Using health policy and systems research to influence national health policies: lessons from Mexico, Cambodia and Ghana.

Health system reforms across Africa, Asia and Latin America in recent decades demonstrate the value of health policy and systems research (HPSR) in moving towards the goals of universal health coverage in different circumstances and by various means. The role of evidence in policy making is widely accepted; less well understood is the influence of the concrete conditions under which HPSR is carried out within the national context and which often determine policy outcomes. We investigated the varied experiences of HPSR in Mexico, Cambodia and Ghana (each selected purposively as a strong example reflecting important lessons under varying conditions) to illustrate the ways in which HPSR is used to influence health policy. We reviewed the academic and grey literature and policy documents, constructed three country case studies and interviewed two leading experts from each of Mexico and Cambodia and three from Ghana (using semi-structured interviews, anonymized to ensure objectivity). For the design of the study, design of the semi-structured topic guide and the analysis of results, we used a modified version of the context-based analytical framework developed by Dobrow et al. (Evidence-based health policy: context and utilisation. Social Science & Medicine 2004;58:207-17). The results demonstrate that HPSR plays a varied but essential role in effective health policy making and that the use, implementation and outcomes of research and research-based evidence occurs inevitably within a national context that is characterized by political circumstances, the infrastructure and capacity for research and the longer-term experience with HPSR processes. This analysis of national experiences demonstrates that embedding HPSR in the policy process is both possible and productive under varying economic and political circumstances. Supporting research structures with social development legislation, establishing relationships based on trust between researchers and policy makers and building a strong domestic capacity for health systems research all demonstrate means by which the value of HPSR can be materialized in strengthening health systems.

Protecting the poor? Impact of the national health equity fund on utilization of government health services in Cambodia, 2006-2013.

INTRODUCTION: Cambodia's health equity fund (HEF) is the country's most significant social security scheme, covering the poorest one-fifth of the national population. During the last two decades, the HEF system was scaled up from an initial two health districts to national coverage of public health facilities. This is the first national study to examine the impact of the HEF on the utilisation of public health facilities. METHODS: We first investigated the level of national HEF population coverage and health service use made by HEF eligible members using an administrative HEF operational dataset. Second, through multilevel interrupted time series analysis of routine monthly utilisation statistics during 2006-2013, we evaluated the impact of the HEF on hospital and health centre utilisation. RESULTS: The proportion of HEF beneficiaries using hospital services in a given year (4.6%) appeared to exceed rates in the general population (3.3%). The introduction of the HEF was associated with: a significant level change in the monthly number of consultations at HCs followed by a gradual slope increase in time trend and a significant level change in the monthly number of deliveries. Overall, this was equivalent to a 15.6% net increase in number of consultations and 5.3% in deliveries in the first year. At RHs: a significant level change in the number of RH inpatient cases, followed by a sustained slope increase; a significant slope increase in the number of outpatient consultations and in the overall number of newborn deliveries. Overall, this was equivalent to a 47.9% net increase in inpatient cases, 24.1% in outpatient cases and 31.4% in deliveries in the first year. CONCLUSION: The implementation of the HEF scheme was associated with increased utilisation of primary and secondary care services by the poor.

The impact of ASEAN economic integration on health worker mobility: a scoping review of the literature.

The Association of Southeast Asian Nations (ASEAN) Economic Community (AEC) was inaugurated in December 2015 with the primary aim of achieving a strong and prosperous community through accelerating economic integration. The notion of a single market, underpinned by the free flow of trade in services and skilled labour, is integral to the spirit of the AEC. To facilitate the intra-regional mobility of health professionals, Mutual Recognition Arrangements (MRAs) were signed, for nursing in 2006 and for medicine and dentistry in 2009, and now sit within the AEC objectives. This study examines the observed and potential impact of the health-related MRAs on health worker mobility within the region, particularly with regard to qualified doctors and nurses. To explore the available evidence, the authors undertook a narrative literature and document review, consistent with the RAMESES guidelines for qualitative research in international development and policy making in the area of health. Peer-reviewed articles and the grey literature from the period beginning in 2005 were reviewed. We find that the implementation of health-related MRAs has been slow and complex due to a number of barriers and challenges, such as resistance to the inflow of health professionals by the local workforce, shortcomings in the implementing mechanisms and an individual preference among health professionals for seeking better opportunities outside the region. Despite increasing worker mobility generally within ASEAN through formal and informal mechanisms, the MRAs themselves do not appear yet to have facilitated the freer movement of health workers. To strengthen health worker mobility, the full implementation of the health-related MRAs is essential, requiring support from broader trade and immigration policies and a stronger political commitment. Policy makers in ASEAN Member States will need to manage competing national interests in order to harness support for effective implementation.

