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4.
Global Health ; 15(Suppl 1): 72, 2019 11 28.
Artigo em Inglês | MEDLINE | ID: mdl-31775796

RESUMO

The triple goals of Universal Health Coverage (UHC) are to cover the whole population, to reduce patients' costs, and to expand coverage to all effective services, equitably available to all. This paper analyses the experience of Japan in achieving these goals, focusing on the central role played by the payment system. The payment system, or fee schedule, sets the price of services and pharmaceuticals, as well as the conditions that providers must comply with in order to receive payment. The fee schedule was first introduced following the enactment of social health insurance (SHI) in 1922. Initially, the SHI program covered only manual workers, who comprised a mere 3% of the population. However, the fee schedule of the largest SHI plan was subsequently adopted by all other SHI plans. From 1958, there has been only one fee schedule. Population coverage was achieved in 1961 by mandating all residing in Japan to enroll in SHI, thereby making everyone entitled to all the services and pharmaceuticals listed in the fee schedule. Next, co-insurance was capped to an affordable level by the introduction of catastrophic coverage in 1973. Lastly, extra billing and balance billing were explicitly restricted in 1984. The key to achieving and sustaining UHC goals in Japan lies in being able to contain costs and reallocate resources by revising the fee schedule.


Assuntos
Gastos em Saúde/legislação & jurisprudência , Cobertura Universal do Seguro de Saúde/economia , Cobertura Universal do Seguro de Saúde/organização & administração , Metas , Humanos , Japão
5.
Niger J Clin Pract ; 22(11): 1516-1529, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31719273

RESUMO

Background: A Free Maternal and Child Health program (FMCHP) was implemented in 12 states in Nigeria by the National Health Insurance Scheme (NHIS), between 2009 and 2015, using funds from the debt relief gains. It was called the Millennium Development Goals (MDGs) NHIS-MDG FMCHP. The program ended with the termination of the MDG in 2015. With the creation of the Basic Health Care Provision Fund (BHCPF) in Nigeria, this study sought to examine the past implementation experiences of the NHIS-MCH project with a view to identifying the enabling and constraining factors to program implementation, and the opportunities for adaptation and program scale-up in Nigeria using the BHCPF. Methods: The study was undertaken in the Federal Capital Territory, Abuja, and involved review of relevant documents and in-depth interviews with 21 key informants. The program was assessed in themes from the conceptual framework. Interviews were transcribed and analyzed using thematic analysis. Results: The program enrolled about 1.5 million pregnant women and children during the period of implementation in the country. The respondents perceived the program as pro-poor, efficient, and effective, and led to marked improvement in the functionality of the facilities, availability of services and reduced out-of-pocket expenditure, which led to increased demand and utilization of MCH services. There was inadequate stakeholder consultation, alleged corrupt practices, challenges with registration, issues with counterpart funding and public financing management issues identified. Most respondents supported the idea of using the new fund (BHCPF) to revitalize/scale-up the Free MCH program. Conclusion: This study highlights the key lessons and implementation challenges identified by the respondents. The NHIS-MDG FMCHP had positive impact on the target population though it was not sustained following the conclusion of the MDG program. The findings will inform policy decisions about the appropriateness of sustaining the program and the feasibility of extending healthcare coverage using the proposed BHCPF. The new fund (BHCPF) can be used to reactivate and scale-up the Free MCH program, but the current level of funding will not assure universal health coverage for the target beneficiaries as realized from the costing aspect of this study.


Assuntos
Financiamento Governamental , Gastos em Saúde , Serviços de Saúde Materno-Infantil/economia , Programas Nacionais de Saúde/economia , Cobertura Universal do Seguro de Saúde/economia , Criança , Saúde da Criança , Assistência à Saúde/economia , Feminino , Promoção da Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Seguro Saúde , Serviços de Saúde Materno-Infantil/organização & administração , Nigéria , Gravidez
6.
S Afr Med J ; 109(10): 756-760, 2019 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-31635573

