Healthcare Financing

This analysis of the Austrian health system reviews recent developments in organization and governance, health financing, health-care provision, health reforms and health-system performance. The Austrian health system provides universal coverage for a wide range of benefits and high-quality care. Free choice of providers and unrestricted access to all care levels (general practitioners, specialist physicians and hospitals) are characteristic features of the system. Unsurprisingly, population satisfaction is well above EU average. Income-related inequality in health has increased since 2005, although it is still relatively low compared to other countries. The health-care system has been shaped by both the federal structure of the state and a tradition of delegating responsibilities to self-governing stakeholders. On the one hand, this enables decentralized planning and governance, adjusted to local norms and preferences. On the other hand, it also leads to fragmentation of responsibi...

Anecdotal evidence on hidden inequity in health care in North African countries abounds. Yet firm empirical evidence has been harder to come by. This article fills the gap. It presents the first analysis of equity in the healthcare system using the particular case of Tunisia. Analyses are based on an unusually rich source of data taken from the Tunisian HealthCare Utilization and Morbidity Survey. Payments for health care are derived from the total amount of healthcare spending which was incurred by households over the last year. Utilization of health care is measured by the number of physical units of two types of services: outpatient and inpatient. The measurement of need for health care is apprehended through a rich set of ill-health indicators and demographics. Findings are presented and compared at both the aggregate level, using the general summary index approach, and the disaggregate level, using the distribution-free stochastic dominance approach. The overall picture is that direct out-of-pocket payments, which constitute a sizeable share in the current financing mix, emerge to be a progressive means of financing health care overall. Interestingly, however, when statistical testing is applied at the disaggregate level progressivity is retained over the top half of the distribution. Further analyses of the distributions of need for-and utilization of-two types of health care-outpatient and inpatient-reveal that the observed progressivity is rather an outcome of the heavy use, but not need, for health care at the higher income levels. Several policy relevant factors are discussed, and some recommendations are advanced for future reforms of the health care in Tunisia.

The HiT profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Ukrainian health system has preserved the fundamental features of the Soviet Semashko system against a background of other changes, which are developed on market economic principles. The transition from centralized financing to its extreme decentralization is the main difference in the health system in comparison with the classic Soviet model. Health facilities are now functionally subordinate to the Ministry of Health, but managerially and financially answerable to the regional and local self-govern...

Yemen is a low-middle-income country where more than half of the population live in rural areas and lack access to the most basic health care. At US$40 per capita, Yemen's annual total health expenditure (THE) is among the lowest worldwide. This study analyses the preconditions and options for implementing basic social health protection in Yemen. It reveals a four-tiered healthcare system characterised by high geographic and financial access barriers mainly for the poor. Out-of-pocket payments constitute 55% of THE, and cost-sharing exemption schemes are not well organised. Resource-allocation practices are inequitable because about 30% of THE gets spent on treatment abroad for a small number of patients, mainly from better-off families. Against the background of a lack of social health protection, a series of small-scale and often informal solidarity schemes have developed, and a number of public and private companies have set up health benefit schemes for their employees. Employment-based schemes usually provide reasonable health care at an average annual cost of YR44 000 (US$200) per employee. In contrast, civil servants contribute to a mandatory health-insurance scheme without receiving any additional health benefits in return. A number of options for initiating a pathway towards a universal health-insurance system are discussed. populous country in the Arabian Peninsula, Yemen has the lowest human development index rank among the Arab nations, ranking 153rd out of 177 countries (United Nations Development Programme, 2007). Consistent with the situation in neighbouring lowincome countries, shrinking government spending for health and unacceptably high levels of out-of-pocket spending are a common reality in Yemen.

China has made remarkable progress in strengthening its primary health-care system. Nevertheless, the system still faces challenges in structural characteristics, incentives and policies, and quality of care, all of which diminish its preparedness to care for a fifth of the world's population, which is ageing and which has a growing prevalence of chronic non-communicable disease. These challenges include inadequate education and qualifications of its workforce, ageing and turnover of village doctors, fragmented health information technology systems, a paucity of digital data on everyday clinical practice, financial subsidies and incentives that do not encourage cost savings and good performance, insurance policies that hamper the efficiency of care delivery, an insufficient quality measurement and improvement system, and poor performance in the control of risk factors (such as hypertension and diabetes). As China deepens its health-care reform, it has the opportunity to build an...

A B S T R A C T Background: The Ethiopian health care system is under tremendous reform. One of the issues high on the agenda is health care financing. In an effort to protect citizens from catastrophic effects of the clearly high share of out-of-pocket expenditure, the government is currently working to introduce health insurance. Objective: This article aims to highlight the components of the Ethiopian health care financing reform and discuss its implications on access to essential medicines. Methods: A desk review of government policy documents and proclamations was done. Moreover, a review of the scientific literature was done via PubMed and search of other local journals not indexed in PubMed. Results: Revenue retention by health facilities, systematizing the fee waiver system, standardizing exemption services, out-sourcing of nonclinical services, user fee setting and revision, initiation of compulsory health insurance (community-based health insurance and social health insurance), establishment of a private wing in public hospitals, and health facility autonomy were the main components of the health care financing reform in Ethiopia. Although limited, the evidence shows that there is increased health care utilization, access to medicines, and quality of services as a result of the reforms. Conclusions: Encouraging progress has been made in the implementation of health care financing reforms in Ethiopia. However, there is shortage of evidence on the effect of the health care financing reforms on access to essential medicines in the country. Thus, a clear need exists for well-organized research on the issue.

