Maryam Bigdeli

Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries

While World Health Organization member countries embraced the concept of universal coverage as early as 2005, few low-income countries have yet achieved the objective. This is mainly due to numerous barriers that hamper access to needed health services. In this paper we provide an overview of the various dimensions of barriers to access to health care in low-income countries (geographical access, availability, affordability and acceptability) and outline existing interventions designed to overcome these barriers. These barriers and consequent interventions are arranged in an analytical framework, which is then applied to two case studies from Cambodia. The aim is to illustrate the use of the framework in identifying the dimensions of access barriers that have been tackled by the interventions. The findings suggest that a combination of interventions is required to tackle specific access barriers but that their effectiveness can be influenced by contextual factors. It is also necessary to address demand-side and supply-side barriers concurrently. The framework can be used both to identify interventions that effectively address particular access barriers and to analyse why certain interventions fail to tackle specific barriers.

Trends in Health Policy and Systems Research over the Past Decade: Still Too Little Capacity in Low-Income Countries

Background The past decade has seen several high-level events and documents committing to strengthening the field of health policy and systems research (HPSR) as a critical input to strengthening health systems. Specifically, they called for increased production, capacity to undertake and funding for HPSR. The objective of this paper is to assess the extent to which progress has been achieved, an important feedback for stakeholders in this field. Methods and Finding Two sources of data have been used. The first is a bibliometric analysis to assess growth in production of HPSR between 2003 and 2009. The six building blocks of the health system were used to define the scope of this search. The second is a survey of 96 research institutions undertaken in 2010 to assess the capacity and funding availability to undertake HPSR, compared with findings from the same survey undertaken in 2000 and 2008. Both analyses focus on HPSR relevant to low-income and middle-income countries (LMICs). Overall, we found an increasing trend of publications on HPSR in LMICs, although only 4% were led by authors from low-income countries (LICs). This is consistent with findings from the institutional survey, where despite improvements in infrastructure of research institutions, a minimal change has been seen in the level of experience of researchers within LIC institutions. Funding availability in LICs has increased notably to institutions in Sub-Saharan Africa; nonetheless, the overall increase has been modest in all regions. Conclusion Although progress has been made in both the production and funding availability for HPSR, capacity to undertake the research locally has grown at a much slower pace, particularly in LICs where there is most need for this research. A firm commitment to dedicate a proportion of all future funding for research to building capacity may be the only solution to turn the tide.

Composition of pluralistic health systems: how much can we learn from household surveys? An exploration in Cambodia.

In spite of all efforts to build national health services, health systems of many low-income countries are today highly pluralistic. Households use a vast range of public and private health care providers, many of whom are not controlled by national health authorities. Experts have called on Ministries of Health to re-establish themselves as stewards of the entire health system. Modern stewardship will require national and decentralized health authorities to have an overall view of their pluralistic health system, especially of the components outside the public sector. Little guidance has been provided so far on how to develop such a view. In this paper, we explore whether household surveys could be a source of information. The study builds on secondary data analysis of a household survey carried out in three health districts in rural Cambodia and of two national surveys. Cambodia is indeed an interesting case, as massive efforts by donors in favour of the public sector go hand in hand with a dominant role of the private sector in the provision of health care services. The study confirms that the health care sector in Cambodia is now highly pluralistic, and that the great majority of health seeking behaviour takes place outside the public health system. Our analysis of the survey also shows that the disaffection of the population with public health facilities varies across places, socio-economic groups and health problems. We illustrate how such knowledge could allow stewards to better identify challenges for existing or future health policies. We argue that a whole research programme on the composition of pluralistic health systems still needs to be developed. We identify some challenges and opportunities.

Bridging community-based health insurance and social protection for health care - a step in the direction of universal coverage?

