Financing of health services for undocumented immigrants in Iran: common challenges and potential solutions.

INTRODUCTION: Iran is host to one of the largest urban refugee populations worldwide, about two million of whom are undocumented immigrants (UIs). UIs are not eligible to enroll in the Iranian health insurance scheme and have to pay out-of-pocket to access most health services. This increases the likelihood that they will delay or defer seeking care, or incur substantial costs if they do seek care, resulting in worse health outcomes. This study aims to improve understanding of the financial barriers that UIs face in utilizing health services and provide policy options to ensure financial protection to enhance progress towards UHC in Iran. METHODS: This qualitative study was conducted in 2022. A triangulation approach, including interviews with key informants and comparing them with other informative sources to find out the complementary findings, was applied to increase data confirmability. Both purposive and snowball sampling approaches were used to select seventeen participants. The data analysis process was done based on the thematic content analysis approach. RESULTS: The findings were explained under two main themes: the financial challenges in accessing health services and the policy solutions to remove these financial barriers, with 12 subthemes. High out-of-pocket payments, high service prices for UIs, fragmented financial support, limited funding capacity, not freeing all PHC services, fear of deportation, and delayed referral are some of the barriers that UIs face in accessing health care. UIs can get insurance coverage by using innovative ways to get money, like peer financing and regional health insurance, and by using tools that make it easier, like monthly premiums without policies that cover the whole family. CONCLUSION: The formation of a health insurance program for UIs in the current Iranian health insurance mechanism can significantly reduce management costs and, at the same time, facilitate risk pooling. Strengthening the governance of health care financing for UIs in the form of network governance may accelerate the inclusion of UIs in the UHC agenda in Iran. Specifically, it is necessary to enhance the role of developed and rich regional and international countries in financing health services for UIs.

Continuum of public health dismantling during the covid-19 crisis: Bolsonaro's neofascism / Continuum de desmontes da saúde pública na crise do covid-19: o neofascismo de Bolsonaro

Resumo Neste artigo, aprofunda-se a discussão crítica às políticas adotadas pelo governo Bolsonaro em relação à saúde pública, particularmente no que tange ao financiamento em geral, ao enfrentamento da pandemia e ao primeiro ano de implantação do novo modelo de "financiamento" para a Atenção Primária à Saúde (APS). A análise evidencia o acirramento da legitimidade restrita do regime político, assumida por políticas ultraneoliberais e pelo neofascismo do governo Bolsonaro. Estas formas de dominação - política e econômica - engendram uma conjuntura interna que visa remodelar a acumulação de capital na saúde pública via APS por meio de mecanismos "operacionais" burocráticos sutis de desconstrução da universidade do "financiamento". Na primeira parte, discute-se a abrangência da crise tripla do capital - sanitária, econômica e ecológica - e sua relação orgânica com o Estado no capitalismo dependente brasileiro, abrindo espaço para o crescimento da restrição do regime político endossado pela ascensão do neofascismo. Na segunda parte, aborda-se a escalada do desfinanciamento do Sistema Único de Saúde (SUS) em plena crise de covid-19 e os efeitos da implementação do modelo de financiamento da APS, evidenciando a continuidade do processo de valorização de um "SUS operacional" em detrimento do seu princípio de universalidade como dimensão neofascista do governo Bolsonaro.

Abstract This article deepens the critical discussion about the policies of the Bolsonaro government regarding public health, particularly regarding the general financing, the confrontation of the pandemic, and the first year of implementation of the new financing model for Primary Health Care (PHC). The analysis evidences the aggravation of the restrict legitimacy of the political regime, assumed by ultra-neoliberal policies and by the neofascism of the Bolsonaro government. These forms of domination - political and economic - produce an internal conjuncture that seeks to remodel the capital accumulation in public health by PHC by subtle bureaucratic "operational" mechanisms of deconstruction of financing universality. In the first part, the coverage of the triple crisis of the capital - sanitary, economic and ecological - and its organic relationship to the State in the Brazilian dependent capitalism is discussed, opening space to the increase of the restriction of the political regime endorsed by the ascension of the neofascism. In the second part, the increase of the de-financing of the Unified Health System (SUS) right in the middle of the covid-19 crisis and the effects of the implementation of the financing model of the PHC, evidencing the continuity of the process of valuing an "operational SUS" in detriment of its universality principle as a neofascist dimension of Bolsonaro's government.