No two markets for voluntary health insurance (VHI) are identical. All differ in some way because they are heavily shaped by the nature and performance of publicly financed health systems and by the contexts in which they have evolved. This volume contains short, structured profiles of markets for VHI in 34 countries in Europe. These are drawn from European Union member states plus Armenia, Iceland, Georgia, Norway, the Russian Federation, Switzerland and Ukraine. The book is aimed at policymakers and researchers interested in knowing more about how VHI works in practice in a wide range of contexts. Each profile, written by one or more local experts, identifies gaps in publicly financed health coverage, describes the role VHI plays, outlines the way in which the market for VHI operates, summarises public policy towards VHI, including major developments over time, and highlights national debates and challenges. The book is part of a study on VHI in Europe prepared jointly by the European Observatory on Health Systems and Policies and the WHO Regional Office for Europe. A companion volume provides an analytical overview of VHI markets across the 34 countries.

This analysis of the Austrian health system reviews recent developments in organization and governance, health financing, health-care provision, health reforms and health-system performance. The Austrian health system provides universal coverage for a wide range of benefits and high-quality care. Free choice of providers and unrestricted access to all care levels (general practitioners, specialist physicians and hospitals) are characteristic features of the system. Unsurprisingly, population satisfaction is well above EU average. Income-related inequality in health has increased since 2005, although it is still relatively low compared to other countries. The health-care system has been shaped by both the federal structure of the state and a tradition of delegating responsibilities to self-governing stakeholders. On the one hand, this enables decentralized planning and governance, adjusted to local norms and preferences. On the other hand, it also leads to fragmentation of responsibi...

This analysis of the Lithuanian health system reviews the developments in organization and governance, health financing, health-care provision, health reforms and health system performance since 2000.The Lithuanian health system is a mixed system, predominantly funded from the National Health Insurance Fund through a compulsory health insurance scheme, supplemented by substantial state contributions on behalf of the economically inactive population amounting to about half of its budget. Public financing of the health sector has gradually increased since 2004 to 5.2 per cent of GDP in 2010.Although the Lithuanian health system was tested by the recent economic crisis, Lithuanias counter-cyclical state health insurance contribution policies (ensuring coverage for the economically inactive population) helped the health system to weather the crisis, and Lithuania successfully used the crisis as a lever to reduce the prices of medicines.Yet the future impact of cuts in public health spen...

The protracted LRA war in northern Uganda was characterised by the
abduction and abuse of an unknown but significant number of girls and
women. These girls were forced to carry guns and become wives to
rebels, among other roles during captivity. Based on thirteen child
mothers’ interviews and eight key informant interviews, the study found
that the lives of formerly abducted mothers are tainted with stigma,
rejection, and discrimination by in-laws, relatives, and the community,
which leads to identity problems and limited possibilities for their
integration. Child mothers’ return to school, small business engagement,
and social involvement reduced their plight.

Background To achieve the United Nations Millennium Development Goals, particularly reduction in child mortality (Millennium Development Goal 4), effective interventions to address severe and moderate acute malnutrition (SAM and MAM) among children under 5 years of age must be implemented and brought to scale alongside preventive measures. Bangladesh has an estimated 600,000 children with SAM, for a prevalence of 4%, while 1.8 million children suffer from MAM. Objective To assess the feasibility and constraints of community-based management of acute malnutrition (CMAM), a relatively new approach, in managing SAM and MAM among children in Bangladesh. Methods The methodology involved desk reviews of documents by searching through PubMed and other databases for published literature on CMAM in Bangladesh. We also did a hand search of policy and program documents, including the draft National Nutrition Policy 2013; the Health, Nutrition, Population Sector Development Program document of ...

This analysis of the Lithuanian health system reviews the developments in organization and governance, health financing, health-care provision, health reforms and health system performance since 2000.The Lithuanian health system is a mixed system, predominantly funded from the National Health Insurance Fund through a compulsory health insurance scheme, supplemented by substantial state contributions on behalf of the economically inactive population amounting to about half of its budget. Public financing of the health sector has gradually increased since 2004 to 5.2 per cent of GDP in 2010.Although the Lithuanian health system was tested by the recent economic crisis, Lithuanias counter-cyclical state health insurance contribution policies (ensuring coverage for the economically inactive population) helped the health system to weather the crisis, and Lithuania successfully used the crisis as a lever to reduce the prices of medicines.Yet the future impact of cuts in public health spen...

Stakeholder analysis is widely recommended as a tool for gathering insights on policy actor interests in, positions on, and power to influence, health policy issues. Such information is recognized to be critical in developing viable health policy proposals, and is particularly important for new health care financing proposals that aim to secure universal coverage (UC).

