Health system inequities in Lao People's Democratic Republic: Evidence from a nationally representative phone survey.

BACKGROUND: Despite substantial economic growth in Lao People's Democratic Republic (PDR) over the past 20 years, high levels of income inequality and poverty persist and have likely been exacerbated by the COVID-19 pandemic. In this article, we use novel survey data to assess the extent to which socioeconomic status is associated with access to quality care in Lao PDR. METHODS: We utilised data from the Lao People's Voice Survey (PVS), which was designed to measure health system performance from the perspective of the population. The survey was conducted between May and August 2022. Primary outcomes of interest were having a usual source of healthcare, using a government health centre (rather than a hospital or private clinic) as the usual source for care, receiving preventive health services, experiencing unmet healthcare needs, the quality of recent healthcare visit, and confidence in accessing and affording healthcare when needed. Poverty was measured using household asset ownership. We used logit models to assess the associations between poverty and health system performance measures, and additionally assessed differences between these associations in urban vs. rural areas by interacting urban residence with poverty. RESULTS: Poverty was negatively associated with having a regular provider for care (adjusted odds ratio (aOR) 0.45, 95% CI 0.26-0.78), receiving preventive health services (aOR 0.54, 95% CI 0.37-0.80), and confidence in the ability to receive care (aOR 0.50, 95% CI 0.34-0.72) and afford care (aOR 0.50, 95% CI 0.34-0.73) when needed. Poverty was positively associated with using government managed health centres as a usual source or for care (aOR 2.16, 95% CI 1.35-3.48). Poverty was not significantly associated with user experience or perceived quality of care in the last visit to the health facility. No differences in the associations between poverty and access to quality care were found between rural and urban settings. CONCLUSIONS: The results presented in this article suggest socioeconomic disparities in health care access in Lao PDR despite major national efforts to provide universal access to care. Universal health care policies may not be reaching the poor and additional targeted efforts may be needed to meet their healthcare needs.

Health system utilization and perceived quality among adults in Lao PDR: evidence from a nationally representative phone survey.

BACKGROUND: The World Health Organization (WHO) defines quality health services as being effective, safe, people-centered, timely, equitable, integrated and efficient. It is critical to understand people's perspectives and care experiences to measure progress against these goals. However, many low- and middle-income governments do not routinely collect such information. In this study, we aim to measure health systems performance from the perspective of the adult population of users and non-users in Lao PDR. METHODS: Using the People's Voice Survey (PVS), a novel phone-based survey designed to integrate people's voices into primary care performance measurement, we conducted a cross-sectional survey of the general adult (18+) population in Lao PDR in 2022. We analyzed health care utilization patterns, user-reported quality of care, and coverage of key preventive health services. Data from the most recent MICS survey was used to create sampling weights generating nationally representative estimates. RESULTS: A total of 2007 adults completed interviews in approximately 3.5 months. About two thirds (65%) of respondents reported visiting a health facility in the past year and, of these, the majority (61%) visited a hospital as opposed to a health center or clinic. Among those that recently visited health facilities, 28% rated their experience as "poor" or "fair". 16% had unmet need for care and 12% reported discrimination during treatment in the past year. 12% of women over 50 years old reported receiving a mammogram and 59% of adults reported receiving blood pressure screening in the previous year. CONCLUSIONS: The study presents data from the first nationally representative survey in Lao PDR to measure health system performance. The results indicate that, despite progress towards universal coverage of health insurance in Lao PDR, significant gaps remain, particularly with respect to bypassing of primary care facilities, significant unmet need for care, experiences of discrimination, and overall low perceptions of quality of care.

Health system quality and COVID-19 vaccination: a cross-sectional analysis in 14 countries.