Health financing and public financial management during the Covid-19 pandemic: Evidence from Pakistan as low-income country.

PURPOSE: This article aims to explore the areas of misalignment between the public financial management (PFM) and health financing during the COVID-19 pandemic in Pakistan. ORIGINALITY/VALUE: To the best of our knowledge, it is the first study on South Asian countries to adopt a framework and bring forward the dominant themes that cause the misalignment between PFM and health financing. The timing of the research was excellent as the world was facing the biggest health challenge in the form of COVID-19 which has put pressure on the PFM and has seriously hampered health service delivery. Therefore, the findings of the study are helpful for the ministry of health to draft policies to improve health allocations and move towards Universal Health Coverage. DESIGN/METHODOLOGY/APPROACH: In-depth semi-structured interviews of 15 participants were used to explore the areas of misalignment between PFM and health financing. Based on qualitative data, thematic content analysis has been carried out. FINDINGS: The findings of the study can be divided into five clusters and their explanations. First overall budget allocation has an impact on the health sector budget. For example, the budget for priority health interventions is not reflected in the budget allocation process. Further, the budget is classified by inputs rather than disease and finally, the budget is not released by the health priorities. The second cluster was the devolution of health to provinces which is unfinished agenda. Under this cluster fiscal decentralisation has been found to cause problems for the provinces as they have not provided fiscal autonomy to spend the money and there is a lack of coordination between the federal and provincial authorities. The third cluster was donor funding, and it was observed that it is not aligned with the government policies and priorities. Forth cluster was procurement and it was discovered that it is a lengthy process and caused delays in procuring the essential health equipment. The fifth cluster was an organisational culture that is not conducive to the health sector. Under this cluster, the attitude, knowledge, and practices of departments responsible for the health sector require complete revamping.

Global financing for health policy and systems research: a review of funding opportunities.

Health policy and systems research (HPSR) is a neglected area in global health financing. Despite repeated calls for greater investment, it seems that there has been little growth. We analysed trends in reported funding and activity between 2015 and 2021 using a novel real-time source of global health data, the Devex.com database, the world's largest source of funding opportunities related to international development. We performed a systematic search of the Devex.com database for HPSR-related terms with a focus on low- and middle-income countries. We included 'programs', 'tenders & grants' and 'contract awards', covering all call statuses (open, closed or forecast). Such funding opportunities were included if they were related specifically to HPSR funding or had an HPSR component; pure biomedical funding was excluded. Our findings reveal a relative neglect of HPSR, as only ∼2% of all global health funding calls included a discernible HPSR component. Despite increases in funding calls until 2019, this situation reversed in 2020, likely reflecting the redirection of resources to rapid assessments of the impacts of the coronavirus disease 2019 (COVID-19) pandemic. Most identified projects represented small-scale opportunities-commonly for consultancies or technical assistance. To the extent that new data were generated, these projects were either tied to a specific large intervention or were narrow in scope to meet a specific challenge-with many examples informing policy responses to the Covid-19 pandemic. Nearly half of advertised funding opportunities were multi-country projects, usually addressing global policy priorities like health systems strengthening or development of coordinated public health policies at a regional level. The Covid-19 pandemic has shown why investing in HPSR is more important than ever to enable the delivery of effective health interventions and avoid costly implementation failures. The evidence presented here highlights the need to scale up efforts to convince global health funders to institutionalize the inclusion of HPSR components in all funding calls.

Comparison of the Distribution of Household Financial Contributions to the Health System before and during COVID-19 Outbreak: Evidence from Nationwide Survey in Iran.