Pathways to DRG-based hospital payment systems in Japan, Korea, and Thailand.

Countries in Asia are working towards achieving universal health coverage while ensuring improved quality of care. One element is controlling hospital costs through payment reforms. In this paper we review experiences in using Diagnosis Related Groups (DRG) based hospital payments in three Asian countries and ask if there is an "Asian way to DRGs". We focus first on technical issues and follow with a discussion of implementation challenges and policy questions. We reviewed the literature and worked as an expert team to investigate existing documentation from Japan, Republic of Korea, and Thailand. We reviewed the design of case-based payment systems, their experience with implementation, evidence about impact on service delivery, and lessons drawn for the Asian region. We found that countries must first establish adequate infrastructure, human resource capacity and information management systems. Capping of volumes and prices is sometimes essential along with a high degree of hospital autonomy. Rather than introduce a complete classification system in one stroke, these countries have phased in DRGs, in some cases with hospitals volunteering to participate as a first step (Korea), and in others using a blend of different units for hospital payment, including length of stay, and fee-for-service (Japan). Case-based payment systems are not a panacea. Their value is dependent on their design and implementation and the capacity of the health system.

A framework for comparative analysis of health systems: experiences from the Asia Pacific Observatory on Health Systems and Policies

Drawing on published work from the Asia Pacific Observatory on Health Systems and Policies, this paper presents a framework for undertaking comparative studies on the health systems of countries. Organized under seven types of research approaches, such as national case-studies using a common format, this framework is illustrated using studies of low- and middle-income countries published by the Asia Pacific Observatory. Such studies are important contributions, since much of the health systems research literature comes from high-income countries. No one research approach, however, can adequately analyse a health system, let alone produce a nuanced comparison of different countries. Multiple comparative studies offer a better understanding, as a health system is a complex entity to describe and analyse. Appreciation of context and culture is crucial: what works in one country may not do so in another. Further, a single research method, such as performance indicators, or a study of a particular health system function or component, produces only a partial picture. Applying a comparative framework of several study approaches helps to inform and explain progress against health system targets, to identify differences among countries, and to assess policies and programmes. Multi-method comparative research produces policy-relevant learning that can assist countries to achieve Sustainable Development Goal 3: ensure healthy lives and promoting well-being for all at all ages by 2030

A framework for comparative analysis of health systems: experiences from the Asia Pacific Observatory on Health Systems and Policies.

Drawing on published work from the Asia Pacific Observatory on Health Systems and Policies, this paper presents a framework for undertaking comparative studies on the health systems of countries. Organized under seven types of research approaches, such as national case-studies using a common format, this framework is illustrated using studies of low- and middle-income countries published by the Asia Pacific Observatory. Such studies are important contributions, since much of the health systems research literature comes from high-income countries. No one research approach, however, can adequately analyse a health system, let alone produce a nuanced comparison of different countries. Multiple comparative studies offer a better understanding, as a health system is a complex entity to describe and analyse. Appreciation of context and culture is crucial: what works in one country may not do so in another. Further, a single research method, such as performance indicators, or a study of a particular health system function or component, produces only a partial picture. Applying a comparative framework of several study approaches helps to inform and explain progress against health system targets, to identify differences among countries, and to assess policies and programmes. Multi-method comparative research produces policy-relevant learning that can assist countries to achieve Sustainable Development Goal 3: ensure healthy lives and promoting well-being for all at all ages by 2030.

Administrative reform and pay-for-performance methods of primary health service delivery: A comparison of 3 health districts in Cambodia, 2006-2012.

Since 1999, performance-based financing or pay-for-performance (P4P) methods have been piloted in the Cambodian public health sector, first as one part of external contracting approaches with international nongovernment organizations and from 2009 as a part of internal contracting arrangements between units within the Ministry of Health under a wider public sector administrative reform. This study analyses these reforms and compares outcomes in 3 health districts. The study analysed routine quantitative data for primary care service delivery by using the interrupted time series method. Qualitative data were collected from key informant interviews. Both the level and the trend line of key service delivery indicators during earlier contracting/P4P models were at least maintained and in most cases increased with the move to internal contracting. The results of the interrupted time series analysis were mixed, mainly due to contextual issues. Qualitative results indicated an increased sense of local ownership and financial sustainability. Despite the gains, the management of personnel and the implementation and the integrity of contract monitoring were found to be compromised in this case. To be fully effective, contracting and P4P approaches must be accompanied by changes in the structure and culture of government administration.

Factors Driving Changes in the Design, Implementation, and Scaling-Up of the Contracting of Health Services in Rural Cambodia, 1997-2015.

