Costing for universal health coverage: insight into essential economic data from three provinces in Cambodia.

BACKGROUND: Knowledge of the costs of health services improves health facility management and aids in health financing for universal health coverage. Because of resource requirements that are often not present in low- and middle-income countries, costing exercises are rare and infrequent. Here we report findings from the initial phase of establishing a routine costing system for health services implemented in three provinces in Cambodia. METHODS: Data was collected for the 2016 financial year from 20 health centres (including four with beds) and five hospitals (three district hospitals and two provincial hospitals). The costs to the providers for health centres were calculated using step-down allocations for selected costing units, including preventive and curative services, delivery, and patient contact, while for hospitals this was complemented with bed-day and inpatient day per department. Costs were compared by type of facility and between provinces. RESULTS: All required information was not readily available at health facilities and had to be recovered from various sources. Costs per outpatient consultation at health centres varied between provinces (from US$2.33 to US$4.89), as well as within provinces. Generally, costs were inversely correlated with the quantity of service output. Costs per contact were higher at health centres with beds than health centres without beds (US$4.59, compared to US$3.00). Conversely, costs for delivery were lower in health centres with beds (US$128.7, compared to US$413.7), mainly because of low performing health centres without beds. Costs per inpatient-day varied from US$27.61 to US$55.87 and were most expensive at the lowest level hospital. CONCLUSIONS: Establishing a routine health service costing system appears feasible if recording and accounting procedures are improved. Information on service costs by health facility level can provide useful information to optimise the use of available financial and human resources.

Adapting Pharmacoeconomics to Shape Efficient Health Systems en Route to UHC - Lessons from Two Continents.

Background: Pharmacoeconomics is receiving increasing attention globally as a set of tools ensuring efficient use of resources in health systems, albeit with different applications depending on the contextual, cultural and development stages of each country. The factors guiding design, implementation and optimisation of pharmacoeconomics as a steering tool under the universal health coverage paradigm are explored using case studies of Germany and South Africa. Findings: German social health insurance is subject to the efficiency precept. Pharmaco-regulatory tools reflect the respective framework conditions under which they developed at particular points in time. The institutionalization and integration of pharmacoeconomics into the remit of the Institute for Quality and Efficiency in Health Care occurred only rather recently. The road has not been smooth, requiring political discourse and complex processes of negotiation. Although enshrined in the National Drug Policy, South Africa has had a more fragmented approach to medicine selection and pricing with different policies in private and public sectors. The regulatory reform for use of pharmacoeconomic tools is ongoing and will be further shaped by the introduction of National Health Insurance. Conclusion: A clear vision or framework is essential as the regulatory introduction of pharmacoeconomics is not a single event but rather a growing momentum. The path will always be subject to influences of politics, economics and market forces beyond the healthcare system so delays and modifications to pharmacoeconomic tools are to be expected. Health systems are dynamic and pharmacoeconomic reforms need to be sufficiently flexible to evolve alongside.

Synthesizing qualitative and quantitative evidence on non-financial access barriers: implications for assessment at the district level.

INTRODUCTION: A key element of the global drive to universal health coverage is ensuring access to needed health services for everyone, and to pursue this goal in an equitable way. This requires concerted efforts to reduce disparities in access through understanding and acting on barriers facing communities with the lowest utilisation levels. Financial barriers dominate the empirical literature on health service access. Unless the full range of access barriers are investigated, efforts to promote equitable access to health care are unlikely to succeed. This paper therefore focuses on exploring the nature and extent of non-financial access barriers. METHODS: We draw upon two structured literature reviews on barriers to access and utilization of maternal, newborn and child health services in Ghana, Bangladesh, Vietnam and Rwanda. One review analyses access barriers identified in published literature using qualitative research methods; the other in published literature using quantitative analysis of household survey data. We then synthesised the key qualitative and quantitative findings through a conjoint iterative analysis. RESULTS: Five dominant themes on non-financial access barriers were identified: ethnicity; religion; physical accessibility; decision-making, gender and autonomy; and knowledge, information and education. The analysis highlighted that non-financial factors pose considerable barriers to access, many of which relate to the acceptability dimension of access and are challenging to address. Another key finding is that quantitative research methods, while yielding important findings, are inadequate for understanding non-financial access barriers in sufficient detail to develop effective responses. Qualitative research is critical in filling this gap. The analysis also indicates that the nature of non-financial access barriers vary considerably, not only between countries but also between different communities within individual countries. CONCLUSIONS: To adequately understand access barriers as a basis for developing effective strategies to address them, mixed-methods approaches are required. From an equity perspective, communities with the lowest utilisation levels should be prioritised and the access barriers specific to that community identified. It is, therefore, critical to develop approaches that can be used at the district level to diagnose and act upon access barriers if we are to pursue an equitable path to universal health coverage.

Quantifying the costs and benefits of occupational health and safety interventions at a Bangladesh shipbuilding company.

BACKGROUND: This study is the first cost-benefit analysis (CBA) of occupational health and safety (OHS) in a low-income country. It focuses on one of the largest shipbuilding companies in Bangladesh, where globally recognised Occupational Health and Safety Advisory Services (OHSAS) 18001 certification was achieved in 2012. OBJECTIVES: The study examines the relative costs of implementing OHS measures against qualitative and quantifiable benefits of implementation in order to determine whether OHSAS measures are economically advantageous. METHODS: Quantifying past costs and benefits and discounting future ones, this study looks at the returns of OHS measures at Western Marine Shipbuilding Company Ltd. RESULTS: Costs included investments in workplace and environmental safety, a new clinic that also serves the community, and personal protective equipment (PPE) and training. The results are impressive: previously high injury statistics dropped to close to zero. CONCLUSIONS: OHS measures decrease injuries, increase efficiency, and bring income security to workers' families. Certification has proven a competitive edge for the shipyard, resulting in access to greater markets. Intangible benefits such as trust, motivation and security are deemed crucial in the CBA, and this study finds the high investments made are difficult to offset with quantifiable benefits alone.

