Digital technologies for health financing in low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: Universal health coverage (UHC) is a global priority, ensuring equitable access to quality healthcare services without financial hardship. Many countries face challenges in progressing towards UHC. Health financing is pivotal for advancing UHC by raising revenues, enabling risk-sharing through pooling of funds and allocating resources. Digital technologies in the healthcare sector offer promising opportunities for health systems. In low-income and middle-income countries (LMICs), digital technologies for health financing (DTHF) have gained traction, supporting these three main functions of health financing for UHC. As existing information on DTHF in LMICs is limited, our scoping review aims to provide a comprehensive overview of DTHF in LMICs. Our objectives include identifying and describing existing DTHF, exploring evaluation approaches, examining their positive and negative effects, and investigating facilitating factors and barriers to implementation at the national level. METHODS AND ANALYSIS: Our scoping review follows the six stages proposed by Arksey and O'Malley, further developed by Levac et al and the Joanna Briggs Institute. The reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework. Eligibility criteria for studies reflect the three core elements of the search: (1) health financing, (2) digital technologies and (3) LMICs. We search multiple databases, including Medline via PubMed, EMBASE via Ovid, the Web of Science Core Collection, CENTRAL via Cochrane and the Global Index Medicus by the WHO. The extracted information is synthesised from both quantitative and qualitative studies. ETHICS AND DISSEMINATION: As our scoping review is based solely on information gathered from previously published studies, documents and publicly available scientific literature, ethical clearance is not required for its conduct. The findings are presented and discussed in a peer-reviewed article, as well as shared at conferences relevant to the topic.

Willingness to pay for National Health Insurance Services and Associated Factors in Africa and Asia: a systematic review and meta-analysis.

Background: Universal health coverage (UHC) is crucial for public health, poverty eradication, and economic growth. However, 97% of low- and middle-income countries (LMICs), particularly Africa and Asia, lack it, relying on out-of-pocket (OOP) expenditure. National Health Insurance (NHI) guarantees equity and priorities aligned with medical needs, for which we aimed to determine the pooled willingness to pay (WTP) and its influencing factors from the available literature in Africa and Asia. Methods: Database searches were conducted on Scopus, HINARI, PubMed, Google Scholar, and Semantic Scholar from March 31 to April 4, 2023. The Joanna Briggs Institute's (JBI's) tools and the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement" were used to evaluate bias and frame the review, respectively. The data were analyzed using Stata 17. To assess heterogeneity, we conducted sensitivity and subgroup analyses, calculated the Luis Furuya-Kanamori (LFK) index, and used a random model to determine the effect estimates (proportions and odds ratios) with a p value less than 0.05 and a 95% CI. Results: Nineteen studies were included in the review. The pooled WTP on the continents was 66.0% (95% CI, 54.0-77.0%) before outlier studies were not excluded, but increased to 71.0% (95% CI, 68-75%) after excluding them. The factors influencing the WTP were categorized as socio-demographic factors, income and economic issues, information level and sources, illness and illness expenditure, health service factors, factors related to financing schemes, as well as social capital and solidarity. Age has been found to be consistently and negatively related to the WTP for NHI, while income level was an almost consistent positive predictor of it. Conclusion: The WTP for NHI was moderate, while it was slightly higher in Africa than Asia and was found to be affected by various factors, with age being reported to be consistently and negatively related to it, while an increase in income level was almost a positive determinant of it.

Utilisation, out-of-pocket payments and access before and after COVID-19: Thailand's Universal Health Coverage Scheme.

The goal of Universal Health Coverage (UHC) is that everyone needing healthcare can access quality services without financial hardship. Recent research covering countries with UHC systems documents the emergence, and acceleration following the COVID-19 pandemic of unapproved informal payment systems by providers that collect under-the-table payments from patients. In 2001, Thailand extended its '30 Baht' government-financed coverage to all uninsured people with little or no cost sharing. In this paper, we update the literature on the performance of Thailand's Universal Health Coverage Scheme (UCS) with data covering 2019 (pre-COVID-19) through 2021. We find that access to care for Thailand's UCS-covered population (53 million) is similar to access provided to populations covered by the other major public health insurance schemes covering government and private sector workers, and that, unlike reports from other UHC countries, no evidence that informal side payments have emerged, even in the face of COVID-19 related pressures. However, we do find that nearly one out of eight Thailand's UCS-covered patients seek care outside the UCS delivery system where they will incur out-of-pocket payments. This finding predates the COVID-19 pandemic and suggests the need for further research into the performance of the UHC-sponsored delivery system.

Reconciling devolution with health financing and public financial management: challenges and policy options for the health sector.

The interplay between devolution, health financing and public financial management processes in health-or the lack of coherence between them-can have profound implications for a country's progress towards universal health coverage. This paper explores this relationship in seven Asian and African countries (Burkina Faso, Kenya, Mozambique, Nigeria, Uganda, Indonesia and the Philippines), highlighting challenges and suggesting policy solutions. First, subnational governments rely heavily on transfers from central governments, and most are not required to allocate a minimum share of their budget to health. Central governments channelling more funds to subnational governments through conditional grants is a promising way to increase public financing for health. Second, devolution makes it difficult to pool funding across populations by fragmenting them geographically. Greater fiscal equalisation through improved revenue sharing arrangements and, where applicable, using budgetary funds to subsidise the poor in government-financed health insurance schemes could bridge the gap. Third, weak budget planning across levels could be improved by aligning budget structures, building subnational budgeting capacity and strengthening coordination across levels. Fourth, delays in central transfers and complicated procedures for approvals and disbursements stymie expenditure management at subnational levels. Simplifying processes and enhancing visibility over funding flows, including through digitalised information systems, promise to improve expenditure management and oversight in health. Fifth, subnational governments purchase services primarily through line-item budgets. Shifting to practices that link financial allocations with population health needs and facility performance, combined with reforms to grant commensurate autonomy to facilities, has the potential to enable more strategic purchasing.

Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method.

BACKGROUND: Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana. METHODS: Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses. RESULTS: The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services. CONCLUSION: Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030.

Model-based estimation of the health care expenditure and out-of-pocket payment for assisted reproductive technology: A retrospective linkage study using the Japanese national ART registry.

AIM: From April 2022, the Japanese government funding system for assisted reproductive technology (ART) has shifted from government subsidies to universal health insurance. To date, studies estimating the health care expenditure for ART are scarce. We estimated health care expenditures for ART cycles and compared the proportion of patients' out-of-pocket payment by ovarian stimulation protocols under the Japanese government subsidy system. METHODS: We linked payment information for government subsidies in Saitama Prefecture during 2016 and 2017 with the Japanese ART registry. Health care expenditures for all treatment cycles in Japan during 2017 among women aged <43 years (n = 369 757) were estimated using a generalized linear model. RESULTS: We linked 6269 subsidy applications to the Japanese ART registry. The average treatment fee for a fresh cycle was 376 434 JPY (standard deviation = 159 581). However, significant variation was observed across ovarian stimulation protocols. The estimated health care expenditure for ART during 2017 was 101 278 629 888 JPY (920 714 817 USD), leading to a 0.24% increase in the national health care expenditure for fiscal year 2017. Fresh cycles accounted for 70% of the expenditure. The proportion of the average patient out-of-pocket payment for one treatment cycle was smaller for natural (0%) and mild ovarian stimulation using clomiphene citrate (4.5%-20.7%) than those of conventional stimulation (30.3%-32.4%). CONCLUSIONS: Health insurance coverage for ART would increase national health care expenditure by 0.24%. Under the subsidy system, the proportion of the average patient out-of-pocket payment was smaller for natural and mild ovarian stimulation than conventional stimulations.

Characteristics Associated With Financial or Non-financial Barriers to Healthcare in a Universal Health Insurance System: A Longitudinal Analysis of Korea Health Panel Survey Data.

While many studies have explored the financial barriers to healthcare, there is little evidence regarding the non-financial barriers to healthcare. This study identified characteristics associated with financial and non-financial barriers to healthcare and quantified the effects of these characteristics in South Korea, using a nationally representative longitudinal survey dataset. Overall, 68,930 observations of 16,535 individuals aged 19 years and above were sampled from Korea Health Panel survey data (2014-2018). From self-reported information about respondents' experiences of unmet healthcare needs, a trichotomous dependent variable-no barrier, non-financial barrier, and financial barrier-was derived. Sociodemographics, physical and health conditions were included as explanatory variables. The average adjusted probability (AAP) of experiencing each barrier was predicted using multivariable and panel multinomial logistic regression analyses. According to the results, the percentage of people experiencing non-financial barriers was much higher than that of people experiencing financial barriers in 2018 (9.6 vs. 2.5%). Women showed higher AAPs of experiencing both non-financial (9.9 vs. 8.3%) and financial barriers (3.6 vs. 2.5%) than men. Men living in the Seoul metropolitan area showed higher AAPs of experiencing non-financial (8.7 vs. 8.0%) and financial barriers (3.4 vs. 2.1%) than those living outside it. Household income showed no significant associations in the AAP of experiencing a non-financial barrier. People with a functional limitation exhibited a higher AAP of experiencing a non-financial barrier, for both men (17.8 vs. 7.8%) and women (17.4 vs. 9.0%), than those without it. In conclusion, people in South Korea, like those in most European countries, fail to meet their healthcare needs more often due to non-financial barriers than financial barriers. In addition, the characteristics associated with non-financial barriers to healthcare differed from those associated with financial barriers. This finding suggests that although financial barriers may be minimised through various policies, a considerable degree of unmet healthcare needs and disparity among individuals is very likely to persist due to non-financial barriers. Therefore, current universal health insurance systems need targeted policy instruments to minimise non-financial barriers to healthcare to ensure effective universal health coverage.

Estimating and Comparing Health and Financial Risk Protection Outcomes in Economic Evaluations.

OBJECTIVES: Improving health and financial risk protection (FRP, the prevention of medical impoverishment) and their distributions is a major objective of national health systems. Explicitly describing FRP and disaggregated (eg, across socioeconomic groups) impact of health interventions in economic evaluations can provide decision makers with a broader set of health and financial outcomes to compare and prioritize interventions against each other. METHODS: We propose methods to synthesize such a broader set of outcomes by estimating and comparing the distributions in both health and FRP benefits procured by health interventions. We build on benefit-cost analysis frameworks and utility-based models, and we illustrate our methods with the case study of universal public finance (financing by government regardless of whom an intervention is targeting) of disease treatment in a low- and middle-income country setting. RESULTS: Two key findings seem to emerge: FRP is critical when diseases are less lethal (eg, case fatality rates <1% or so), and quantitative valuation of inequality aversion across income groups matters greatly. We recommend the use of numerous sensitivity analyses and that all distributional health and financial outcomes be first presented in a disaggregated form (before potential subsequent aggregation). CONCLUSIONS: Estimation approaches such as the one we propose provide explicit disaggregated considerations of equity, FRP, and poverty impact for the development of health sector policies, with high relevance for population-based preventive measures.

Learning by Doing: Accelerate Towards the NCD Target in SDG Through Primary Healthcare Comment on "Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare".

Health systems built on the foundation of primary healthcare (PHC) are essential to achieve universal health coverage (UHC). To adequately respond to the needs of people with non-communicable diseases (NCDs) and enable optimal management in primary care settings, changes are needed at many levels. PHC levers recommended in the UHC framework as the cornerstone of achieving Sustainable Development Goal (SDG) goals by strengthening the primary care system include strategic and operational levers. Experience from hypertension control programs across 18 countries has shown that rapid scale-up can be achieved through systematic improvement of the PHC system brought about by political commitment, financial support, and high-quality people-centred primary care. As countries are gripped with the pandemic the importance of an appropriate and resilient health system fit for the country is emerging as a priority for building preparedness. While there are general principles, each country must learn by doing and scale up models relevant to the national context.

Recalling the universal health coverage vision and equity in the COVID-19 vaccine distribution plan.

The COVID-19 pandemic has changed the world in so many ways since 2019 when the first case was recorded. COVID-19 pandemic has impacted negatively on economy, health, education and infrastructure globally. COVID-19 vaccine was developed with the aim of stopping the pandemic and allowing the rebuilding of our societies and economies. The vaccine was rolled out in December 2020 and the distribution plan appears to be skewed in favour of high income countries. This paper highlights the need for consideration of the principles of equity and universal health coverage in the distribution plan of the vaccine. It emphasizes the need to ensure that the interests of citizens of developing and low income countries are well protected. The paper concludes that issues of disparity in economic status of countries entering agreement with the vaccine manufacturing companies, absence of logistic support among others should not be a barrier to ensuring equitable access to vaccine for all consistent with the sustainable development goal 3.7.

Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis.

BACKGROUND: Universal health coverage (UHC) encompasses 2 main components: access to essential healthcare services and protection from financial hardship when using healthcare. This study examines Myanmar's efforts to achieve UHC on a national and subnational level. It is a primer of studying the concept of UHC on a subnational level, and it also establishes a baseline for assessing future progress toward reaching UHC in Myanmar. METHODS AND FINDINGS: The study uses the Demographic and Health Survey (2015) and the Myanmar Living Conditions Survey (MLCS; 2017) and adapts a previously developed UHC index to provide insights into the main barriers preventing the country's progress toward UHC. We find a negative correlation between the UHC index and the state/region poverty levels. The equity of access analysis reveals significant pro-rich inequity in access to all essential healthcare services. Socioeconomic status and limited availability of healthcare infrastructure are the main driving forces behind the unequal access to interventions that are crucial to achieving UHC by 2030. Finally, financial risk protection analysis shows that the poor are less likely to use healthcare services, and, once they do, they are at a greater risk of suffering financial catastrophe. Limitations of this study revolve around its correlational, rather than causal, nature. CONCLUSIONS: We suggest a 2-pronged approach to help Myanmar achieve UHC: Government and state authorities should reduce the financial burden of seeking healthcare, and, coupled with this, significant investment in and expansion of health infrastructure and the health workforce should be made, particularly in the poorer and more remote states.