Abstract-Contracting approaches have been used in various forms to improve the delivery of public health services in low- and middle-income countries. Cambodia has embarked on a public-sector reform that includes a model of internal contracting of health care through the Ministry of Health, supported by incentive payments for staff and facilities. Contracting for health care in Cambodia has evolved through three phases during 1997-2015, each with particular design features, arrangements, and structures; different levels of involvement of local and international stakeholders; and modifications based on evidence from operational research. Based on a review of published and gray literature and interviews with 29 local and international key informants, we identify national ownership, financial sustainability, and the need to strengthen service delivery institutions as the major forces that have shaped contracting in Cambodia, culminating in the move to internal contracting arrangements for public health care delivery. There remains a need to strengthen contracting governance arrangements.

Health systems and noncommunicable diseases in the Asia-Pacific region: a review of the published literature.

Addressing the growing burden of noncommunicable diseases (NCDs) in countries of the Asia-Pacific region requires well-functioning health systems. In low- and middle-income countries (LMICs), however, health systems are generally characterized by inadequate financial and human resources, unsuitable service delivery models, and weak information systems. The aims of this review were to identify (a) health systems interventions being implemented to deliver NCD programs and services and their outcomes and (b) the health systems bottlenecks impeding access to or delivery of these programs and services in LMICs of the Asia-Pacific region. A search of 4 databases for literature published between 1990 and 2010 retrieved 36 relevant studies. For each study, information on basic characteristics, type of health systems bottleneck/intervention, and outcome was extracted, and methodological quality appraised. Health systems interventions and bottlenecks were classified as per the World Health Organization health systems building blocks framework. The review identified interventions and bottlenecks in the building blocks of service delivery, health workforce, financing, health information systems, and medical products, vaccines, and technologies. Studies, however, were heterogeneous in methodologies used, and the overall quality was generally low. There are several gaps in the evidence base around NCDs in the Asia-Pacific region that require further investigation.

Overcoming access barriers to health services through membership-based microfinance organizations: a review of evidence from South Asia.

It is a challenge for the poor to overcome the barriers to accessing health services. Membership-based microfinance with associated health programmes can improve health outcomes for the poor. This study reviewed the evidence published between 1993 and 2013 on the role of membership-based microfinance with associated health programmes in improving health outcomes for the poor in South Asia. A total of 661 papers were identified and 26 selected for inclusion, based on the relevance and rigour of the research methods. Of these 26, five were evidence reviews. Of the remaining 21 papers, 12 were from India, seven from Bangladesh, and one each from Sri Lanka and Indonesia. Three papers addressed more than one theme. Five key themes emerged from the review: (i) the impact of microfinance programmes on the social and economic situation of the poor; (ii) the impact of microfinance programmes on community health; (iii) the impact of integrated microfinance health programmes on raising client awareness; (iv) the impact of integrated microfinance health programmes on financing health care; and (v) the impact of integrated microfinance health programmes on affordable health-care products and services. The review provides new evidence on the pathways through which microfinance helps to improve population health and value for money for such programmes. Among countries with large populations in the informal sector, there is a strong case for policy-makers to support these groups in providing access to life-saving health care among the poor.

The effect of Self-Help Groups on access to maternal health services: evidence from rural India.

INTRODUCTION: The main challenge for achieving universal health coverage in India is ensuring effective coverage of poor and vulnerable communities in the face of high levels of income and gender inequity in access to health care. Drawing on the social capital generated through women's participation in community organizations like SHGs can influence health outcomes. To date, evidence about the impact of SHGs on health outcomes has been derived from pilot-level interventions, some using randomised controlled trials and other rigorous methods. While the evidence from these studies is convincing, our study is the first to analyse the impact of SHGs at national level. METHODS: We analyzed the entire dataset from the third national District Level Household Survey from 601 districts in India to assess the impact of the presence of SHGs on maternal health service uptake. The primary predictor variable was presence of a SHG in the village. The outcome variables were: institutional delivery; feeding newborns colostrum; knowledge about family planning methods; and ever used family planning. We controlled for respondent education, wealth, heard or seen health messages, availability of health facilities and the existence of a village health and sanitation committee. RESULTS: Stepwise logistic regression shows respondents from villages with a SHG were 19 per cent (OR: 1.19, CI: 1.13-1.24) more likely to have delivered in an institution, 8 per cent (OR: 1.08, CI: 1.05-1.14) more likely to have fed newborns colostrum, have knowledge (OR: 1.48, CI 1.39 - 1.57) and utilized (OR: 1.19, CI 1.11 - 1.27) family planning products and services. These results are significant after controlling for individual and village-level heterogeneities and are consistent with existing literature that the social capital generated through women's participation in SHGs influences health outcome. CONCLUSION: The study concludes that the presence of SHGs in a village is associated with higher knowledge of family planning and maternal health service uptake in rural India. To achieve the goal of improving public health nationally, there is a need to understand more fully the benefits of systematic collaboration between the public health community and these grassroots organizations.

Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: a study of policy barriers and opportunities in Cambodia.

Reaching out to the poor and the informal sector is a major challenge for achieving universal coverage in lesser-developed countries. In Cambodia, extensive coverage by health equity funds for the poor has created the opportunity to consolidate various non-government health financing schemes under the government's proposed social health protection structure. This paper identifies the main policy and operational challenges to strengthening existing arrangements for the poor and the informal sector, and considers policy options to address these barriers. Conducted in conjunction with the Cambodian Ministry of Health in 2011-12, the study reviewed policy documents and collected qualitative data through 18 semi-structured key informant interviews with government, non-government and donor officials. Data were analysed using the Organizational Assessment for Improving and Strengthening Health Financing conceptual framework. We found that a significant shortfall related to institutional, organisational and health financing issues resulted in fragmentation and constrained the implementation of social health protection schemes, including health equity funds, community-based health insurance, vouchers and others. Key documents proposed the establishment of a national structure for the unification of the informal-sector schemes but left unresolved issues related to structure, institutional capacity and the third-party status of the national agency. This study adds to the evidence base on appropriate and effective institutional and organizational arrangements for social health protection in the informal sector in developing countries. Among the key lessons are: the need to expand the fiscal space for health care; a commitment to equity; specific measures to protect the poor; building national capacity for administration of universal coverage; and working within the specific national context.

Strengthening district health service management and delivery through internal contracting: lessons from pilot projects in Cambodia.

Following a decade of piloting different models of contracting, in mid-2009 the Cambodian Ministry of Health began to test a form of 'internal contracting' for health care delivery in selected health districts (including hospitals and health centers) contracted by the provincial health department as Special Operating Agencies (SOAs) and provided with greater management autonomy. This study assesses the internal contracting approach as a means for improving the management of district health services and strengthening service delivery. While the study may contribute to the emerging field now known as performance-based financing, the lessons deal more broadly with the impact of management reform and increased autonomy in contrast to traditional public sector line-management and budgeting. Carried out during 2011, the study was based on: (i) a review of the literature and of operational documents; (ii) primary data from semi-structured key informant interviews with 20 health officials in two provinces involved in four SOA pilot districts; and (iii) routine data from the 2011 SOA performance monitoring report. Five prerequisites were identified for effective contract management and improved service delivery: a clear understanding of roles and responsibilities by the contracting parties; implementation of clear rules and procedures; effective management of performance; effective monitoring of the contract; and adequate and timely provision of resources. Both the level and allocation of incentives and management bottlenecks at various levels continue to impede implementation. We conclude that, in contracted arrangements like these, the clear separation of contracting functions (purchasing, commissioning, monitoring and regulating), management autonomy where responsibilities are genuinely devolved and accepted, and the provision of resources adequate to meet contract demands are necessary conditions for success.

Institutional design and organizational practice for universal coverage in lesser-developed countries: challenges facing the Lao PDR.

There is now widespread acceptance of the universal coverage approach, presented in the 2010 World Health Report. There are more and more voices for the benefit of creating a single national risk pool. Now, a body of literature is emerging on institutional design and organizational practice for universal coverage, related to management of the three health-financing functions: collection, pooling and purchasing. While all countries can move towards universal coverage, lower-income countries face particular challenges, including scarce resources and limited capacity. Recently, the Lao PDR has been preparing options for moving to a single national health insurance scheme. The aim is to combine four different social health protection schemes into a national health insurance authority (NHIA) with a single national fund- and risk-pool. This paper investigates the main institutional and organizational challenges related to the creation of the NHIA. The paper uses a qualitative approach, drawing on the World Health Organization's institutional and Organizational Assessment for Improving and Strengthening health financing (OASIS) conceptual framework for data analysis. Data were collected from a review of key health financing policy documents and from 17 semi-structured key informant interviews. Policy makers and advisors are confronting issues related to institutional arrangements, funding sources for the authority and government support for subsidies to the demand-side health financing schemes. Compulsory membership is proposed, but the means for covering the informal sector have not been resolved. While unification of existing schemes may be the basis for creating a single risk pool, challenges related to administrative capacity and cross-subsidies remain. The example of Lao PDR illustrates the need to include consideration of national context, the sequencing of reforms and the time-scale appropriate for achieving universal coverage.

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.

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 People's 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.

Barriers to access and the purchasing function of health equity funds: lessons from Cambodia.

PROBLEM: High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined. APPROACH: Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers. LOCAL SETTING: Two-thirds of total health expenditure consists of patients' out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes. RELEVANT CHANGES: HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care. LESSONS LEARNED: HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully.