Catastrophic health care expenditure in Myanmar: policy implications in leading progress towards universal health coverage.

BACKGROUND: Around the world, millions of people are impoverished due to health care spending. The highest catastrophic health expenditures are found in countries in transition. Our study analyzes the extent of financial protection by estimating the incidence of catastrophic health care expenditure in Myanmar and its association with sociodemographic factors. METHODS: We performed a secondary analysis of data from the household surveys conducted by the Livelihoods and Food Security Trust Fund (LIFT) in 2013 and 2015 in Myanmar. To estimate the magnitude of catastrophic health care expenditure, we applied the definition of catastrophic payment proposed by the World Health Organization (WHO); a household's out-of-pocket payment for health care is considered catastrophic if it exceeds 40% of the household capacity to pay. We also examined the changes in catastrophic payments at three different threshold levels (20, 30, 40%) with one equation allowing for a negative capacity to pay (modified WHO approach) and another equation with adjusted negative capacity to pay (standard WHO approach). RESULTS: In 2013, the incidence of catastrophic expenditure was 21, 13, 7% (standard WHO approach) and 48, 43, 41% (modified WHO approach) at the 20, 30, 40% threshold level respectively, while in 2015, these estimates were 18, 8, 6% (standard WHO approach) and 47, 41, 39% (modified WHO approach) respectively. Geographical location, gender of the household head, total number of household members, number of children under 5, and number of disabled persons in the household were statistically significantly associated with catastrophic health care expenditures in both studied years 2013 and 2015. Education of household head was statistically significantly associated with catastrophic health expenditure in 2013. We found that the incidence of catastrophic expenditures varied by the approach used to estimate expenditures. CONCLUSIONS: Although the level of catastrophic health care expenditure varies depending on the approach and threshold used, the problem of catastrophic expenditures in Myanmar cannot be denied. The government of Myanmar needs to scale up the current Social Security Scheme (SSS) or establish a new financial protection mechanism for the population. Vulnerable groups, such as households with a household head with a low-level of education, households with children under the age of 5 years or disabled persons, and low-income households should be prioritized by policymakers to improve access to essential health care.

A systematic review of the health-financing mechanisms in the Association of Southeast Asian Nations countries and the People's Republic of China: Lessons for the move towards universal health coverage.

We systematically review the health-financing mechanisms, revenue rising, pooling, purchasing, and benefits, in the Association of Southeast Asian Nations (ASEAN) and the People's Republic of China, and their impact on universal health coverage (UHC) goals in terms of universal financial protection, utilization/equity and quality. Two kinds of sources are reviewed: 1) academic articles, and 2) countries' health system reports. We synthesize the findings from ASEAN countries and China reporting on studies that are in the scope of our objective, and studies that focus on the system (macro level) rather than treatment/technology specific studies (micro level).The results of our review suggest that the main sources of revenues are direct/indirect taxes and out of pocket payments in all ASEAN countries and China except for Brunei where natural resource revenues are the main source of revenue collection. Brunei, Indonesia, Philippines, Malaysia, and Viet Nam have a single pool for revenue collection constituting a national health insurance. Cambodia, China, Lao, Singapore, and Thailand have implemented multiple pooling systems while Myanmar has no formal arrangement. Capitation, Fee-for-Service, DRGs, Fee schedules, Salary, and Global budget are the methods of purchasing in the studied countries. Each country has its own definition of the basic benefit package which includes the services that are perceived as essential for the population health. Although many studies provide evidence of an increase in financial protection after reforming the health-financing mechanisms in the studied countries, inequity in financial protection continue to exist. Overall, the utilization of health care among the poor has increased as a consequence of the implementation of government subsidized health insurance schemes which target the poor in most of the studied countries. Inappropriate policies and provider payment mechanisms impact on the quality of health care provision. We conclude that the most important factors to attain UHC are to prioritize and include vulnerable groups into the health insurance scheme. Government subsidization for this kind of groups is found to be an effective method to achieve this goal. The higher the percentage of government expenditure on health, the greater the financial protection is. At the same time, there is a need to weigh the financial stability of the health-financing system. A unified health insurance system providing the same benefit package for all, is the most efficient way to attain equitable access to health care. Capacity building for both administrative and health service providers is crucial for sustainable and good quality health care.

Patterns of health care use and out-of-pocket payments among general population and social security beneficiaries in Myanmar.