RESUMO

BACKGROUND: Evidence-informed priority setting is vital to improved investment in public health interventions. This is particularly important as South Africa (SA) makes the shift to universal health coverage and institution of National Health Insurance. OBJECTIVES: To measure the financial impact of increasing the demand for modern contraceptive methods in the SA public health sector. We estimated the total cost of providing contraceptives, and specifically the budgetary impact of premature removals of long-acting reversible contraceptives. METHODS: We created a deterministic model in Microsoft Excel to estimate the costs of contraception provision over a 5-year time horizon (2018 - 2023) from a healthcare provider perspective. Only direct costs of service provision were considered, including drugs, supplies and personnel time. Costs were not discounted owing to the short time horizon. Scenario analyses were conducted to test uncertainty. RESULTS: The base-case cost of current contraceptive use in 2018 was estimated to be ZAR1.64 billion (ZAR29 per capita). Injectable contraceptives accounted for ~47% of total costs. To meet the total demand for family planning, SA would have to spend ~30% more than the estimate for current contraceptive use. In the year 2023, the 'current use' of modern contraceptives would increase to ZAR2.2 billion, and fulfilling the total demand for family planning would require ZAR2.9 billion. The base-case cost of implantable contraceptives was estimated at ZAR54 million. Assuming a normal removal rate, the use of implants is projected to increase by 20% during the 5-year period between 2019 and 2023, with an estimated 46% increase in costs. The cost of early removal of Implanon NXT is estimated at ZAR75 million, with total contraception costs estimated at ZAR102 million in 2019, compared with ZAR56 million when a normal removal rate is applied. CONCLUSIONS: The costs of scaling up modern contraceptives in SA are substantial. Early and premature removals of implantable contraceptives are costly to the nation and must be minimised. The government should consider conducting appropriate health technology assessments to inform the introduction of new public health interventions as SA makes the shift to universal health coverage by means of National Health Insurance.


Assuntos
Comportamento Contraceptivo/estatística & dados numéricos , Anticoncepção/estatística & dados numéricos , Anticoncepcionais/administração & dosagem , Programas Nacionais de Saúde/economia , Cobertura Universal do Seguro de Saúde/economia , Anticoncepção/economia , Anticoncepção/tendências , Comportamento Contraceptivo/tendências , Anticoncepcionais/economia , Implantes de Medicamento/administração & dosagem , Implantes de Medicamento/economia , Serviços de Planejamento Familiar , Humanos , Contracepção Reversível de Longo Prazo/economia , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Contracepção Reversível de Longo Prazo/tendências , Modelos Teóricos , Setor Público/economia , Setor Público/tendências , África do Sul
8.
Med Care ; 57(11): 875-881, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31567859

RESUMO

OBJECTIVE: Until recently, the options for summarizing Canadian patient complexity were limited to health risk predictive modeling tools developed outside of Canada. This study aims to validate a new model created by the Canadian Institute for Health Information (CIHI) for Canada's health care environment. RESEARCH DESIGN: This was a cohort study. SUBJECTS: The rolling population eligible for coverage under Ontario's Universal Provincial Health Insurance Program in the fiscal years (FYs) 2006/2007-2016/2017 (12-13 million annually) comprised the subjects. MEASURES: To evaluate model performance, we compared predicted cost risk at the individual level, on the basis of diagnosis history, with estimates of actual patient-level cost using "out-of-the-box" cost weights created by running the CIHI software "as is." We next considered whether performance could be improved by recalibrating the model weights, censoring outliers, or adding prior cost. RESULTS: We were able to closely match model performance reported by CIHI for their 2010-2012 development sample (concurrent R=48.0%; prospective R=8.9%) and show that performance improved over time (concurrent R=51.9%; prospective R=9.7% in 2014-2016). Recalibrating the model did not substantively affect prospective period performance, even with the addition of prior cost and censoring of cost outliers. However, censoring substantively improved concurrent period explanatory power (from R=53.6% to 66.7%). CONCLUSIONS: We validated the CIHI model for 2 periods, FYs 2010/2011-2012/2013 and FYs 2014/2015-2016/2017. Out-of-the-box model performance for Ontario was as good as that reported by CIHI for the development sample based on 3-province data (British Columbia, Alberta, and Ontario). We found that performance was robust to variations in model specification, data sources, and time.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Modelos Econômicos , Medição de Risco/métodos , Estatística como Assunto/métodos , Cobertura Universal do Seguro de Saúde/economia , Canadá , Estudos de Coortes , Humanos
11.
Bull World Health Organ ; 97(9): 620-630, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31474775