Background: Health and economy has substantially been influenced by the coronavirus disease 2019 (COVID-19) pandemic. Because of these impacts, household financial contribution to health system is likely to be changed. This study aimed to compare the distribution of household financial contributions before and during the COVID-19 epidemic. Methods: This is a cross-sectional study. The data were obtained from Iran's Households Income and Expenditure Survey as a national representative survey and included 38,328 households in 2019 (before COVID-19) and 37,577 households in 2020 (during COVID-19 pandemic). The household expenditures deflated according to the Consumer Price Index. The indices of households' out-of-pocket Payments (OPP), catastrophic health expenditures (CHE), and impoverishment were calculated based on a standard methodology. Data analysis was done using an Excel-based software. Results: The households' total expenditures declined for both urban and rural areas during the COVID-19 outbreak. Meanwhile, health expenditure experienced a negative growth rate for urban and rural households at -25.75% and -15.47%, respectively. The average per capita of OOP annually was 1,220,416 ($41.086 PPP) Rials for urban households and 1,017,760 Rials ($34.263 PPP) for rural households in 2020 (the era of COVID-19), which had dropped -30% and -16%, respectively, relative to 2019 (before COVID-19). The proportional share of health service types from the total health expenditure did not change importantly after the onset of COVID-19. The incidence of CHE and impoverishment due to health payments reduced after the onset of COVID-19. Conclusion: The households' health expenditures changed considerably during the COVID-19 pandemic and these changes were the same for the urban and rural areas. Despite COVID-19 multi-faceted shocks, the findings of this study showed a slight decline in the incidence of CHE and impoverishment caused by health expenditures. It might be due to forgone health services during the COVID-19 pandemic. Data from these household surveys have some limits to depicting the real effects of this crisis.

Financing care for Severe Stigmatizing Skin Diseases (SSSDs) in Liberia: challenges and opportunities.

INTRODUCTION: Neglected tropical diseases (NTDs) are an important global health challenge, however, little is known about how to effectively finance NTD related services. Integrated management in particular, is put forward as an efficient and effective treatment modality. This is a background study to a broader health economic evaluation, seeking to document the costs of integrated case management of NTDs versus standard care in Liberia. In the current study, we document barriers and facilitators to NTD care from a health financing perspective. METHODS: We carried out key informant interviews with 86 health professionals and 16 national health system policymakers. 46 participants were active in counties implementing integrated case management and 40 participants were active in counties implementing standard care. We also interviewed 16 patients and community members. All interviews were transcribed and analysed using the thematic framework approach. FINDINGS: We found that decentralization for NTD financing is not yet achieved - financing and reporting for NTDs is still centralized and largely donor-driven as a vertical programme; government involvement in NTD financing is still minimal, focused mainly on staffing, but non-governmental organisations (NGOs) or international agencies are supporting supply and procurement of medications. Donor support and involvement in NTDs are largely coordinated around the integrated case management. Quantification for goods and budget estimations are specific challenges, given the high donor dependence, particularly for NTD related costs and the government's limited financial role at present. These challenges contribute to stockouts of medications and supplies at clinic level, while delays in payments of salaries from the government compromise staff attendance and retention. For patients, the main challenges are high transportation costs, with inflated charges due to fear and stigma amongst motorbike taxi riders, and out-of-pocket payments for medication during stockouts and food/toiletries (for in-patients). CONCLUSION: Our findings contribute to the limited work on financing of SSSD services in West African settings and provide insight on challenges and opportunities for financing and large costs in accessing care by households, which is also being exacerbated by stigma.

Does It Still Show a Deficit? Arguing Post-COVID-19 Health Financing System in Bogor, Indonesia

Before the COVID-19 pandemic, the Bogor City Government regulated to cover the health financing claim during the Indonesian National Health Insurance (NHI) integration period due to the lower amount of health care claim per episode in regional hospitals compared to ones that NHI paid. This study aimed to address post-COVID-19 health financing at two hospitals in Bogor City, West Java Province, Indonesia. Descriptive analysis using the aggregate statistical summaries was taken to explore the medical care episodes of the data series at two hospitals for the last two years. Of the 890 checked medical records data, the deficit occurred in 197 (22.1%) medical care episodes, while five (0.6%) exceeded the hospitals' tariffs. The remaining 688 (77.3%) medical care episodes had suits with the Indonesian-Case Based Groups. Almost a quarter of medical care episodes in aggregate experienced a deficit in the two years before the pandemic. This study is the first to provide new insight into the discussion on medical care financing in a developing country's post-pandemic era in a newly-implemented NHI system. Copyright © 2022 Kesmas.