Background Progress in tuberculosis control worldwide, including achievement of 2015 global targets, requires adequate fi nancing sustained for many years. WHO began yearly monitoring of tuberculosis funding in 2002. We used data reported to WHO to analyse tuberculosis funding from governments and international donors (in real terms, constant 2011 US$) and associated progress in tuberculosis control in low-income and middle-income countries between 2002 and 2011. We then assessed funding needed to 2015 and how this funding could be mobilised. Methods We included low-income and middle-income countries that reported data about fi nancing for tuberculosis to WHO and had at least three observations between 2002 and 2011. When data were missing for specifi c country-year combinations, we imputed the missing data. We aggregated country-specifi c results for eight country groups defi ned according to income level, political and economic profi le, geography, and tuberculosis burden. We compared absolute changes in total funding with those in the total number of patients successfully treated and did crosscountry comparisons of cost per successfully treated patient relative to gross domestic product. We estimated funding needs for tuberculosis care and control for all low-income and middle-income countries to 2015, and compared these needs with domestic funding that could be mobilised. Findings Total funding grew from $1•7 billion in 2002 to $4•4 billion in 2011. It was mostly spent on diagnosis and treatment of drug-susceptible tuberculosis. 43 million patients were successfully treated, usually for $100-500 per person in countries with high burdens of tuberculosis. Domestic funding rose from $1•5 billion to $3•9 billion per year, mostly in Brazil, Russia, India, China, and South Africa (BRICS), which collectively account for 45% of global cases, where national contributions accounted for more than 95% of yearly funding. Donor funding increased from $0•2 billion in 2002 to $0•5 billion in 2011, and accounted for a mean of 39% of funding in the 17 countries with the highest burdens (excluding BRICS) and a mean of 67% in low-income countries by 2011. BRICS and upper middleincome countries could mobilise almost all of their funding needs to 2015 from domestic sources. A full response to the tuberculosis epidemic to 2015, including investments to tackle multidrug-resistant tuberculosis, will require international donor funding of $1•6-2•3 billion each year. Interpretation Funding for tuberculosis control increased substantially between 2002 and 2011, resulting in impressive and cost-eff ective gains. The increasing self-suffi ciency of many countries, including BRICS, which account for almost half the world's tuberculosis cases, is a success story for control of tuberculosis. Nonetheless, international donor funding remains crucial in many countries and more is needed to achieve 2015 targets. Funding None.

Background The primary care system in Vietnam has been shown to play a crucial role in disease prevention and health promotion. This study described the primary care system in a selected rural area in Vietnam in terms of its capacity for prevention and control of non-communicable diseases (NCDs). Methods The study was conducted in 2011 in Dong Hy district, Thai Nguyen province-a rural community located in northern Vietnam. Mixed methods were used, including quantitative and qualitative and literature review approaches, to collect data on the current status of the six building blocks of the primary care system in Dong Hy district. Selected health workers and stakeholders in the selected healthcare facilities were surveyed. Results A description of Dong Hy district's primary care capacity for NCD prevention and control is reported. (i) Service delivery: The current practice in NCD prevention and treatment is mainly based on a single risk factor rather than a combination of cardiovascular disease risks. (ii) Governance: At the primary care level, multi-sectoral collaborations are limited, and there is insufficient integration of NCD preventive activities. (iii) Financing: A national budget for NCD prevention and control is lacking. The cost of treatment and medicines is high, whereas the health insurance scheme limits the list of available medicines and the reimbursement ceiling level. Health workers have low remuneration despite their important roles in NCD prevention. (iv) Human resources: The quantity and quality of health staff working at the primary care level, especially those in preventive medicine, are insufficient.

Building health systems commensurate to the challenges of st century Africa requires action in the critical areas of:  people-centred health systems, universal health coverage, the social determinants of health, and health outcomes  leadership, stewardship, civil society engagement, and accountability at all levels  financing for health  commodity security (i.e. medicines, technologies, essential equipment, tools, supplies, etc)  public health systems  health workforce development  research and higher education  innovation in products, service delivery, and governance. These eight interconnected areas are covered in separate sections of the report. We describe the different areas where changes are needed and make recommendations for the way forward, recognising the great diversity within the region. This Commission's vision and aspiration is that by 2030 Africans should have the same opportunities for long and healthy lives that new technologies, well functioning health systems, and good governance offer people living on other continents. The report concludes with an agenda for action based on the following key messages. A paradigm shift is needed to deliver better health outcomes through people-centred health systems and universal health coverage. Current paradigms rely on hospitals and individual care and are unlikely to lead to the achievement of greatly improved health for all Africans. A rapid expansion of new, African-bred approaches to people-centred health systems focused on prevention, primary care, and public health supported by clinical referral systems and quality tertiary care is required to move to the next stage of better health. Universal health coverage should be designed with local values, sustainability, and equity in mind from the onset. There are historic, not to be missed opportunities to improve health within the next decade. Given the region's economic growth and societal changes, and building on the momentum from the beginning of the SDG era, most sub-Saharan countries have an opportunity to bring some traditional health challenges under control and to prevent others from taking hold and having the same devastating impact seen in other regions of the world. Examples include eliminating polio and guinea worm, meeting demand for modern contraceptives, reducing maternal mortality and water borne diseases, greatly reducing the mortality and incidence of HIV infection, making significant progress on sanitation, and preventing an epidemic of tobacco-related diseases, among others. Achieving good health for all citizens should be a political and investment priority for every sub-Saharan country. In addition to a better life for people, investing more in health will contribute to economic growth and sustainable development. Good health for all citizens is a central responsibility of the state and its elected bodies, requiring considerable investment of public funds, a legislative framework, and a whole-of-society response. Accountability requires mechanisms to hold duty-bearers to account, and people need to have the capacity to demand their rights. Each country needs to chart its own sustainable path to improve health outcomes. Each country needs home-bred solutions, building the required systems based on its own culture while making maximal use of international experiences and evidence, strengthened stewardship of health, and commitment to accountability. All domestic and external resources for health should be aligned to a country's national health strategy, with actions evaluated by specific health outcomes. All countries can and should invest more in health and do more to address inefficiencies. Governments need to identify new funding sources and maintain steady progress over time towards increasing the share of prepaid contributions in total health expenditure and towards prioritising health in domestic budgets. Although there is no single benchmark to determine funding needs, targets to aim for include 5% of GDP, 15% of government expenditure, and US$ 86 per capita. Improving access and outcomes for the poor must remain a priority and requires more effort in identifying and reaching these groups. Improving public financial management is the foundation of better health spending and must be complemented with taking a systemic approach to implementing reforms with a view to reducing fragmentation and inefficiencies across health system functions, public sector portfolios, and stakeholders. Closing health equity gaps should be a core concern for policy and action. The poor in Africa still have disproportionately less access to health services and are more exposed to impoverishing expenditure compared to the non-poor. All efforts to improve health must explicitly address the crying inequities within countries. Health inequities are greatest among the very poor, rural populations, those who are marginalised or excluded from society, and those who live in humanitarian settings and conflict zones. A key priority is reducing out-of-pocket payments: despite overall progress during the past decade, some countries have had little reduction in their share of total health expenditure. In more than a third of the countries such payments make up more than 40% of total health expenditure, and in only five countries (Botswana, Mozambique, Namibia, Seychelles, and South Africa) they represent less than 10%. Further progress is needed in removing user fees and ensuring the poor benefit the most from health insurance schemes. Investments in higher education and research are essential for better health and sustainable development. Higher education is vital for developing an adequate and skilled health workforce and increasing health research capacity and should receive a higher priority in national and regional agendas. Because of the importance of context in improving health and delivering health services, local research is necessary to identify challenges, set priorities, devise original solutions, and make the best use of limited resources. Generating and using innovation will accelerate better health outcomes and reduce inequities. Capitalising on innovation is key to the future of health in sub-Saharan Africa and can support "leapfrogging" health improvements. There is huge scope for innovative, low-cost vaccines, diagnostics, therapies, and IT applications for prevention and care. Also urgently needed are innovations in health professional education, health service delivery, and governance, particularly those using information and communication technologies. Stronger regional cooperation will add value to national health efforts. Pooling resources among sub-Saharan countries and collaborating on issues related to commodity security, surveillance, emergency response, governance, the health workforce, and research and development would benefit population health and the quality of care in countries and the region as a whole, and would facilitate more proactive sharing of data, innovations, and technical expertise.