Building optimal and sustainable kidney care in low resource settings: The role of healthcare systems.

Healthcare systems in low-income and lower-middle income countries (LLMICs) face significant challenges in the provision of health services, for example, kidney care to the population. Although this is linked to several high-level factors such as poor infrastructure, socio-demographic and political factors, healthcare funding has often been cited as the major reason for the wide gap in availability, accessibility and quality of care between LLMICs and rich countries. With the steady rising incidence and prevalence of kidney diseases globally, as well as cost of care, LLMICs are likely to suffer more consequences of these increases than rich countries and may be unable to meet targets of universal health coverage (UHC) for kidney diseases. As health systems in LLMICs continue to adapt in finding ways to provide access to affordable kidney care, various empirical and evidence-based strategies can be applied to assist them. This review uses a framework for healthcare strengthening developed by the World Health Organization (WHO) to assess various challenges that health systems in LLMICs confront in providing optimal kidney care to their population. We also suggest ways to overcome these barriers and strengthen health systems to improve kidney care in LLMICs.

Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: A qualitative study among key stakeholders.

INTRODUCTION: The National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce "out-of-pocket" payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders' views on ways to improve the financial sustainability of the operations of NHIS. METHODS: Twenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software. RESULTS: Stakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers' fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims' reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage. CONCLUSION: The Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers.

The federal spending power: Building forward after the pandemic.

The phrase, "the federal spending power," identifies the federal government's ability to spend in areas beyond its constitutional authority to legislate-a power that has supported the development of a national system of universal healthcare coverage in Canada. Even before the COVID-19 pandemic, this power was critical to the expansion of Canada's narrow but deep basket of universally covered services. The challenges exposed by the pandemic mean that still more federal investment will be required. Yet for traditionalists, the material basis of this power is now constrained: the federal government may possess the constitutional authority to invest, but it lacks the fiscal capacity; some form of belt tightening-even austerity-will be necessary. As debates over public spending intensify, health leaders will need to address these questions. Depending on how they do so, health leaders will either support or detract from a healthy recovery.

Does social health insurance prevent financial hardship in Mongolia? Inpatient care: A case in point.

BACKGROUND: Protecting people from financial hardship and impoverishment due to health care costs is one of the fundamental purposes of the Mongolian health system. However, the inefficient, oversized hospital sector is considered one of the main shortcomings of the system. The aim of this study is to contribute to policy discussions by estimating the extent of catastrophic health expenditure and impoverishment due to inpatient care at secondary-level and tertiary-level public hospitals and private hospitals. METHODS: Data were derived from a nationally representative survey, the Household Socio-Economic Survey 2012, conducted by the National Statistical Office of Mongolia. A total of 12,685 households were involved in the study. "Catastrophic health expenditure" is defined as out-of-pocket payments for inpatient care that exceed a threshold of 40% of households' non-discretionary expenditure. The "impoverishment" effect of out-of-pocket payments for inpatient care was estimated as the difference between the poverty level before health care payments and the poverty level after these payments. RESULTS: At the threshold of 40% of capacity to pay, 0.31%, 0.07%, and 0.02% of Mongolian households suffered financially as a result of their member(s) staying in tertiary-level and secondary-level public hospitals and private hospitals respectively. About 0.13% of the total Mongolian population was impoverished owing to out-of-pocket payments for inpatient care at tertiary-level hospitals. Out-of-pocket payments for inpatient care at secondary-level hospitals and private hospitals were responsible for 0.10% and 0.09% respectively of the total population being pushed into poverty. CONCLUSIONS: Although most inpatient care at public hospitals is covered by the social health insurance benefit package, patients who utilized inpatient care at tertiary-level public hospitals were more likely to push their households into financial hardship and poverty than the inpatients at private hospitals. Improving the hospital sector's efficiency and financial protection for inpatients would be a crucial means of attaining universal health coverage in Mongolia.