Access as a policy-relevant concept in low- and middle-income countries.

Although access to health care is frequently identified as a goal for health care policy, the precise meaning of access to health care often remains unclear. We present a conceptual framework that defines access to health care as the empowerment of an individual to use health care and as a multidimensional concept based on the interaction (or degree of fit) between health care systems and individuals, households, and communities. Three dimensions of access are identified: availability, affordability, and acceptability, through which access can be evaluated directly instead of focusing on utilisation of care as a proxy for access. We present the case for the comprehensive evaluation of health care systems as well as the dimensions of access, and the factors underlying each dimension. Such systemic analyses can inform policy-makers about the 'fit' between needs for health care and receipt of care, and provide the basis for developing policies that promote improvements in the empowerment to use care.

Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania.

The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.

Information, communication and equitable access to health care: a conceptual note.

This conceptual paper addresses the health policy goal of equitable access to health care from a perspective that highlights the role of choice. It sketches a framework around the three access dimensions availability, affordability, and acceptability. The "degree of fit" with respect to each of these dimensions between the health system and individuals or communities plays a role in determining the level of access to health services by outlining the existing choice set. Yet it is the degree of informedness about the choices that ultimately determines access to health services. Access is therefore defined as the freedom to utilize. The paper focuses on information and its properties, which cut across the dimensions of access. It is argued that equity-oriented health policy should stimulate communicative action in order to empower individuals and communities by expanding their subjective choice sets.

Information, communication and equitable access to health care: a conceptual note

This conceptual paper addresses the health policy goal of equitable access to health care from a perspective that highlights the role of choice. It sketches a framework around the three access dimensions availability, affordability, and acceptability. The degree of fit with respect to each of these dimensions between the health system and individuals or communities plays a role in determining the level of access to health services by outlining the existing choice set. Yet it is the degree of informedness about the choices that ultimately determines access to health services. Access is therefore defined as the freedom to utilize. The paper focuses on information and its properties, which cut across the dimensions of access. It is argued that equity-oriented health policy should stimulate communicative action in order to empower individuals and communities by expanding their subjective choice sets.

Este artigo conceitual discute a meta política do acesso eqüitativo à assistência em saúde, com um foco especial no papel da escolha. Estabelece um arcabouço teórico baseado nas três dimensões do acesso: disponibilidade, acessibilidade financeira e aceitabilidade. No que diz respeito a cada uma dessas dimensões, o grau de ajuste entre o sistema de saúde e os indivíduos ou comunidades tem um papel determinante no nível de acesso aos serviços de saúde, na medida em que define o conjunto de escolhas. No entanto, em última análise, é o grau de informação sobre as escolhas que determina o acesso aos serviços de saúde. Portanto, acesso é definido como liberdade de utilização. O artigo analisa a informação e suas características (que atravessam as diversas dimensões do acesso), argumentando que uma política de saúde eqüitativa deve estimular a ação comunicativa para fortalecer os indivíduos e as comunidades na expansão dos seus conjuntos de escolhas subjetivas.

Rethinking the economic costs of malaria at the household level: evidence from applying a new analytical framework in rural Kenya.

BACKGROUND: Malaria imposes significant costs on households and the poor are disproportionately affected. However, cost data are often from quantitative surveys with a fixed recall period. They do not capture costs that unfold slowly over time, or seasonal variations. Few studies investigate the different pathways through which malaria contributes towards poverty. In this paper, a framework indicating the complex links between malaria, poverty and vulnerability at the household level is developed and applied using data from rural Kenya. METHODS: Cross-sectional surveys in a wet and dry season provide data on treatment-seeking, cost-burdens and coping strategies (n = 294 and n = 285 households respectively). 15 case study households purposively selected from the survey and followed for one year provide in-depth qualitative information on the links between malaria, vulnerability and poverty. RESULTS: Mean direct cost burdens were 7.1% and 5.9% of total household expenditure in the wet and dry seasons respectively. Case study data revealed no clear relationship between cost burdens and vulnerability status at the end of the year. Most important was household vulnerability status at the outset. Households reporting major malaria episodes and other shocks prior to the study descended further into poverty over the year. Wealthier households were better able to cope. CONCLUSION: The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future. To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.

Information and access to health care: is there a role for trust?

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure.

Rethinking the economic costs of malaria at the household level: Evidence from applying a new analytical framework in rural Kenya

Background Malaria imposes significant costs on households and the poor are disproportionately affected. However; cost data are often from quantitative surveys with a fixed recall period. They do not capture costs that unfold slowly over time; or seasonal variations. Few studies investigate the different pathways through which malaria contributes towards poverty. In this paper; a framework indicating the complex links between malaria; poverty and vulnerability at the household level is developed and applied using data from rural Kenya. Methods Cross-sectional surveys in a wet and dry season provide data on treatment-seeking; cost-burdens and coping strategies (n=294 and n=285 households respectively). 15 case study households purposively selected from the survey and followed for one year provide in-depth qualitative information on the links between malaria; vulnerability and poverty. Results Mean direct cost burdens were 7.1and 5.9of total household expenditure in the wet and dry seasons respectively. Case study data revealed no clear relationship between cost burdens and vulnerability status at the end of the year. Most important was household vulnerability status at the outset. Households reporting major malaria episodes and other shocks prior to the study descended further into poverty over the year. Wealthier households were better able to cope. Conclusion The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications; influencing household ability to withstand malaria and other contingencies in future. To protect the poor and vulnerable; malaria control policies need to be integrated into development and poverty reduction programmes