Background In September, 2012, the UN Commission on Life Saving Commodities (UNCoLSC) outlined a plan to expand availability and access to 13 life saving commodities. We profi le global and country progress against these recommendations between 2012 and 2015. Methods For 12 countries in sub-Saharan Africa that were off-track to achieve the Millennium Development Goals for maternal and child survival, we reviewed key documents and reference data, and conducted interviews with ministry staff and partners to assess the status of the UNCoLSC recommendations. The RMNCH fund provided short-term catalytic fi nancing to support country plans to advance the commodity agenda, with activities coded by UNCoLSC recommendation. Our network of technical resource teams identifi ed, addressed, and monitored progress against cross-cutting commodity-related challenges that needed coordinated global action. Findings In 2014 and 2015, child and maternal health commodities had fewer bottlenecks than reproductive and neonatal commodities. Common bottlenecks included regulatory challenges (ten of 12 countries); poor quality assurance (11 of 12 countries); insuffi cient staff training (more than half of facilities on average); and weak supply chains systems (11 of 12 countries), with stock-outs of priority commodities in about 40% of facilities on average. The RMNCH fund committed US$175•7 million to 19 countries to support strategies addressing crucial gaps. $68•2 million (39•0%) of the funds supported systems-strengthening interventions with the remainder split across reproductive, maternal, newborn, and child health. Health worker training ($88•6 million, 50•4%), supply chain ($53•3 million, 30•0%), and demand generation ($21•1 million, 12•0%) were the major topics of focus. All priority commodities are now listed in the WHO Essential Medicines List; appropriate price reductions were secured; quality manufacturing was improved; a fast-track registration mechanism for prequalifi ed products was established; and methods were developed for advocacy, quantifi cation, demand generation, supply chain, and provider training. Slower progress was evident around regulatory harmonisation and quality assurance. Interpretation Much work is needed to achieve full implementation of the UNCoLSC recommendations. Coordinated eff orts to secure price reductions beyond the 13 commodities and improve regulatory effi ciency, quality, and supply chains are still needed alongside broader dissemination of work products. Funding Governments of Norway (NORAD) and the UK (DFID).

This thesis examines the introduction of compulsory medical insurance in the Russian Federation in the 1990s as part of the re-structuring of welfare in the years after communism. The reforms brought in strong decentralisation of governance in comparison to Soviet rule. Minimal national legislation and guidance, subsequent adjustments in the face of implementation problems and a pattern of “negotiated federalism” have led to wide variation in regional systems within Russia. This thesis looks in particular at implementation in two federal units (from 89): Volgograd Oblast’ and St. Petersburg City.

In the first part, it considers the decision to introduce insurance in the context of the international health care debate, and examines the relationship between health care reform and broader issues of the “transition” away from communism to the market. Particular attention is drawn to how these two discourses in practice have run contrary to each other. It also documents experimental internal market health reform in the Gorbachev era in Leningrad (St. Petersburg), as well as the genesis, formulation and implementation of health insurance at the national level.