RESUMO

Increasing overall fiscal space is important for the health sector due to the centrality of public financing to make progress towards universal health coverage. One strategy is to mobilize additional government revenues through new taxes or increased tax rates on goods and services. We illustrate how countries can assess the feasibility and quantitative potential of different revenue-raising mechanisms. We review and synthesize the processes and results from country assessments in Benin, Mali, Mozambique and Togo. The studies analysed new taxes or increased taxes on airplane tickets, phone calls, alcoholic drinks, tourism services, financial transactions, lottery tickets, vehicles and the extractive industries. Study teams in each country assessed the feasibility of new revenue-raising mechanisms using six qualitative criteria. The quantitative potential of these mechanisms was estimated by defining different scenarios and setting assumptions. Consultations with stakeholders at the start of the process served to select the revenue-raising mechanisms to study and later to discuss findings and options. Exploring feasibility was essential, as this helped rule out options that appeared promising from the quantitative assessment. Stakeholders rated stability and sustainability positive for most mechanisms, but political feasibility was a key issue throughout. The estimated additional revenues through new revenue-raising mechanisms ranged from 0.47-1.62% as a share of general government expenditure in the four countries. Overall, the revenue raised through these mechanisms was small. Countries are advised to consider multiple strategies to expand fiscal space for health.


Assuntos
Financiamento da Assistência à Saúde , Impostos/economia , Cobertura Universal do Seguro de Saúde/economia , Benin , Comércio/economia , Gastos em Saúde , Política de Saúde , Humanos , Mali , Moçambique , Participação dos Interessados , Togo
14.
Lancet ; 394(10196): 432-442, 2019 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-31379334

RESUMO

New Zealand was one of the first countries to establish a universal, tax-funded national health service. Unique features include innovative Maori services, the no-fault accident compensation scheme, and the Pharmaceutical Management Agency, which negotiates with pharmaceutical companies to get the best value for medicines purchased by public money. The so-called universal orientation of the health system, along with a strong commitment to social service provision, have contributed to New Zealand's favourable health statistics. However, despite a long-standing commitment to reducing health inequities, problems with access to care persist and the system is not delivering the promise of equitable health outcomes for all population groups. Primary health services and hospital-based services have developed largely independently, and major restructuring during the 1990s did not produce the expected efficiency gains. A focus on individual-level secondary services and performance targets has been prioritised over tackling issues such as suicide, obesity, and poverty-related diseases through community-based health promotion, preventive activities, and primary care. Future changes need to focus on strengthening the culture and capacity of the system to improve equity of outcomes, including expanding Maori health service provision, integrating existing services and structures with new ones, aligning resources with need to achieve pro-equity outcomes, and strengthening population-based approaches to tackling contemporary drivers of health status.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Cobertura Universal do Seguro de Saúde/economia , Financiamento Governamental , Programas Governamentais , Humanos , Programas Nacionais de Saúde , Nova Zelândia , Cobertura Universal do Seguro de Saúde/organização & administração
15.
Health Res Policy Syst ; 17(1): 81, 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31438972

RESUMO

BACKGROUND: There is widespread and growing interest in designing and implementing social health insurance schemes (SHIS) across many low- and middle-income countries as a means to improve financial protection and achieve universal health coverage. SHIS recently gained traction in Nigeria, but evidence regarding optimal design features of SHIS is sparse and there is lack of a simple and standardised checklist that scheme designers, implementers and researchers could use to assess, guide and inform the design of SHIS. This paper seeks to develop a checklist based on concepts as well as theoretical and empirical evidence that can inform and guide scheme designers and implementers on design options to maximise the effectiveness of the scheme. METHODS: We conducted a review of literature exploring the relevant concepts for the development of a framework and checklist to identify the key factors or variables required to inform the design of SHIS. The checklist details critical considerations/questions to address and options for design. The developed checklist was then used to examine conditions for readiness and appropriateness of SHIS design in two states in Nigeria (Kaduna and Niger). RESULTS: This paper describes the development of a SHIS checklist. The findings also demonstrate that the newly developed checklist, consisting of six design domains, can be used by scheme designers and policy-makers as a simple and effective tool to assess and inform SHIS design features across Nigeria to maximise the chances of the effectiveness of the schemes. CONCLUSION: In conclusion, given that the development of SHIS in the Nigerian states is still in its early stages, applying the SHIS design checklist can serve as a first step to ensuring a feasible and sustainable insurance scheme. The introduction of SHIS, if properly designed and implemented, can be a significant first step towards improving the accessibility, equity and efficiency of healthcare in Nigeria.