keywords health care, community-based health insurance, social protection, universal coverageAccess to affordable and effective health care is a majorproblem in low and middle income countries (LMIC) andout-of-pocket expenditure for health care a major cause ofimpoverishment (Meessen et al. 2003; Frenk et al. 2006;McIntyre et al. 2006; Van Doorslaer et al. 2006). Oneway to facilitate access and overcome catastrophic expen-diture is through a health insurance mechanism, wherebyrisks are shared and financial inputs pooled by way ofcontributions from salaries or taxation (Carrin et al.2005). In European history, social health insurance (SHI)initially covered salaried workers and their families. Theself-employed, unemployed and destitute were onlycovered at a later stage (Ba¨rnighausen & Sauerborn 2002).In LMIC today, the majority of people are either self-employed or work in the informal sector, which makesexpansion of formal health insurance, if any, much moredifficult. Taxation systems are generally insufficientlydeveloped and do not allow for adequate revenue collec-tion to ensure universal coverage (Carrin et al. 2005).One response to the difficulty of providing insurancecoverage for people in the informal sector is the develop-ment of community-based health insurance (CBHI). Suchan arrangement implies that the community plays animportant role in mobilizing, pooling, allocating, manag-ing and/or supervising health-care resources (Jakab K Jakab & Krishnan 2001;van Ginneken 2002; Carrin et al. 2005). CBHI schemesattempt to tap willingness and ability to pay for health careand try to build local risk-sharing arrangements based onsolidarity which requires time to mature. In practice,however, most CBHI schemes are small. A review of 258CBHI schemes found that 50% had less than 500 members[International Labour Organisation (ILO) 2002], whichundermines the CBHI’s potential (Criel & Waelkens 2003;Carrin et al. 2005).Small-scheme federations or networks can be establishedto increase membership and improve financial leverage ofCBHI (Waelkens & Criel 2004). Support organizations canbe set up to provide management assistance at the outset;scheme management can be subcontracted to an umbrellaorganization or schemes may even merge (Carrin et al.2005). Alternatively, a scheme with a larger membershipmay be started (Carrin et al. 2005), although this may onlybe possible if premiums are subsidized. In this respect,Bennett (2004) suggests that government subsidies toschemes should target the poor, more specifically thoseunabletopayapremium,toenableequitableaccesstohealthservices. The situation of CBHI in sub-Saharan Africa leadsto a similar analysis (Ndiaye et al. 2007): CBHI is not anoption for the poorest, and someone else therefore needs topay the insurance premium for them – in full or in part.Hence, the need for subsidies to cover the poorest house-holds–whileatthesametimeexercisinggreatcautionnottoundermine and jeopardize local solidarity dynamics andwillingness to pay by other than the poorest households.Rationale for bridging CBHI and social protectionprogrammes (SPP) for health careThe World Bank defines SPP as public interventions that:(i) assist households and communities to better manage

Access to Essential Medicines in Pakistan: Policy and Health Systems Research Concerns

Introduction Inadequate access to essential medicines is a common issue within developing countries. Policy response is constrained, amongst other factors, by a dearth of in-depth country level evidence. We share here i) gaps related to access to essential medicine in Pakistan; and ii) prioritization of emerging policy and research concerns. Methods An exploratory research was carried out using a health systems perspective and applying the WHO Framework for Equitable Access to Essential Medicine. Methods involved key informant interviews with policy makers, providers, industry, NGOs, experts and development partners, review of published and grey literature, and consultative prioritization in stakeholder’s Roundtable. Findings A synthesis of evidence found major gaps in essential medicine access in Pakistan driven by weaknesses in the health care system as well as weak pharmaceutical regulation. 7 major policy concerns and 11 emerging research concerns were identified through consultative Roundtable. These related to weaknesses in medicine registration and quality assurance systems, unclear and counterproductive pricing policies, irrational prescribing and sub-optimal drug availability. Available research, both locally and globally, fails to target most of the identified policy concerns, tending to concentrate on irrational prescriptions. It overlooks trans-disciplinary areas of policy effectiveness surveillance, consumer behavior, operational pilots and pricing interventions review. Conclusion Experience from Pakistan shows that policy concerns related to essential medicine access need integrated responses across various components of the health systems, are poorly addressed by existing evidence, and require an expanded health systems research agenda.

Patient-centred innovation to ensure access to diabetes care in Cambodia: the case of MoPoTsyo

BackgroundThe increasing prevalence of chronic diseases puts a high burden on the health care systems of Low and Middle Income Countries which are often not adapted to provide the care needed. Peer support programmes are promoted to address health system constraints. This case study analyses a peer educator diabetes programme in Cambodia, MoPoTsyo, from a health system’s perspective. Which strategies were used and how did these strategies change? How is the programme perceived?MethodsData were collected through semi-structured interviews with patients, MoPoTsyo staff and peer educators, contracted pharmacy staff and health workers, health care workers and non-contracted pharmacists and managers and policy makers at district, provincial and national level. Four areas were purposively selected to do the interviews. An inductive content analysis was done independently by two researchers.ResultsMoPoTsyo developed into three stages: a focus on diabetes self-management; a widening scope to ensure affordable medicines and access to other health care services; and aiming for sustainability through more integration with the Cambodian public system and further upscaling. All respondents acknowledged the peer educators’ role and competence in patient education, but their ideas about additional tasks and their place in the system differed. Indirectly involved stakeholders and district managers emphasized the particular roles and responsibilities of all actors in the system and the particular role of the peer educator in the community. MoPoTsyo’s diagnostics and laboratory services were perceived as useful, especially by patients and project staff. Respondents were positive about the revolving drug fund, but expressed concerns about its integration into the government system. The degree of collaboration between health care staff and peer educators varied.ConclusionMoPoTsyo responds to the needs of people with diabetes in Cambodia. Key success factors were: consistent focus on and involvement of the target group, backed up by a strong organisation; simultaneous reduction of other barriers to care; and the ongoing maintenance of relations at all levels within the health system. Despite resistance, MoPoTsyo has established a more balanced relationship between patients and health service providers, empowering patients to self-manage and access services that meet their needs.