The main body of the thesis considers the development of compulsory health insurance in the two research sites, drawing primarily on interview data from 34 interviews with representatives of the main actors within the new system –the municipal administration, parastatal funds and insurance companies – as well as representatives of the health care workforce. Of particular significance is found to be: the impact of financial shortages on the viability of insurance; the extent to which elements of Russian local government reform can undermine regional health care governance; the innovation of decentralisation and the introduction of elements of contract and negotiation in place of vertical command and control structures; and conflict between parastatal health funds and insurance companies. In general the St. Petersburg system was more successful than that in Volgograd. The former was fortunate in its local government structures and in its legacy of institutional reform in health care, but also key policy choices have simplified the systems operation. In Volgograd Oblast’ the system suffers from over complexity, institutional conflict and a lack of clear and effective governance structures.

Using testimony and analysis from Russian newspaper and journal archives these issues are explored across Russia. Regional statistical material drawn from a wide range of sources is employed to consider what might be the main determinants/pre-conditions (economic, political, demographic) in system design.

Drawing five main conclusions in relation to the material above, the thesis additionally argues that “marketisation”, although partly the inspiration for the new system, is unhelpful as an analytical tool; that the main strength of the reforms has been to stabilise health care financing, but that without sufficient funds it may serve to reinforce Soviet-era distributional inefficiencies rather than solve them.

Universal health coverage (UHC) has been defined as the desired outcome of health system performance whereby all people who need health services (promotion, prevention, treatment, rehabilitation, and palliation) receive them, without undue financial hardship. UHC has two interrelated components: the full spectrum of good-quality, essential health services according to need, and protection from financial hardship, including possible impoverishment, due to out-of-pocket payments for health services. Both components should benefit the entire population. This paper summarizes the findings from 13 country case studies and five technical reviews, which were conducted as part of the development of a global framework for monitoring progress towards UHC. The case studies show the relevance and feasibility of focusing UHC monitoring on two discrete components of health system performance: levels of coverage with health services and financial protection, with a focus on equity. These component...

Community-based care (CBC) can increase access to key services for people affected by HIV/AIDS through the mobilization of community interests and resources and their integration with formal health structures. Yet, the lack of a systematic framework for analysis of CBC focused on HIV/AIDS impedes our ability to understand and study CBC programs. We sought to develop taxonomy of CBC programs focused on HIV/ AIDS in resource-limited settings in an effort to understand their key characteristics, uncover any gaps in programming, and highlight the potential roles they play. Our review aimed to systematically identify key CBC programs focused on HIV/AIDS in resource-limited settings. We used both bibliographic database searches (Medline, CINAHL, and EMBASE) for peer-reviewed literature and internet-based searches for gray literature. Our search terms were 'HIV' or 'AIDS' and 'community-based care' or 'CBC'. Two co-authors developed a descriptive taxonomy through an iterative, inductive process using the retrieved program information. We identified 21 CBC programs useful for developing taxonomy. Extensive variation was observed within each of the nine categories identified: region, vision, characteristics of target populations, program scope, program operations, funding models, human resources, sustainability, and monitoring and evaluation strategies. While additional research may still be needed to identify the conditions that lead to overall program success, our findings can help to inform our understanding of the various aspects of CBC programs and inform potential logic models for CBC programming in the context of HIV/AIDS in resourcelimited settings. Importantly, the findings of the present study can be used to develop sustainable HIV/AIDSservice delivery programs in regions with health resource shortages.

This paper will review three recent papers that discuss the future prospects of public health finance in the United States. Most commentators agree that the current long-run growth path of public healthcare spending in the US is unsustainable. Each of the papers examined here address this problem from a different perspective, and their conclusions are, in some cases, extremely different. Each paper, however, constructs a useful framework within which to analyze what exactly is meant by the notion that “rising healthcare costs are a problem,” provides valuable insights necessary to crafting a solution.

In Germany risk adjustment is a core element of the regulatory framework of competition between sickness funds. It shall create a level playing field between funds with very heterogeneous risk structures. Prior to 2009 risk adjustment was mainly by a demographic model. In 2009 morbidity based risk adjustment was introduced, embedded in a broader reform of the statutory health insurance system. The new formula covers 80 "severe" or "costly and chronic" diseases structured in a system of hierarchical groups.

In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-of-pocket payments and health insurance for the informal sector are regressive. The distribution of health care benefits is generally pro-rich. This paper explores the factors influencing these distributions in the three countries. Qualitative data were collected through focus group discussions and in-depth interviews with insurance scheme members, the uninsured, health care providers and managers. Household surveys were also conducted in all countries. Flat-rate contributions contributed to the regressivity of informal sector voluntary schemes, either by design (in Tanzania) or due to difficulties in identifying household income levels (in Ghana). In all three countries, the regressivity of out-of-pocket payments is due to the incomplete enforcement of exemption and waiver policies, partial or no insurance cover among poorer segments of the population and limited understanding of entitlements among these groups. Generally, the pro-rich distribution of benefits is due to limited access to higher level facilities among poor and rural populations, who rely on public primary care facilities and private pharmacies. Barriers to accessing health care include medical and transport costs, exacerbated by the lack of comprehensive insurance coverage among poorer groups. Service availability problems, including frequent drug stock-outs, limited or no diagnostic equipment, unpredictable opening hours and insufficient skilled staff also limit service access. Poor staff attitudes and lack of confidence in the skills of health workers were found to be important barriers to access. Financing reforms should therefore not only consider how to generate funds for health care, but also explicitly address the full range of affordability, availability and acceptability barriers to access in order to achieve equitable financing and benefit incidence patterns.

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The health status of the Greek population has strongly improved over the last few decades and seems to compare relatively favourably with other OECD and European Union (EU) countries. The health system is a mixture of public integrated, public contract and public reimbursement models, comprising elements from both the public and private sectors and incorporating principles of different organizational patterns. Access to services is based on citizenship as well as on occupat...