The social and behavioural determinants of COVID-19 vaccination have been described previously. However, little is known about how vaccinated people use and rate their health system. We used surveys conducted in 14 countries to study the health system correlates of COVID-19 vaccination. Country-specific logistic regression models were adjusted for respondent age, education, income, chronic illness, history of COVID-19, urban residence, and minority ethnic, racial, or linguistic group. Estimates were summarised across countries using random effects meta-analysis. Vaccination coverage with at least two or three doses ranged from 29% in India to 85% in Peru. Greater health-care use, having a regular and high-quality provider, and receiving other preventive health services were positively associated with vaccination. Confidence in the health system and government also increased the odds of vaccination. By contrast, having unmet health-care needs or experiencing discrimination or a medical mistake decreased the odds of vaccination. Associations between health system predictors and vaccination tended to be stronger in high-income countries and in countries with the most COVID-19-related deaths. Access to quality health systems might affect vaccine decisions. Building strong primary care systems and ensuring a baseline level of quality that is affordable for all should be central to pandemic preparedness strategies.

The path to universal health coverage in five African and Asian countries: examining the association between insurance status and health-care use.

Despite major efforts to achieve universal health coverage (UHC), progress has lagged in many African and Asian countries. A key strategy pursued by many countries is the use of health insurance to increase access and affordability. However, evidence on insurance coverage and on the association between insurance and UHC is mixed. We analysed nationally representative cross-sectional data collected between 2022 and 2023 in Ethiopia, Kenya, South Africa, India, and Laos. We described public and private insurance coverage by sociodemographic factors and used logistic regression to examine the associations between insurance status and seven health-care use outcomes. Health insurance coverage ranged from 25% in India to 100% in Laos. The share of private insurance ranged from 1% in Ethiopia to 13% in South Africa. Relative to the population with private insurance, the uninsured population had reduced odds of health-care use (adjusted odds ratio 0·68, 95% CI 0·50-0·94), cardiovascular examinations (0·63, 0·47-0·85), eye and dental examinations (0·54, 0·42-0·70), and ability to get or afford care (0·64, 0·48-0·86); private insurance was not associated with unmet need, mental health care, and cancer screening. Relative to private insurance, public insurance was associated with reduced odds of health-care use (0·60, 0·43-0·82), mental health care (0·50, 0·31-0·80), cardiovascular examinations (0·62, 0·46-0·84), and eye and dental examinations (0·50, 0·38-0·65). Results were highly heterogeneous across countries. Public health insurance appears to be only weakly associated with access to health services in the countries studied. Further research is needed to improve understanding of these associations and to identify the most effective financing strategies to achieve UHC.

Measuring people's views on health system performance: Design and development of the People's Voice Survey.

Todd Lewis and co-authors discuss development and use of the People's Voice Survey for health system assessment.

Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysis.

BACKGROUND: Primary care is of insufficient quality in many low-income and middle-income countries. Some health facilities perform better than others despite operating in similar contexts, although the factors that characterise best performance are not well known. Existing best-performance analyses are concentrated in high-income countries and focus on hospitals. We used the positive deviance approach to identify the factors that differentiate best from worst primary care performance among health facilities across six low-resource health systems. METHODS: This positive deviance analysis used nationally representative samples of public and private health facilities from Service Provision Assessments of the Democratic Republic of the Congo, Haiti, Malawi, Nepal, Senegal, and Tanzania. Data were collected starting June 11, 2013, in Malawi and ending Feb 28, 2020, in Senegal. We assessed facility performance through completion of the Good Medical Practice Index (GMPI) of essential clinical actions (eg, taking a thorough history, conducting an adequate physical examination) according to clinical guidelines and measured with direct observations of care. We identified hospitals and clinics in the top decile of performance (defined as best performers) and conducted a quantitative, cross-national positive deviance analysis to compare them with facilities performing below the median (defined as worst performers) and identify facility-level factors that explain the gap between best and worst performance. FINDINGS: We identified 132 best-performing and 664 worst-performing hospitals, and 355 best-performing and 1778 worst-performing clinics based on clinical performance across countries. The mean GMPI score was 0·81 (SD 0·07) for the best-performing hospitals and 0·44 (0·09) for the worst-performing hospitals. Among clinics, mean GMPI scores were 0·75 (0·07) for the best performers and 0·34 (0·10) for the worst performers. High-quality governance, management, and community engagement were associated with best performance compared with worst performance. Private facilities out-performed government-owned hospitals and clinics. INTERPRETATION: Our findings suggest that best-performing health facilities are characterised by good management and leaders who can engage staff and community members. Governments should look to best performers to identify scalable practices and conditions for success that can improve primary care quality overall and decrease quality gaps between health facilities. FUNDING: Bill & Melinda Gates Foundation.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

Effect of lifting COVID-19 restrictions on utilisation of primary care services in Nepal: a difference-in-differences analysis.