Assuntos
Lista de Checagem , Seguro Saúde/organização & administração , Programas Nacionais de Saúde/organização & administração , Cobertura Universal do Seguro de Saúde/organização & administração , Gastos em Saúde , Humanos , Seguro Saúde/economia , Programas Nacionais de Saúde/economia , Nigéria , Mecanismo de Reembolso , Fatores Socioeconômicos , Cobertura Universal do Seguro de Saúde/economia
16.
Int J Equity Health ; 18(1): 118, 2019 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-31362749

RESUMO

BACKGROUND: Around the world, millions of people are impoverished due to health care spending. The highest catastrophic health expenditures are found in countries in transition. Our study analyzes the extent of financial protection by estimating the incidence of catastrophic health care expenditure in Myanmar and its association with sociodemographic factors. METHODS: We performed a secondary analysis of data from the household surveys conducted by the Livelihoods and Food Security Trust Fund (LIFT) in 2013 and 2015 in Myanmar. To estimate the magnitude of catastrophic health care expenditure, we applied the definition of catastrophic payment proposed by the World Health Organization (WHO); a household's out-of-pocket payment for health care is considered catastrophic if it exceeds 40% of the household capacity to pay. We also examined the changes in catastrophic payments at three different threshold levels (20, 30, 40%) with one equation allowing for a negative capacity to pay (modified WHO approach) and another equation with adjusted negative capacity to pay (standard WHO approach). RESULTS: In 2013, the incidence of catastrophic expenditure was 21, 13, 7% (standard WHO approach) and 48, 43, 41% (modified WHO approach) at the 20, 30, 40% threshold level respectively, while in 2015, these estimates were 18, 8, 6% (standard WHO approach) and 47, 41, 39% (modified WHO approach) respectively. Geographical location, gender of the household head, total number of household members, number of children under 5, and number of disabled persons in the household were statistically significantly associated with catastrophic health care expenditures in both studied years 2013 and 2015. Education of household head was statistically significantly associated with catastrophic health expenditure in 2013. We found that the incidence of catastrophic expenditures varied by the approach used to estimate expenditures. CONCLUSIONS: Although the level of catastrophic health care expenditure varies depending on the approach and threshold used, the problem of catastrophic expenditures in Myanmar cannot be denied. The government of Myanmar needs to scale up the current Social Security Scheme (SSS) or establish a new financial protection mechanism for the population. Vulnerable groups, such as households with a household head with a low-level of education, households with children under the age of 5 years or disabled persons, and low-income households should be prioritized by policymakers to improve access to essential health care.


Assuntos
Doença Catastrófica/economia , Financiamento Pessoal/economia , Gastos em Saúde/estatística & dados numéricos , Cobertura Universal do Seguro de Saúde/economia , Criança , Feminino , Serviços de Saúde/economia , Acesso aos Serviços de Saúde/economia , Humanos , Masculino , Mianmar , Pobreza/estatística & dados numéricos , Organização Mundial da Saúde , Adulto Jovem
18.
BMC Health Serv Res ; 19(1): 580, 2019 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-31426781

