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.     

Health care financing in Hong Kong: a case for tax‐based financing

With the new government of the Hong Kong Special Administrative Region currently conducting a review of Hong Kong's health care financing system, this article argues that the existing tax‐based system not only works well at present, but is also sustainable in the future. The performance of the system is analysed in terms of cost, health outcomes and access. The arguments for change are discussed, and the case for maintaining the status quo is presented. The author concludes that the way forward would be to fine tune the existing system rather than to replace it with other systems which are known to have higher transaction costs and more serious supply‐side moral hazards. Copyright © 1999 John Wiley & Sons, Ltd.     

A sustainability assessment of a health equity fund initiative in Cambodia

All but one of the health equity funds (HEFs) currently operating in Cambodia, introduced to address the adverse effects of low user fee exemption rates, rely heavily on external funding and have high administrative overheads. This article reports on a study of one type of HEF, based in Kirivong Operational Health District (KOD) and operated through local pagoda structures, which demonstrates minimal reliance on external funding and low administrative overheads. We utilize an adapted sustainability assessment framework to assess the ability of pagoda structures to enable financial access for the poorest to public sector health services. We further analyse the strengths and limitations of the pagoda-managed equity fund initiative, with a view to assessing not only its sustainability but its potential for replication in other settings.Our study shows that, against key sustainability indicators (health service utilization and health outcomes; management capacity and financial viability; community mobilization and government support), the pagoda-managed equity fund initiative scores well. However, it is evident that some external financial support is needed to allow the HEFs to function effectively. We conclude with recommendations for replicating the initiative, which include working innovatively with indigenous grassroots organizations to enhance community HEF ownership and to keep administrative overheads low.     

Responsibility‐Sensitive Fairness in Health Financing: Judgments in Four European Countries

Risky health behaviours substantially increase medical and social costs. We document the extent to which a sample of European students (from Denmark, France, Italy and Sweden) consider that individuals should assume the financial burden of paying the costs of risky behaviour. We test the acceptability of different ways of financing costs because of ill health that is more or less associated with risky behaviour in accordance with a normative framework relating to responsibility‐sensitive fairness. We find that the majority of students agree with assuming financial responsibility for risky behaviours and that there should be compensation for unfavourable circumstances. Students agree that two individuals with the same responsibility variables should make an equal financial contribution and that more effort in maintaining health for given circumstances should be rewarded with a lower financial contribution. The specific health context and the type of risky behaviours involved matter in determining perceptions of justice in health financing. Copyright © 2014 John Wiley & Sons, Ltd.     

The Impact of Community‐Based Health Insurance on Utilization and Out‐of‐Pocket Expenditures in Lao People's Democratic Republic

Community‐based health insurance in Lao People's Democratic Republic targets the informal workforce. Estimates of the program's impact on utilization and out‐of‐pocket expenditures (OOPs) were obtained using a case‐comparison study of 3000 households (14 804 individuals) in urban and semi‐urban areas. We used propensity score matching to control for bias on observables and to account for heterogeneity. We check the sensitivity of the results using a weighted regression combined with propensity score matching, which leads to doubly robust treatment effect estimates. The results are robust across the two approaches and show that the insured have significantly higher utilization, lower OOPs and lower incidence of catastrophic expenditures, and are less likely to employ coping mechanisms. However, coverage of the scheme is extremely low, indicating negligible population level impact. Furthermore, the results show that the scheme provides greater protection to the better off than to the poor: the poor are less likely to enrol, and among the poor who are enrolled, there has been no significant impact on utilization of outpatient services, total OOPs or catastrophic expenditures. We discuss the policy implications in the context of the international debate regarding the prospects for the role of community‐based health insurance in national financing strategies. Copyright © 2013 John Wiley & Sons, Ltd.     

The impact of the introduction of user fees at a district hospital in Cambodia

Proponents of user fees in the health sector in poor countries cite a number of often interrelated rationales, relating inter alia to cost recovery, improved equity and greater efficiency. Opponents argue that dramatic and sustained decreases in service utilization follow the introduction of user fees, highlighting evidence that user fees reduce service utilization when they fail to result in improved quality of care and/or when services are priced higher than those charged by private health care providers. Utilization of public health services in Cambodia is low. Supply-side factors are significant determinants of such low public sector utilization, including low official salaries of service providers (forcing many to seek additional income in the private sector), and operations budgets which are erratic and often insufficient to cover running costs of service delivery outlets. The Cambodia Ministry of Health (MOH) encourages user fee schemes at operational district level. By allowing revenue to be retained at the health facility level, the MOH aims to improve health care delivery--and consequently service utilization--through increased salaries to health facility staff and increases in operations budgets. This case study of the introduction of user fees at a district referral hospital in Kirivong Operational District in Cambodia, using the findings from empirical research, examines the impact of user fees on health-careseeking behaviour, ability to pay and consultation prices at private practitioners. The research showed that consultation fees charged by private providers increased in tandem with price increases introduced at the referral hospital. It further demonstrates--for the first time that we are aware of from the available literature--that the introduction and subsequent increase in user fees created a 'medical poverty trap', which has significant health and livelihood impact (including untreated morbidity and long-term impoverishment). Addressing the medical poverty trap will require two interventions to be implemented immediately: regulation of the private sector, and reimbursing health facilities for services provided to patients who are exempted from paying user fees because of poverty. A third, longer-term initiative is also suggested: the establishment of a social health insurance mechanism.     