INTRODUCTION: An increasing number of studies have reported disruptions in health service utilisation due to the COVID-19 pandemic and its associated restrictions. However, little is known about the effect of lifting COVID-19 restrictions on health service utilisation. The objective of this study was to estimate the effect of lifting COVID-19 restrictions on primary care service utilisation in Nepal. METHODS: Data on utilisation of 10 primary care services were extracted from the Health Management Information System across all health facilities in Nepal. We used a difference-in-differences design and linear fixed effects regressions to estimate the effect of lifting COVID-19 restrictions. The treatment group included palikas that had lifted restrictions in place from 17 August 2020 to 16 September 2020 (Bhadra 2077) and the control group included palikas that had maintained restrictions during that period. The pre-period included the 4 months of national lockdown from 24 March 2020 to 22 July 2020 (Chaitra 2076 to Ashar 2077). Models included month and palika fixed effects and controlled for COVID-19 incidence. RESULTS: We found that lifting COVID-19 restrictions was associated with an average increase per palika of 57.5 contraceptive users (95% CI 14.6 to 100.5), 15.6 antenatal care visits (95% CI 5.3 to 25.9) and 1.6 child pneumonia visits (95% CI 0.2 to 2.9). This corresponded to a 9.4% increase in contraceptive users, 34.2% increase in antenatal care visits and 15.6% increase in child pneumonia visits. Utilisation of most other primary care services also increased after lifting restrictions, but coefficients were not statistically significant. CONCLUSIONS: Despite the ongoing pandemic, lifting restrictions can lead to an increase in some primary care services. Our results point to a causal link between restrictions and health service utilisation and call for policy makers in low- and middle-income countries to carefully consider the trade-offs of strict lockdowns during future COVID-19 waves or future pandemics.

Best and worst performing health facilities: A positive deviance analysis of perceived drivers of primary care performance in Nepal.

Primary care services are on average of low quality in Nepal. However, there is marked variation in performance of basic clinical and managerial functions between primary health care centers. The determinants of variation in primary care performance in low- and middle-income countries have been understudied relative to the prominence of primary care in national health plans. We used the positive deviance approach to identify best and worst performing primary health care centers in Nepal and investigated perceived drivers of best performance. We selected eight primary health care centers in Province 1, Nepal, using an index of basic clinical and operational activities to identify four best and four worst performing primary health care centers. We conducted semi-structured, in-depth interviews with managers and clinical staff from each of the eight primary health care centers for a total of 32 interviews. We identified the following factors that distinguished best from worst performers: 1) Managing the facility effectively, 2) engaging local leadership, 3) building active community accountability, 4) assessing and responding to facility performance, 5) developing sources of funding, 6) compensating staff fairly, 7) managing clinical staff performance, and 8) promoting uninterrupted availability of supplies and equipment. These findings can be used to inform quality improvement efforts and health system reforms in Nepal and other similarly under-resourced health systems.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

The price of quality care: cross-sectional associations between out-of-pocket payments and quality of care in six low-income countries.

OBJECTIVE: To assess the relationship between out-of-pocket (OOP) payments and primary health care quality in six low-income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania. METHODS: We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history-taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non-profit and private for-profit facilities controlling for patient, provider, and facility characteristics. RESULTS: Across the six countries, an average of 42% of the 29 677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history-taking and exam items during antenatal care visits, and with counselling in private for-profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high-quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality. CONCLUSION: Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.

Hospital-provision of essential primary care in 56 countries: determinants and quality.

OBJECTIVE: To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres. METHODS: We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data. FINDINGS: On average across 56 countries, public hospitals were used as the sole source of care by 16.9% of 126 012 women who obtained contraceptives, 23.1% of 418 236 women who received routine antenatal care, 19.9% of 47 677 children with diarrhoea and 18.5% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received. CONCLUSION: As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.