RESUMO

BACKGROUND: Care-seeking behavior is widely acknowledged to have strong influences on health outcomes among individuals with chronic conditions including diabetes. Despite its dynamic nature, care seeking behavior are often considered as time invariant in most studies. The likelihood of patients changing their regularity and source of chronic care over time is often neglected. This study aimed to determine the long-term trajectories of care-seeking patterns of both care-seeking regularity and health provider choices; and their associated factors among patients with type 2 diabetes under the National Health Insurance (NHI) program in Taiwan. METHODS: We utilized population-based data from the National Health Insurance Research Database (NHIRD) in Taiwan. Three thousand, nine hundred and eighty-seven adult patients with newly diagnosed type 2 diabetes in 1999 were enrolled in the cohort. We assessed their trajectories of regular care visits and sources of diabetes care from 2000 to 2010. A group-based trajectory model was applied. RESULTS: Seven distinct groups of long-term care-seeking patterns were identified. Only 51.44% of patients with newly diagnosed diabetes had regularly visited their providers over time. Among them, 56.41 and 16.09% had persistently sought care from generalized and specialized providers, respectively. 27.50% had sought care from different levels of providers. Patients who were male, elderly, low-income, and had a higher baseline diabetes severity were significantly more likely to either continue with their irregular care-seeking behavior or fail to maintain their regular care seeking behavior over time. Those who were younger, had a higher socioeconomic status, and lived in an urban area were significantly more likely to persistently seek care from specialized care settings. CONCLUSIONS: This study is the first population-based assessment of long-term care-seeking behaviors of type 2 diabetes patients under a single-payer system with a comprehensive benefit coverage. The most alarming finding was that, despite the existence of the comprehensive universal health insurance coverage in Taiwan, almost 50% of patients did not seek or maintain regular visits to providers over time as recommended. Understanding variations in the long-term trajectories of care adherence and sources of care may help to identify gaps in diabetes care management.


Assuntos
Diabetes Mellitus Tipo 2/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Sistema de Fonte Pagadora Única/estatística & dados numéricos , Adulto , Idoso , Doença Crônica , Diabetes Mellitus Tipo 2/economia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/estatística & dados numéricos , Pobreza/economia , Pobreza/estatística & dados numéricos , Estudos Retrospectivos , Taiwan , Cobertura Universal do Seguro de Saúde/economia , Cobertura Universal do Seguro de Saúde/estatística & dados numéricos , Adulto Jovem
19.
PLoS One ; 14(8): e0219731, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31461458

RESUMO

BACKGROUND: Expanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years. METHODS: We reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status. FINDINGS: 8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies). INTERPRETATION: Increased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage.


Assuntos
Países em Desenvolvimento/economia , Países em Desenvolvimento/estatística & dados numéricos , Nível de Saúde , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Cobertura Universal do Seguro de Saúde/economia , Cobertura Universal do Seguro de Saúde/estatística & dados numéricos , Humanos
20.
Int J Health Policy Manag ; 8(6): 329-336, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-31256565

RESUMO

BACKGROUND: In planning for universal health coverage, many countries have been examining their fiscal decentralization policies with the goal of increasing efficiency and equity via "additionalities." The concept of "additionality," when the government of a lower administrative level increases the funding allocated to a particular issue when extra funds are present, is often used in these contexts. Although the definition of "additionality" can be used more broadly, for the purposes of this paper we focus narrowly on the additional allocation of primary healthcare expenditures. This paper explores this idea by examining the impact of central level primary healthcare expenditure, on individual state level contributions to primary healthcare expenditure within 16 Indian states between 2005 and 2013. METHODS: In examining 5 main variables, we compared differences between government expenditures, contributions, and revenues for Empowered Action Group (EAG) states, and non-EAG states. EAG states are normally larger states that have weaker public health infrastructure and hence qualify for additional funding. Finally, using a model that captured the quantity of central level primary healthcare expenditure distributions to these states, we measured its impact on each state's own contributions to primary healthcare spending. RESULTS: Our results show that, at the state level, growth in per capita central level primary healthcare expenditure has increased by 110% from 2005-2013, while state's own contributions to primary healthcare expenditure per capita increased by 32%. Further analyses show that a 1% change disbursement from the central level leads to a -0.132%, although not significant, change by states in their own expenditure. The effect for wealthier states is -0.151% and significant and for poorer states the effect is smaller at -0.096% and not significant. CONCLUSION: This analysis suggests that increases in central level primary healthcare expenditure to states have an inverse relationship with primary healthcare expenditures by the state level. Furthermore, this effect is more pronounced in wealthier Indian states. This finding has policy implications on India's decision to increase block grants to states in place of targeted program expenditures.


Assuntos
Organização do Financiamento/economia , Recursos em Saúde/economia , Acesso aos Serviços de Saúde/economia , Cobertura Universal do Seguro de Saúde/economia , Gastos em Saúde , Humanos , Índia , Atenção Primária à Saúde/economia , Saúde Pública/economia , Fatores Socioeconômicos
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