BACKGROUND: As a consequence of the low government expenditure and limited access to health insurance offered by the Social Security Scheme (SSS), out-of-pocket payments (OOPPs) have become the main source of payment for health care in Myanmar. This study aims to provide evidence on the patterns of health care use and OOPPs by the general population and SSS beneficiaries in Myanmar. METHOD: Face-to-face interviews were conducted among two samples drawn independently of each other. The first sample, the general population sample of persons not insured by SSS, was drawn from the general population in the Yangon Region. The second sample, the SSS sample, was drawn from those possessing SSS insurance. The data were analyzed per sample. Mann-Whitney U tests were applied to compare ordinal variables and independent sample t-tests were applied to compare continuous variables between the two samples. Two-step cluster analysis was applied to identify clusters of respondents with similar patterns of health care use and OOPPs. After the clustering procedure, we used regression analysis to examine the association between socio-demographic characteristics and cluster membership (patterns of health care use and OOPPs) for the two samples separately. RESULTS: Only 23% of those who belonged to the SSS sample and sought health care during the past 12 months, report receiving health care from a SSS clinic during the last episode of illness. Close distance is the main reason for choosing a specific health facility in both samples. OOPPs for health care and pharmaceuticals, used during the last episode of illness are significantly higher in the general population sample. The regression analysis shows that the pattern of health care use is significantly associated with household income. In addition, respondents in the general population sample with a higher income pay higher amounts for their last health care used and were significantly more likely to have to borrow money or sell assets as a coping strategy to cover the payments. CONCLUSION: Significantly higher OOPPs in the general population sample highlight the need of financial protection among this group. Myanmar needs to extend social protection for both coverage breadths and coverage depth.

Health insurance in Myanmar: Knowledge, perceptions, and preferences of Social Security Scheme members and general adult population.

OBJECTIVE: Our study explores the knowledge, perceptions, willingness to pay, and preferences of potential health insurance beneficiaries about health insurance in Myanmar. METHODS: Cross-sectional survey data were collected among two samples: the general population and Social Security Scheme (SSS) member. Mann-Whitney U test and independent sample t test were applied to compare the two samples. The data on willingness to pay for health insurance were analyzed using regression analysis. RESULTS: Low level of knowledge and weak positive perception are found in both samples. More than 90% of the SSS sample and 75% of the general sample are willing to pay health insurance premiums. The largest shares of both samples are willing to pay for monthly premiums between 2000 and 4000 MMK (1.8-3.6 USD). Health status, age, gender, income, and trust are significantly associated with willingness to pay for health insurance among general sample while occupation, civil status, income, and positive perception on prepayment principle are found among SSS sample. CONCLUSIONS: The government of Myanmar should be aware of the preferences of beneficiaries to pay a relatively low level of monthly health insurance premiums without co-payment.

Assessing the accuracy and feasibility of a refractive error screening program conducted by school teachers in pre-primary and primary schools in Thailand.

INTRODUCTION: As part of the development of a system for the screening of refractive error in Thai children, this study describes the accuracy and feasibility of establishing a program conducted by teachers. OBJECTIVE: To assess the accuracy and feasibility of screening by teachers. METHODS: A cross-sectional descriptive and analytical study was conducted in 17 schools in four provinces representing four geographic regions in Thailand. A two-staged cluster sampling was employed to compare the detection rate of refractive error among eligible students between trained teachers and health professionals. Serial focus group discussions were held for teachers and parents in order to understand their attitude towards refractive error screening at schools and the potential success factors and barriers. RESULTS: The detection rate of refractive error screening by teachers among pre-primary school children is relatively low (21%) for mild visual impairment but higher for moderate visual impairment (44%). The detection rate for primary school children is high for both levels of visual impairment (52% for mild and 74% for moderate). The focus group discussions reveal that both teachers and parents would benefit from further education regarding refractive errors and that the vast majority of teachers are willing to conduct a school-based screening program. CONCLUSION: Refractive error screening by health professionals in pre-primary and primary school children is not currently implemented in Thailand due to resource limitations. However, evidence suggests that a refractive error screening program conducted in schools by teachers in the country is reasonable and feasible because the detection and treatment of refractive error in very young generations is important and the screening program can be implemented and conducted with relatively low costs.

Health technology assessments as a mechanism for increased value for money: recommendations to the Global Fund.

The Global Fund is experiencing increased pressure to optimize results and improve its impact per dollar spent. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. This paper assesses the efficacy of current Global Fund investment and examines how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidized by the Global Fund. In addition, this paper identifies areas where the application of HTAs can exert the greatest impact and proposes ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, it addresses the challenges facing the Global Fund in realizing the full potential of HTAs.

Advanced health biotechnologies in Thailand: redefining policy directions.

BACKGROUND: Thailand faces a significant burden in terms of treating and managing degenerative and chronic diseases. Moreover, incidences of rare diseases are rising. Many of these-such as diabetes, cancer, and inherited inborn metabolic diseases-have no definite treatments or cure. Meanwhile, advanced health biotechnology has been found, in principle, to be an effective solution for these health problems. METHODS: Qualitative approaches were employed to analyse the current situation and examine existing public policies related to advanced health biotechnologies in Thailand. The results of this analysis were then used to formulate policy recommendations. RESULTS: Our research revealed that the system in Thailand in relation to advanced health biotechnologies is fragmented, with multiple unaddressed gaps, underfunding of research and development (R&D), and a lack of incentives for the private sector. In addition, there are no clear definitions of advanced health biotechnologies, and coverage pathways are absent. Meanwhile, false advertising and misinformation are prevalent, with no responsible bodies to actively and effectively provide appropriate information and education (I&E). The establishment of a specialised institution to fill the gaps in this area is warranted. CONCLUSION: The development and implementation of a comprehensive national strategic plan related to advanced health biotechnologies, greater investment in R&D and I&E for all stakeholders, collaboration among agencies, harmonisation of reimbursement across public health schemes, and provision of targeted I&E are specifically recommended.