Background: Implementation of quality improvements in palliative care (PC) is challenging, and detailed knowledge about factors that may facilitate or hinder implementation is essential for success. One part of the EUfunded IMPACT project (IMplementation of quality indicators in PAlliative Care sTudy) aiming to increase the knowledge base, was to conduct national studies in PC services. This study aims to identify factors perceived as barriers or facilitators for improving PC in cancer and dementia settings in Norway. Methods: Individual, dual-participant and focus group interviews were conducted with 20 employees working in different health care services in Norway: two hospitals, one nursing home, and two local medical centers. Thematic analysis with a combined inductive and theoretical approach was applied. Results: Barriers and facilitators were connected to (1) the innovation (e.g. credibility, advantage, accessibility, attractiveness); (2) the individual professional (e.g. motivation, PC expertise, confidence); (3) the patient (e.g. compliance); (4) the social context (e.g. leadership, culture of change, face-to-face contact); (5) the organizational context (e.g. resources, structures/facilities, expertise); (6) the political and economic context (e.g. policy, legislation, financial arrangements) and (7) the implementation strategy (e.g. educational, meetings, reminders). Four barriers that were particular to PC were identified: the poor general condition of patients in need of PC, symptom assessment tools that were not validated in all patient groups, lack of PC expertise and changes perceived to be at odds with staff's philosophy of care. Conclusion: When planning an improvement project in PC, services should pay particular attention to factors associated with their chosen implementation strategy. Leaders should also involve staff early in the improvement process, ensure that they have the necessary training in PC and that the change is consistent with the staff's philosophy of care. An important consideration when implementing a symptom assessment tool is whether or not the tool has been validated for the relevant patient group, and to what degree patients need to be involved when using the tool.

Background: Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up. Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC. Results: Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks. Conclusions: There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

Background: As a tropical depression in the East Sea, Vietnam is greatly affected by climate change and natural disasters. Knowledge of the current capacity of the primary healthcare system in Vietnam to respond to health issues associated with storms and floods is very important for policy making in the country. However, there has been little scientific research in this area. Objective: This research was to assess primary healthcare system capacities in a rural district in central Vietnam to respond to such health issues. Design: This was a cross-sectional descriptive study using quantitative and qualitative approaches. Quantitative methods used self-administered questionnaires. Qualitative methods (in-depth interviews and focus groups discussions) were used to broaden understanding of the quantitative material and to get additional information on actions taken. Results: 1) Service delivery: Medical emergency services, especially surgical operations and referral systems, were not always available during the storm and flood seasons. 2) Governance: District emergency plans focus largely on disaster response rather than prevention. The plans did not clearly define the role of primary healthcare and had no clear information on the coordination mechanism among different sectors and organizations. 3) Financing: The budget for prevention and control of flood and storm activities was limited and had no specific items for healthcare activities. Only a little additional funding was available, but the procedures to get this funding were usually time-consuming. 4) Human resources: Medical rescue teams were established, but there were no epidemiologists or environmental health specialists to take care of epidemiological issues. Training on prevention and control of climate change and disaster-related health issues did not meet actual needs. 5) Information and research: Data that can be used for planning and management (including population and epidemiological data) were largely lacking. The district lacked a disease early-warning system. 6) Medical products and technology: Emergency treatment protocols were not available in every studied health facility. Conclusions: The primary care system capacity in rural Vietnam is inadequate for responding to storm and flood-related health problems in terms of preventive and treatment healthcare. Developing clear facility preparedness plans, which detail standard operating procedures during floods and identify specific job descriptions, would strengthen responses to future floods. Health facilities should have contingency funds available for emergency response in the event of storms and floods. Health facilities should ensure that standard protocols exist in order to improve responses in the event of floods. Introduction of a computerized health information system would accelerate information and data processing. National and local policies need to be strengthened and developed in a way that transfers into action in local rural communities.

This analysis of the Estonian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In 2017, the Estonian government took the historic step of expanding the revenue base of the health system, which has been a longstanding challenge. However, in terms of percentage of GDP it remains a small increase and long-term financial sustainability could still pose a problem. That said, if these additional funds are invested wisely, they could play a positive role in further improving the health system. Indeed, although Estonia has made remarkable progress on many health indicators (e.g. the strongest gains in life expectancy of all EU countries, strongly falling amenable mortality rates), there are opportunities for improvements. They include overcoming the large health disparities between socioeconomic groups, improving population coverage, developing a comprehensive plan to tackle workf...

The main aim of this work was to identify and present the situation and changes in the level of expenditure on healthcare in the European Union in the years 2013–2017. This involved an analysis of the available literature on healthcare financing, data from the EUROSTAT database. For this work, the comparative method was used, dynamics indicators were used, the Gini concentration coefficient was calculated, and the degree of concentration was presented using the Lorenz curve. Pearson’s linear correlation coefficients were also used. A descriptive, tabular and graphic method was used to present the test results that were obtained. A high concentration of expenditure on healthcare was found in the EU countries with the largest population and that are the most economically developed. These results also relate to these expenses on a per capita basis. The main factor differentiating the level of healthcare financing was the level of economic development. This regularity was confirmed in the statement of expenditure per capita, the relationship between this expenditure and the value of GDP and the results obtained when calculating the correlation between expenditure and economic development. In addition to the economic situation, an important factor determining the amount of expenditure on healthcare was the percentage of the country’s population that are older people.