Health system barriers to access and use of magnesium sulfate for women with severe pre-eclampsia and eclampsia in Pakistan: evidence for policy and practice.

Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified.

A functional model for monitoring equity and effectiveness in purchasing health insurance premiums for the poor: evidence from Cambodia and the Lao PDR.

OBJECTIVES To assess the impact on equity and effectiveness of introducing targeted subsidies for the poor into existing voluntary health insurance schemes in Low Income Countries with special reference to cross-subsidisation. METHODS A functional model was constructed using routine collected financial data to analyse changes in financial flows and resulting shifts in cross-subsidization between poor and non-poor. Data were collected from two sites, in Cambodia at Kampot operational health district and in the Lao Peoples Democratic Republic at Nambak district. RESULTS Six key variables were identified as determining the financial flows between the subsidy and the insurance schemes and with health providers: population coverage, premium rate, facility contact rate, capitation rate, cost of treatment and changes in administration costs. Negative cross-subsidization was revealed where capitation was used as the payment mechanism and where utilisation rates of the poor were significantly below the non-poor. The same level of access for the poor could have been achieved with a lower Health Equity Fund subsidy if used as a direct reimbursement of user charges by the Health Equity Fund to the provider rather than through the Community Based Health Insurance scheme. CONCLUSIONS Purchasing premiums for the poor under these conditions is more costly than direct reimbursement to the provider for the same level of service delivery. Negative cross-subsidization is a serious risk that must be managed appropriately and the benefits of a larger risk pool (cross-subsidization of the poor) are not evident. Benefits from combined coverage may accrue in the longer term with an expanded base of voluntary payers or when those with subsidized premiums are lifted out of poverty.

Health policy and systems research in access to medicines: a prioritized agenda for low- and middle-income countries

ObjectivesTo identify priority policy issues in access to medicines (ATM) relevant for low- and middle-income countries, to identify research questions that would help address these policy issues, and to prioritize these research questions in a health policy and systems research (HPSR) agenda.MethodsThe study involved i) country- and regional-level priority-setting exercises performed in 17 countries across five regions, with a desk review of relevant grey and published literature combined with mapping and interviews of national and regional stakeholders; ii) interviews with global-level stakeholders; iii) a scoping of published literature; and iv) a consensus building exercise with global stakeholders which resulted in the formulation and ranking of HPSR questions in the field of ATM.ResultsA list of 18 priority policy issues was established following analysis of country-, regional-, and global-level exercises. Eighteen research questions were formulated during the global stakeholders’ meeting and ranked according to four ranking criteria (innovation, impact on health and health systems, equity, and lack of research). The top three research questions were: i) In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of medicines, sustainability of the insurance system, and financial impact on the insured? ii) How can stakeholders use the information available in the system, e.g., price, availability, quality, utilization, registration, procurement, in a transparent way towards improving access and use of medicines? and iii) How do policies and other interventions into private markets, such as information, subsidies, price controls, donation, regulatory mechanisms, promotion practices, etc., impact on access to and appropriate use of medicines?ConclusionsOur HPSR agenda adopts a health systems perspective and will guide relevant, innovative research, likely to bear an impact on health, health systems and equity.

From Scheme to System (Part 2): Findings from Ten Countries on the Policy Evolution of Results-Based Financing in Health Systems

Abstract Abstract— This article presents the enablers and barriers to the scaling-up of results-based financing (RBF) programs. It draws on the Alliance for Health Policy and Systems Researchs multicountry program of research Taking Results Based Financing From Scheme to System, which compared the scale-up of RBF interventions over four phases—generation, adoption, institutionalization, and expansion—across ten countries. Comparing country experiences reveals broad lessons on scale up of RBF for each of the scale-up phases. Though the coming together of global, national, and regional contextual factors was key to the development of pilot projects, national factors were important to scale up these pilots to national programs, including a political context favoring results and transparency, the presence of enabling policies and institutions, and the presence of policy entrepreneurs at the national level. The third transition, from program to policy, was enabled by the availability of domestic financial resources, legislative and financing arrangements to enhance health facility autonomy, and technical and political leadership within and beyond the Ministry of Health. The article provides lessons learned on RBF policy evolution, emphasizing the importance of phase-specific groups of actors, the need to tailor advocacy messages to enable scale-up, the influence of political feasibility on policy content, and policy processes to build national ownership and enable health system strengthening.