Factors associated with misreporting in performance‐based financing in Burkina Faso: Implications for risk‐based verification

Performance‐based financing (PBF) has been piloted in many low‐ and middle‐income countries (LMICs) as a strategy to improve access to and quality of health services. As a key component of PBF, quantity verification is carried out to ensure that reported data matches the actual number of services provided. However, cost concerns have led to a call for risk‐based verification. Existing evidence suggests misreporting is associated with factors such as complexity of indicators, high service volume, and accepted error margin. In contrast, evidence on the association of key facility characteristics with misreporting in PBF is scarce. We contributed to filling this gap in knowledge by combining administrative data from a large‐scale pilot PBF program in Burkina Faso with data from a health facility assessment in the context of an impact evaluation of the intervention. Our results showed the coexistence of both overreporting and underreporting and that misreporting varied by service indicator and health district. We also found that the number of clinical staff at the facility, the population size in the facility catchment area, and the distance between the facility and the district administration were associated with the probability of misreporting. We recommend further research of these factors in the move towards risk‐based verification. In addition, given that our analysis identified relevant associations, but could not explain them, we recommend further qualitative inquiry into verification processes.     

Financing elderly people's long‐term care needs: Evidence from China

Confronted by accelerated population aging, China is establishing a long‐term care (LTC) system. This study discusses challenges and recommendations for financing China's LTC system. On the basis of the data on elderly people's self‐care ability from the Chinese Longitudinal Healthy Longevity Survey, we calculate the size of the elderly population that need LTC for the period from 2015 to 2030 and analyse the increasing tendency of LTC expenses by considering the impact of price increase. We also analyse the local governments' financial capacity for LTC support by comparing the expense level to the fiscal revenue. The study found that aging will double the LTC expenses by 2030. Therefore, this study suggests the establishment of an LTC insurance system that allocates LTC expenses, which are currently borne by individuals and families, more fairly among the government, individuals, and families. Moreover, with the current LTC reforms, implemented primarily by local governments in China, we believe that the central government should bear some of the fiscal responsibility by conducting fiscal transfers to partially support undeveloped regions that are establishing an LTC system.     

Better Measurement for Performance Improvement in Low‐ and Middle‐Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection

Policy Points:

• Strengthening accountability through better measurement and reporting is vital to ensure progress in improving quality primary health care (PHC) systems and achieving universal health coverage (UHC).
• The Primary Health Care Performance Initiative (PHCPI) provides national decision makers and global stakeholders with opportunities to benchmark and accelerate performance improvement through better performance measurement.
• Results from the initial PHC performance assessments in low‐ and middle‐income countries (LMICs) are helping guide PHC reforms and investments and improve the PHCPI's instruments and indicators. Findings from future assessment activities will further amplify cross‐country comparisons and peer learning to improve PHC.
• New indicators and sources of data are needed to better understand PHC system performance in LMICs.

Context

The Primary Health Care Performance Initiative (PHCPI), a collaboration between the Bill and Melinda Gates Foundation, The World Bank, and the World Health Organization, in partnership with Ariadne Labs and Results for Development, was launched in 2015 with the aim of catalyzing improvements in primary health care (PHC) systems in 135 low‐ and middle‐income countries (LMICs), in order to accelerate progress toward universal health coverage. Through more comprehensive and actionable measurement of quality PHC, the PHCPI stimulates peer learning among LMICs and informs decision makers to guide PHC investments and reforms. Instruments for performance assessment and improvement are in development; to date, a conceptual framework and 2 sets of performance indicators have been released.

Methods

The PHCPI team developed the conceptual framework through literature reviews and consultations with an advisory committee of international experts. We generated 2 sets of performance indicators selected from a literature review of relevant indicators, cross‐referenced against indicators available from international sources, and evaluated through 2 separate modified Delphi processes, consisting of online surveys and in‐person facilitated discussions with experts.

Findings

The PHCPI conceptual framework builds on the current understanding of PHC system performance through an expanded emphasis on the role of service delivery. The first set of performance indicators, 36 Vital Signs, facilitates comparisons across countries and over time. The second set, 56 Diagnostic Indicators, elucidates underlying drivers of performance. Key challenges include a lack of available data for several indicators and a lack of validated indicators for important dimensions of quality PHC.

Conclusions

The availability of data is critical to assessing PHC performance, particularly patient experience and quality of care. The PHCPI will continue to develop and test additional performance assessment instruments, including composite indices and national performance dashboards. Through country engagement, the PHCPI will further refine its instruments and engage with governments to better design and finance primary health care reforms.     

Research and Advice Giving: A Functional View of Evidence‐Informed Policy Advice in a Canadian Ministry of Health

Context: As evidence-based medicine grows in influence and scope, its applicability to health policy prompts two questions: Can the principles and, more specifically, the tools used to bring research into the clinical world apply to civil servants offering advice to politicians? If not, what approach should the evidence-oriented health policy organization take to improve the use of research?Methods: This article reviews evidence-based medicine and models of research use in policy. Then it reports the results of interviews with civil servants in the Ontario Ministry of Health, which recently adopted a stewardship rather than an operational role, incorporating many evidence-oriented strategies. The interviews focused on functional roles for research-based evidence in policy advice.Findings: The clinical context and tools for evidence-based medicine can rarely be generalized to policy. Most current models of research use offer lessons to researchers wishing to apply their work to policy but little help for civil servants wishing to become more evidence oriented. The interviews revealed functional roles for research in setting agendas (noting upcoming issues and screening interest groups’ claims), developing new policies (reducing uncertainty, helping speak truth to power, and preventing repetition and duplication), and monitoring or modifying existing policies (continuously improving programs and creating a culture of inquiry). Each area requires different tools to help filter the push of evidence from researchers and set agendas, to facilitate the urgent pull on relevant research by civil servants developing new policy, and to support ongoing linkage and exchange between civil servants and researchers for monitoring and modifying existing policy.Conclusions: A functional framework for evidence-informed policy advice is useful for distinguishing the activity from evidence-based medicine and “auditing” the balance of efforts across the different functional roles of research in policy.