Medicines are important in health care services delivery. Frequent stock outs of medicines have been a major challenge in public health facilities in low-and middle-income countries like Kenya. This research aimed at determining the influence of procurement process on availability of medicines in Bungoma County, Kenya. Descriptive cross sectional research design with mixed approach methods was applied. The target population included the county pharmacist, sub county pharmacists, medical superintendents, procurement officers, health administrative officers, the county procurement officer and the chief officer for health and sanitation. All the nine sub county hospitals were sampled and a census method used to sample four staff from each of the sub county that is the sub county pharmacists, medical superintendents, procurement officers and health administrative officers in all the nine sub counties of the county hence 36 respondents. This was achieved through G-power Priori power analysis. Additionally, the county procurement officer, the chief officer for health and sanitation and the county pharmacist were purposively sampled, making the total number of respondents to be 39. Semi structured questionnaires: in-depth interview guides and a checklist were the study data collection tools. Qualitative and quantitative data analysis methods were applied. Analysis of quantitative data was done using descriptive statistics while Chi square was used as appropriate. Data was presented in tables. Qualitative data was categorized into specific themes and reported in narrative form together with quantitative presentation. 81.2% of respondents reiterated that procurement processes were followed as compared to 18.8% who indicated that in some cases, laid down procurement procedures were not followed. Health administrative officers were a majority of those who reported adherence to these procedures while all the pharmacists and procurement officers said they had full adherence. An analysis of the different carders of health workers involved in this study revealed that there was no significant relationship between adherence to procurement procedures and the cadre of the health professional involved (χ 2 =2.230: p= 0.534). On the same note, it was shown that there was a significant relationship between adherence to procurement procedures and the work experience of the health professional involved (χ 2 = 11.24: p= 0.003). A significant relationship between adherence to procurement procedures and the incidences of discrepancies between received quantities and quantities on the delivery notes (χ2= 6.28: P= 0.025) was established. 87.5% of all respondents noted that their respective health facilities used direct tendering as a method of procuring medicines. Open tendering was said to be in use by only 3.1% of respondents while request for quotation was by 9.4%. Adherence to procurement procedures seemed to have a greater influence on the availability of medicines (OR=4.194, P=0.002). Those involved in the procurement process were health facilities in chargesnurses or clinical officers for rural health facilities or pharmaceutical personnel for hospitals who generate orders. The county pharmacist, county procurement officer, chief officer health & sanitation are involved in sending orders to suppliers and subsequently making payments. Inadequate funding for medicines procurement, inadequate procurement personnel and long procurement process were cited as the main challenges relating to procurement of medicines. The government needs to streamline the procurement process for medicines in order to ensure availability of medicines.

In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-of-pocket payments and health insurance for the informal sector are regressive. The distribution of health care benefits is generally pro-rich. This paper explores the factors influencing these distributions in the three countries. Qualitative data were collected through focus group discussions and in-depth interviews with insurance scheme members, the uninsured, health care providers and managers. Household surveys were also conducted in all countries. Flat-rate contributions contributed to the regressivity of informal sector voluntary schemes, either by design (in Tanzania) or due to difficulties in identifying household income levels (in Ghana). In all three countries, the regressivity of out-of-pocket payments is due to the incomplete enforcement of exemption and waiver policies, partial or no insurance cover among poorer segments of the population and limited understanding of entitlements among these groups. Generally, the pro-rich distribution of benefits is due to limited access to higher level facilities among poor and rural populations, who rely on public primary care facilities and private pharmacies. Barriers to accessing health care include medical and transport costs, exacerbated by the lack of comprehensive insurance coverage among poorer groups. Service availability problems, including frequent drug stock-outs, limited or no diagnostic equipment, unpredictable opening hours and insufficient skilled staff also limit service access. Poor staff attitudes and lack of confidence in the skills of health workers were found to be important barriers to access. Financing reforms should therefore not only consider how to generate funds for health care, but also explicitly address the full range of affordability, availability and acceptability barriers to access in order to achieve equitable financing and benefit incidence patterns.

Introduction: Rational decision making on malaria control depends on an understanding of the epidemiological risks and control measures. National Malaria Control Programmes across Africa have access to a range of state-of-the-art malaria risk mapping products that might serve their decision-making needs. The use of cartography in planning malaria control has never been methodically reviewed.