COVID-19 crisis and fiscal policies to strengthen the healthcare system

This study investigated the dimensions of health financing needs arising in Turkey due to the COVID-19 crisis. It was explained what kind of fiscal policy should be implemented to strengthen the health systems with increasing financing needs. The study's main purpose is to investigate how the health system financing in Turkey can benefit from fiscal policies to meet the cost of the COVID-19 crisis on health systems. In this context, in the first part of the study, after a short introduction about the importance of the subject in the second part, the economic effects of the COVID-19 crisis and the course of health expenditures were investigated. It has been observed that developing countries lag behind in overcoming the effects of the crisis due to their own structural problems. The crisis has brought up the need to increase the expenditures for health financing worldwide. Turkey has the lowest rate among OECD countries in terms of GDP ratio of health expenditures with 4.4 %. The third part has been researched how the financing of health services in Turkey is provided. The most important sources of financing are taxes, social security premiums, private insurance premiums, and out-of-pocket payments. In the research, it has been observed that this deficit, which the Social Security System has given deficit since the 1990s in Turkey, is covered by the financial transfer from the budget. The share allocated to the Ministry of Health from the central government budget for the last four years is nearly only 5 %. In the fourth chapter, in this case, the designs that governments can make on how to strengthen the health system with taxes, public expenditures, and subsidies using fiscal policy are explained. Examples of fiscal policies for health are taxes on tobacco, tobacco products, and alcohol, subsidies on certain food products, and tax incentives for health care purchases. © 2022 Peter Lang AG. All rights reserved.

The impact of COVID-19 on international development aid and health systems strengthening in low-income countries.

Health systems play a critical role in providing services that aim to improve, promote, restore, or maintain the health of communities. Unfortunately, health systems in low-income countries are fragile, having an adverse effect on the health of the population. Whereas international development aid remains crucial in strengthening health systems in low-income countries (LICs), COVID-19 has induced changes in the dynamics in the availability, provision and access to international development aid. These changes have aggravated the already weak health systems of LICs. Understanding the effects of the COVID-19 pandemic on the distribution of international development aid and how these effects impacted on the quality of the health systems in response to the outbreak is critical to improving the health of populations in LICs. This article discusses the impact of the challenges faced by LICs in the context of international development aid needed for the development of health systems.

Revisiting the debate on health financing in Low and Middle-income countries: An integrative review of selected models.

Universal Health Coverage (UHC) as a health policy goal is gaining added currency in the policy agendas of many Low and Middle-Income Countries (LMIC) following the onslaught of the coronavirus (COVID-19) pandemic. The goal of UHC is to ensure that every citizen has access to quality healthcare services that they need without suffering financial hardship. Whereas most industrialised countries have achieved UHC through the implementation of various traditional health financing mechanisms, most LMIC have not made significant progress in providing financial protection against the costs of illness for majority of the population due to limited fiscal space and or lack of political commitment to raise government revenues and increase fiscal space for health. While the onslaught of COVID-19 refreshes the call for reform of countries' health financing policies to reflect the healthcare needs of the population, the debate about the type or combination of health financing models to employ in LMIC has yet to reach a consensus. This review critically analyses five health financing models to ascertain their appropriateness in providing financial risk protection against the cost of illness, especially in this era of COVID-19. Given the limited fiscal space for health in LMICs, we argue that one viable pathway towards achieving UHC is the adoption of an adaptive mix of diverse pooling mechanisms. Moreover, because the creation of fiscal space is context-specific, and UHC is a political issue rather than technical, securing strong political support is necessary for improving the governance and institutional frameworks for health and ensuring sustained economic growth to respond to the fiscal demands of health systems.

Does It Still Show a Deficit? Arguing Post-COVID-19 Health Financing System in Bogor, Indonesia

Before the COVID-19 pandemic, the Bogor City Government regulated to cover the health financing claim during the Indonesian National Health Insurance (NHI) integration period due to the lower amount of health care claim per episode in regional hospitals compared to ones that NHI paid. This study aimed to address post-COVID-19 health financing at two hospitals in Bogor City, West Java Province, Indonesia. Descriptive analysis using the aggregate statistical summaries was taken to explore the medical care episodes of the data series at two hospitals for the last two years. Of the 890 checked medical records data, the deficit occurred in 197 (22.1%) medical care episodes, while five (0.6%) exceeded the hospitals' tariffs. The remaining 688 (77.3%) medical care episodes had suits with the Indonesian-Case Based Groups. Almost a quarter of medical care episodes in aggregate experienced a deficit in the two years before the pandemic. This study is the first to provide new insight into the discussion on medical care financing in a developing country's post-pandemic era in a newly-implemented NHI system.

