегияи ҳифзи солимии аҳолии Ҷумҳурии Тоҷикистон барои давраи то соли 2030) ба далелҳо ва тавсияҳои глобалӣ пайравӣ намуда, ба тавсеаи кумаки аввалияи тиббию санитарӣ такя мекунад. Барои татбиқи стратегия ба Ҷумҳурии Тоҷикистон лозим аст, ки маблағгузории давлатиро ба соҳаи тандурустӣ ба таври қобили мулоҳиза зиёд намояд ва захираҳоро ба он соҳае ҷудо намояд, ки онҳо самараи бештар доранд. Дар айни замон, захираҳои буҷетӣ барои кӯмаки аввалияи тиббию санитарӣ кофӣ нестанд ва дар саросари кишвар нобаробар тақсим карда мешаванд, ки дар натиҷа камбудиҳои ноодилона дар дастрасии хизматрасонии тиббӣ ба вуҷуд меоянд. Аз ин рӯ, дар истифодаи соҳаи тандурустӣ фарқиятҳои беасос вуҷуд доранд. Дар гузориши мазкур имкониятҳои алтернативии зиёд кардани фазои буҷетӣ барои саломатӣ, аз ҷумла захираҳои кӯмаки аввалияи тиббию санитарӣ тавсиф, таҳлил ва муқоиса шудаанд.

Фискальное пространство для сектора здравоохранения в Республике Таджикистан: варианты получения дополнительных финансовых ресурсов

Программа реформы здравоохранения Республики Таджикистан для достижения всеобщего охвата услугами здравоохранения (ВОУЗ) включает в себя улучшение доступа к качественной медицинской помощи для всего населения и более эффективное использование государственных ресурсов. Недавно принятая Национальная стратегия здравоохранения (Стратегия охраны здоровья населения Республики Таджикистан на период до 2030 г.) следует глобальным фактическим данным и рекомендациям и основывается на расширении первичной медико-санитарной помощи. Для реализации стратегии Республике Таджикистан необходимо в значительной степени увеличить государственное финансирование здравоохранения и направить ресурсы туда, где они дадут наибольший эффект. В настоящее время бюджетные ресурсы на первичную медико-санитарную помощь отстают и неравномерно распределяются по стране, что приводит к несправедливым пробелам в доступе к медицинской помощи. Следовательно, существуют необоснованные различия в использовании медицинских услуг. В этом отчете описываются, анализируются и сравниваются альтернативные возможности увеличения фискального пространства для здравоохранения, в частности ресурсов для первичной медико-санитарной помощи.

Budgetary space for health in the Republic of Tajikistan: options for more public resources

The Republic of Tajikistan’s health reform agenda to achieve universal health coverage includes improved access to high-quality health care for the entire population and more efficient use of public resources. The recently adopted National Health Strategy (Strategy for the Healthcare of the Population of the Republic of Tajikistan, 2021–2030) follows global evidence and recommendations, and builds on expanding primary health care. To implement the strategy, Tajikistan needs to increase considerably public funding for health and allocate resources to where they will have the most effect. Currently, budget resources for primary health care are lagging behind, and are unevenly distributed across the country, resulting in unjust gaps in health care access. Consequently, there are unjustified differences in health care utilization.This report describes, analyses and compares alternative opportunities to increase budgetary space for health, in particular resources for primary health care.

Assessment of appropriateness of hospitalisations in Ukraine: analytical framework, method and findings.

OBJECTIVES: This article reviews the applicability of a customised version of the Appropriateness Evaluation Protocol (AEP) to evaluate the magnitude of inappropriate hospitalisations in two regions of Ukraine. DATA AND METHODS: The original AEP was modified to develop a customised tool, which included criteria for the appropriateness of hospitalisation and duration of inpatient stay. The customisation of the tool followed the Delphi procedure. We randomly selected 381 medical records to test the feasibility and reliability of the method and 800 medical records to evaluate the scope of inappropriate hospitalisations. We used descriptive and analytical statistics, receiver operating characteristic curve analysis and Cohen's kappa to check the consistency between the findings of primary reviewers and experts. RESULT: We observed high levels of agreement in conclusions of primary reviewers (reference standard) and experts during testing of the reliability and validity of the method. The external validity check showed that the use of the tool by different experts provided high accuracy: 95.1 sensitivity, 76.6 specificity and area under ROC-curve (AUC)=0.948 (р<0.001) for analysis of the appropriateness of admissions; 95.3 sensitivity, 84.7 specificity and AUC=0.900 (р=0.001) for the duration of hospitalisations. Cohen's kappa coefficient (κ) indicated agreement in expert evaluations of 0.915 (95% СІ 0.799 to 1.000) and 0.812 (95% СІ 0.749 to 0.875), respectively.We found that over one-third of admissions (38.1%; 95% СІ 33.9 to 43.5) and over half of total bed-days were unnecessary (57.4%; 95% СІ 56.4 to 58.5). The highest levels of stay were observed in hospitals' general medicine departments (64.6%; 95% СІ 63.0 to 66.3)compared with other departments included in the analysis. CONCLUSION: The proposed method is robust in assessing the appropriateness of hospitalisations and duration of inpatient stays. The quantified levels of unnecessary hospital care indicate the need for improving efficiency and quality of care and optimising the excessive hospital capacities in Ukraine.

Can people afford to pay for health care? New evidence on financial protection in Ukraine

Out-of-pocket payments account for a very high share of total spending on health in Ukraine. Their share has grown substantially in recent years, as the share of the Government budget allocated to health has fluctuated but fallen overall, reaching a low of 8.6% in 2015; this is below the average of 10.2% for lower middle-income countries and far below the EU average of 13.5% and the European Region average of 12.5%.Inefficiencies and inequities in the way in which these very limited public resources are allocated and used in the health system exacerbate access barriers and financial hardship, particularly for medicines and inpatient care, the two types of health care responsible for almost all catastrophic spending. Financial protection could be improved by addressing these inefficiencies and using any savings gained to enhance coverage for those most in need of protection – poor people and people with chronic conditions. The increase in the incidence of catastrophic spending on health seen in Ukraine between 2013 and 2015 is partly the result of factors beyond the health system – growing poverty and a substantial decline in living standards. Catastrophic and impoverishing out-of-pocket payments are concentrated among the poorest quintile. National statistics indicate that households living in rural areas, households with three or more children and those in which all members are retired are most affected by poverty and, consequently, should be prioritized for enhanced protection. This review is part of a series of country-based studies generating new evidence on financial protection in European health systems.