ÖZ:
Dünya tıp literatüründe yaygın bir uygulama olan triyaj sistemi Sağlık Bakanlığı mevzuatı gereği Türkiye’de de uygulanmaktadır. Sosyal güvenlik mevzuatı yönünden özellik arzeden bir uygulama olan triyajın uygulanma esasları Sağlık Uygulama Tebliği’nde belirlenmiştir. Buna göre triyaj kapsamında yapılan değerlendirme sonucu yeşil alan muayenesi kapsamına giren sağlık hizmetlerinden katılım payı ve ilave ücret alınabilmekteyken, yeşil alan muayenesi kapsamı dışında kalan acil sağlık hizmetlerinden bu tutarlar alınamamaktadır. Bu uygulamayla, acil hizmetlerindeki gereksiz iş yükünün azaltılması yanında aile hekimliği sisteminin sağlıklı işlemesinin sağlanması ve sevk zinciri sistemine geçiş için sağlık hizmetlerinin olgunlaştırılması hedeflenmektedir. Bu çalışma, triyaj sistemlerinin tanımı ve amaçlarının açıklanması yanında sağlık hizmetleri ve sosyal güvenlik mevzuatı açısında Türkiye’de uygulanan triyaj sisteminin yeri ve uygulama esaslarının derli toplu bir şekilde ortaya konulmasını amaçlamaktadır.
ANAHTAR KELİMELER: Triyaj sistemleri, genel sağlık sigortası, yeşil alan muayenesi, muayene katılım payı, ilave ücret.
ABSTARCT
Triage system which is a common practice in world medical literature, has been also implementing in Turkey according to legislation of Ministry of Health. The implementaion principles of triage system, which constitutes a special practice in terms of social security legislation, has determined in Health Budget Notification Act. Accordingly, as a result of the evaluation carried out with triage system, it can be taken contribution fee and additional charge from the health care services within the scope of green category examinations while those amounts can not be taken from emergency healt care services except green category examinations. With this implementation it is being targeted to reduce the burden of unnecessary work on emergency services, in addition to ensure healthy functioning of the family practioners system and to elaborate the health care services for transition to the referral system. This study aims to explain the definition and objectives of the triage systems alongside to disclosure neatly the position and application principles of triage system in Turkey in terms of health care services and social security regulations.
KEYWORDS: Triage Systems, General Health İnsurance, Green Category Examination, Examination Contribution Rate, Additional Fee.

Background Progress in tuberculosis control worldwide, including achievement of 2015 global targets, requires adequate fi nancing sustained for many years. WHO began yearly monitoring of tuberculosis funding in 2002. We used data reported to WHO to analyse tuberculosis funding from governments and international donors (in real terms, constant 2011 US$) and associated progress in tuberculosis control in low-income and middle-income countries between 2002 and 2011. We then assessed funding needed to 2015 and how this funding could be mobilised. Methods We included low-income and middle-income countries that reported data about fi nancing for tuberculosis to WHO and had at least three observations between 2002 and 2011. When data were missing for specifi c country-year combinations, we imputed the missing data. We aggregated country-specifi c results for eight country groups defi ned according to income level, political and economic profi le, geography, and tuberculosis burden. We compared absolute changes in total funding with those in the total number of patients successfully treated and did crosscountry comparisons of cost per successfully treated patient relative to gross domestic product. We estimated funding needs for tuberculosis care and control for all low-income and middle-income countries to 2015, and compared these needs with domestic funding that could be mobilised. Findings Total funding grew from $1•7 billion in 2002 to $4•4 billion in 2011. It was mostly spent on diagnosis and treatment of drug-susceptible tuberculosis. 43 million patients were successfully treated, usually for $100-500 per person in countries with high burdens of tuberculosis. Domestic funding rose from $1•5 billion to $3•9 billion per year, mostly in Brazil, Russia, India, China, and South Africa (BRICS), which collectively account for 45% of global cases, where national contributions accounted for more than 95% of yearly funding. Donor funding increased from $0•2 billion in 2002 to $0•5 billion in 2011, and accounted for a mean of 39% of funding in the 17 countries with the highest burdens (excluding BRICS) and a mean of 67% in low-income countries by 2011. BRICS and upper middleincome countries could mobilise almost all of their funding needs to 2015 from domestic sources. A full response to the tuberculosis epidemic to 2015, including investments to tackle multidrug-resistant tuberculosis, will require international donor funding of $1•6-2•3 billion each year. Interpretation Funding for tuberculosis control increased substantially between 2002 and 2011, resulting in impressive and cost-eff ective gains. The increasing self-suffi ciency of many countries, including BRICS, which account for almost half the world's tuberculosis cases, is a success story for control of tuberculosis. Nonetheless, international donor funding remains crucial in many countries and more is needed to achieve 2015 targets. Funding None.

Zimbabwe&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s public health financing model is mostly hospital-based. Financing generally follows the bigger and higher-level hospitals at the expense of smaller, lower-level ones. While this has tended to perpetuate inequalities, the pattern of healthcare services utilisation and benefits on different levels of care and across different socioeconomic groups remains unclear. The purpose of this study was therefore to assess the utilisation of healthcare services and benefits at different levels of care by different socioeconomic groups. We conducted secondary data analysis of the 2010 National Health Accounts survey, which had 7084 households made up of 26,392 individual observations. Results showed significant utilisation of health services by poorer households at the district level (concentration index of -0.13 [CI:-0.2 to -0.06; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05]), but with mission hospitals showing equitable utilisation by both groups. Provincial and higher levels showed greater utilisation by richer households (0.19; CI: 0.1-0.29; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). The overall results showed that richer households benefited significantly more from public health funds than poorer households (0.26; CI: 0.2-0.4; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Richer households disproportionately benefited from public health subsidies overall, particularly at secondary and tertiary levels, which receive more funding and provide a higher level of care.

For Americans experiencing illnesses and disabilities, crowdfunding has become a popular strategy for addressing the extraordinary costs of health care. The political, social, and health consequences of austerity--along with fallout from the 2008 financial collapse and the shortcomings of the Affordable Care Act (ACA)--are made evident in websites like GoFundMe. Here, patients and caregivers create campaigns to solicit donations for medical care, hoping that they will spread widely through social networks. As competition increases among campaigns, patients and their loved ones are obliged to produce compelling and sophisticated appeals. Despite the growing popularity of crowdfunding, little research has explored the usage, impacts, or consequences of the increasing reliance on it for health in the U.S. or abroad. This paper analyzes data from a mixed-methods study conducted from March-September 2016 of 200 GoFundMe campaigns, identified through randomized selection. In addition to p...