Dominican Republic: The Response to the Pandemic in 2021

This article presents the case of the Dominican Republic in relation to its emergency preparedness, environmental and social vulnerability framework, its response to the COVID-19 pandemic, including the policies implemented to manage it, and its prospects for the future. The Dominican Republic, being highly vulnerable to climate change and environmental risks, needs to be prepared for national emergencies, including the current pandemic. At the time of the pandemic, the country had a weak health system and weak public funding and, in this context, experienced a significant number of confirmed cases. The country’s trajectory in terms of the number of cases, mortality, and availability of beds and intensive care units for the disease is analyzed, and the experience is compared with other countries in the Americas. As of November 2021, the Dominican Republic has been able to respond adequately, maintaining one of the lowest case-fatality rates in the region and substantially controlling its number of cases in the last year, especially after the vaccination process was initiated. The control measures implemented in the country, consisting of restrictive and timely distancing policies, are noteworthy. Likewise, the country’s successful vaccination program is being followed up as part of these measures. Regardless of the good management of the pandemic by the Dominican Republic and the positive outlook for the future in economic and social areas, the need to improve the preparedness of the country’s health system, such as increasing public spending on health and investment in the first level of care, is emphasized. © 2022 Academia Nacional de Medicina. All rights reserved.

Lessons from the implementation of the Health Care Homes program.

Australia's primary health care system works well for most Australians, but 20% of people live with multimorbidity, often receiving fragmented care in a complex system. Australia's 10-year plan for primary health care recognises that person-centred care is essential to securing universal health coverage, improving health outcomes and achieving an integrated sustainable health system. The Health Care Homes trial tested a new model of person-centred care for people with chronic and complex health conditions. This model demonstrated that change can be achieved with dedicated transformational support and highlighted the importance of enablers and reform streams that are now established in the 10-year plan.

Growing debt burden in low- and middle-income countries during COVID-19 may constrain health financing.

Debt burdens are growing steadily in Low- and Middle-Income Countries (LMICs), compounded by the COVID-19 economic recession, threatening to crowd out essential health spending. In 2019, 54 LMICs spent more on servicing their debt to foreign creditors than on financing their health services. While development loans may have positive effects on population health, the ensuing debt servicing requirements may have detrimental effects on health through constrained fiscal space for government health spending. However, the existing evidence is inadequate for an understanding of whether, and if so how and under what circumstances, debt may constrain government health spending. We call for more research on the impacts of debt on health financing and call on creditors and borrowers to carefully consider the potential impacts of lending on borrower countries' ability to finance their health services.

Universal access to comprehensive COVID-19 services for everyone in Thailand.

Despite Thailand having had universal health coverage (UHC) with comprehensive benefit packages since 2002, services are neither listed nor budget earmarked for COVID-19 responses. Policy decisions were made immediately after the first outbreak in 2020 to fully fund a comprehensive benefit package for COVID-19. The Cabinet approved significant additional budget to respond to the unfolding pandemic. The comprehensive benefit package includes laboratory tests, contact tracing, active case findings, 14-day quarantine measures (including tests, food and lodging), field hospitals, ambulance services for referral, clinical services both at hospitals and in home and community isolation, vaccines and vaccination cost, all without copayment by users. No-fault compensation for adverse events or deaths following vaccination is also provided. Services were purchased from qualified public and private providers using the same rate, terms and conditions. The benefit package applies to everyone living in Thailand including Thai citizens and migrant workers. A standardised and comprehensive COVID-19 benefit package for Thai and non-Thai population without copayment facilitates universal and equitable access to care irrespective of capacity to pay and social status and nationality, all while aiming to supporting pandemic containment. Making essential services available, notably laboratory tests, through the engagement of qualified both public and private sectors boost supply side capacity. These policies and implementations in this paper are useful lessons for other low-income and middle-income countries on how UHC reinforces pandemic containment.

Assessing the responsiveness of out-of-pocket healthcare expenditure to macro-fiscal factors and different health financing systems: evidence from the European and OECD area

Purpose>In this paper, the authors assess the responsiveness of OOP healthcare expenditure to macro-fiscal factors, as well as to tax-based, SHI, mixed systems and voluntary PHI financing. Although the relationship between OOP expenditure, macroeconomy, aggregate public and PHI financing is well documented in the existing empirical literature, little is known for the impact of several macro-fiscal drivers and the existing health financing arrangements associated with voluntary PHI on OOP expenditure.Design/methodology/approach>The authors gather panel data by applying three official organizations’ databases. They elaborate static and dynamic panel data methodology to a dataset of 49 European and OECD countries from 2000 to 2015.Findings>The authors’ findings do not indicate a considerable impact of GDP growth and general government debt as a share of GDP on OOP payments. Unemployment rate presents as a positive driver of OOP payments in all three compulsory national health systems post to the 2008 economic crisis. OOP payments are significantly influenced by countries’ fiscal capacity to increase general government expenditure to GDP in SHI and mixed health systems. Additionally, study findings present that government health financing, irrespective of the different health systems structure characteristics, and OOP healthcare payments follow different directions. Voluntary PHI financing considerably counteracts OOP payments only in tax-based health systems.Practical implications>In the backdrop of a new economic crisis associated to the COVID-19 epidemic, health policy planners have to deal with the emerging unprecedented challenges in financing of health systems, especially for these economies that have to face the fiscal capacity constraints owing to the 2008 financial crisis and its severe recession.Originality/value>To the best of authors’ knowledge, there is no empirical consensus on the effects of macro-fiscal parameters, different compulsory health systems financing associated with the parallel voluntary PHI institution funding on OOP expenditure, for the majority of European and OECD settings.

Public Health Financing and Responses to COVID-19: Lessons from South Korea.

Health financing strategies contribute significantly to containing the outbreak of the Coronavirus disease 2019 (COVID-19). This study aims to reassess Korea's financing strategies in response to COVID-19 in 2020, to ascertain its effects and sustainability. The Joint External Evaluation tool was adopted to analyze the data collected from government reports, official statistics, and other sources. Findings show that Korea could maintain a low incidence and fatality rate compared with other countries, at low costs. It was a result of rapidly procured healthcare resources based on laws and policies established after the 2015 epidemic, and the National Health Insurance. However, to achieve long-term sustainability, it is important to enhance the financial stability of the national health insurance and increase the proportion of the public sector in healthcare resources.

Fragility and challenges of health systems in pandemic: lessons from India's second wave of coronavirus disease 2019 (COVID-19).

The unprecedented healthcare demand due to sudden outbreak of coronavirus disease 2019 (COVID-19) pandemic has almost collapsed the health care systems especially in the developing world. Given the disastrous outbreak of COVID-19 second wave in India, the health system of country was virtually at the brink of collapse. Therefore, to identify the factors that resulted into breakdown and the challenges, Indian healthcare system faced during the second wave of COVID-19 pandemic, this paper analysed the health system challenges in India and the way forward in accordance with the six building blocks of world health organization (WHO). Applying integrated review approach, we found that the factors such as poor infrastructure, inadequate financing, lack of transparency and poor healthcare management resulted into the overstretching of healthcare system in India. Although health system in India faced these challenges from the very beginning, but early lessons from first wave should have been capitalized to avert the much deeper crisis in the second wave of the pandemic. To sum-up given the likely future challenges of pandemic, while healthcare should be prioritized with adequate financing, strong capacity-building measures and integration of public and private sectors in India. Likewise fiscal stimulus, risk assessment, data availability and building of human resources chain are other key factors to be strengthened for mitigating the future healthcare crisis in country.

Leveraging COVID-19 pandemic response for improved health system financing: Lessons from Ghana.

The COVID-19 pandemic has exposed health system funding challenges across many developing countries. The needed infrastructure to effectively respond to the pandemic was absent in many developing countries. This has resulted in policymakers resorting to various strategies to mobilise sufficient resources in response to the pandemic, especially in the early stages. This paper reviewed Ghana's efforts to mobilise domestic and external resources for the health sector in response to the pandemic. The paper also assessed lessons from these strategies and highlights how these lessons could be leveraged to sustain financing for the health sector. Using evidence from desk reviews, we demonstrate the existence of fiscal space through external sources, partnership with non-state actors, and effective public financial management (budget space). We also show that the COVID-19 pandemic presents an important momentum to drive future investment in health infrastructure across developing countries.