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In Indonesia, private midwives face barriers to joining JKN, the country’s single-payer health insurance scheme. But there are solutions to breaking down the barriers. Check out ThinkWell’s video on those challenges and strategies to address the problems.

Video by Analyst Meera Chakravarthy 

This piece originally appeared on Health Systems Governance Collaborative.

As country governments execute their COVID-19 response, the World Health Organization and other stakeholders have stressed the importance of engaging the private sector.  One critical part of that is purchasing health services from private providers, the case for which is strongest in places where private health facilities account for a significant share of service provision.

Uganda serves as an example of such a country. According to the 2018 master facility list, nearly 55% of all health facilities in Uganda are private (either for-profit or not-for-profit). The distribution is particularly skewed in urban settings. In the capital city of Kampala, the public sector accounts for only 2% of health facilities in the city, while private for-profit facilities account for 94% (see figure).  While the Government of Uganda has a long history of engaging with faith-based not-for-profit private facilities (PNFP), they have limited mechanisms to use public funds to purchase services from private for-profit facilities.

The absence of such capacity to work with private for-profit providers in urban Uganda is a challenge in the best of times.  Now with the arrival of COVID-19 in Uganda, it becomes all the more imperative to engage the private sector.

Uganda’s response to the pandemic so far

The first case of COVID-19 in Uganda was identified in late March and has the potential to rapidly overwhelm urban health systems as they are currently assembled.  The Government of Uganda moved swiftly to lock down the country, (re)allocate public funds for the response, and set up a coordination approach across multiple sectors. The National Taskforce set up by the Ministry of Health to coordinate the response includes private sector representation through the Uganda Healthcare Federation (UHF), an umbrella association for private providers. The Taskforce has issued guidance to public and private providers on how they should manage COVID-19 and other essential services, which UHF and ThinkWell have used to train private providers. The Government has also conducted service capacity assessments for all faith-based providers and select large for-profit private facilities on their readiness to handle cases.

What else can be done?

Uganda can do much more to leverage the private sector to expand testing, identify and isolate cases, coordinate referrals, and help keep access open for routine services not related to COVID-19, especially in urban areas that have large, densely-packed populations.  There is international guidance on how this can be achieved – the WHO has released an action plan for ministries of health to engage the private sector in response to COVID-19. Other outlets have recommended phased approaches with the private sector, starting with the acute response in the next 3 months, and longer-term phases that involve peer-to-peer support and improving private sector governance.

One promising avenue is that health authorities in Uganda are discussing whether to adopt a “hub and spoke” model. This is a way to organize the system where there is a main hub (e.g. regional referral hospitals and select large private hospitals in Uganda) that can handle moderate and severe COVID cases.  This hub is complemented by an array of spokes, or satellite facilities like lower tier public and private facilities, that can handle testing, case management, and if necessary, refer to the hubs.  These primary health care (PHC) facilities can also ensure continued access to routine services. These models have been found to be highly scalable and efficient, as well as having the potential to enhance quality, coverage, and improve operational consistency.

To realize the potential of this model in Ugandan towns and municipalities, we recommend the following steps:

  • Clarify the capacity of private facilities to decide how they fit into a hub-and-spoke model
  • Channel essential supplies, like personal protective equipment (PPE) and oxygen, to equipped providers along with technical assistance in exchange for joining and reporting into the national health information system
  • Communicate training packages to clarify guidelines and protocols around COVID-19 testing, tracking, and referrals
  • Provide logistical and clinical backup mechanisms to support referral of cases
  • Set up contract arrangements with private providers to receive payments for COVID-related activities

Call to action

As we have seen around the world, this disease can spread quickly and overwhelm health systems.  To protect against this risk, the Ugandan Government should take the steps needed to include the private sector in urban areas to expand the capacity and scale of their response. Preliminary steps have been taken by the Government and discussions around a hub-and-spoke model are promising, but practical steps are needed to take this attractive model and make it work in places like Kampala. The threat of COVID-19 spreading in these highly vulnerable urban areas presents a unique opportunity for the Government to put effective mechanisms in place to purchase health services from the private sector, which it can leverage for achieving universal health coverage going forward.

Written by Anooj Pattnaik, Tapley Jordanwood, Angellah Nakyanzi, Federica Margini, and Nirmala Ravishankar

This piece originally appeared on P4H

The now: removing financial barriers to COVID 19 testing and services

On May 1, the Kenyan Ministry of Health rolled out free testing for COVID 19 in Nairobi and other areas with disease hotspots. Two days later, the Ministry noted in dismay that the turnout for free testing was much lower than what they had hoped. The reason why the average Kenyan was not queuing up to get a free test was because he or she dreaded the prospect of mandatory quarantining at government designated sites. And a big part of that fear stemmed from having to pay for the quarantining. In the weeks preceding the free testing campaign, there had been news reports about people struggling to clear their bills even at public quarantine centers that were meant to be modestly priced and being held at the facility till they find the money. A leading daily paper released a video clip showing detainees scaling the wall to escape from one such facility.

On May 6, the Ministry announced that it was waiving all charges for quarantining. While this will not fix everything – folks who have experienced the quarantine facilities have also complained about unsanitary conditions and a lack of food – it is expected to a go a long way to encourage people to get tested. While this move serves the most immediate need for removing financial barriers to COVID 19 health services, the global pandemic has introduced uncertainty about the future of a much broader and comprehensive reform to enable all Kenyans to access the health services they need without fear of its financial costs.

The forever: improving financial access to healthcare on the path to Universal Health Coverage

Before the pandemic broke, the National Government was poised to scale up the Afya Care universal health coverage (UHC) program, which it initiated in 4 counties in 2019. Under the pilot program, the 4 county governments agreed to discontinue all user charges at public sector hospitals. In its place, they received additional resources from the National Government in the form of medicines and non-pharmaceutical supplies as well as funds to cover the operating costs of public hospitals, invest in additional health infrastructure and health workers, and finance community health services. This program is an extension of a 2013 government policy that removed all user charges at primary care facilities and started reimbursing them for it (see figure that summarizes the history of user fee policies in Kenya).

Taken together, the 2013 policy and the 2018 UHC scheme – when scaled up — will allow Kenyans to access health services from all public facilities free of charge. There has been discussion of this model paving the way for a UHC fund that may eventually be managed by the National Hospital Insurance Fund and the creation of networks of care that include private providers.  Such a transition would be a huge step in the right direction to remove financial barriers to access and increase financial risk protection. In a 2018 household health expenditure survey[1], a fifth of Kenyans cited the costs of seeking health services as a reason for foregoing care when they are ill. As many as 1.1 million individuals are pushed into poverty as a result of out-of-pocket spending on healthcare.

Chronology path to UHC

Before COVID-19 happened, the National Government was moving full steam ahead, signing agreements with counties to scale up the Afya Care program to the whole country. Now, for obvious reasons, all attention and government resources are focused on the pandemic; indeed some UHC funds have already been re-allocated to hiring more health workers. This is understandable and necessary. But even the National Government is moving rapidly to make COVID 19 testing and treatment available to everyone, the clock is being turned back in the UHC pilot counties. The pilot phase having ended, some of the counties are starting to charge patients for hospital visits. This seems particularly worrying given that the pandemic has delivered a heavy blow to the economy and Kenyans around the country – nearly 80% of whom are engaged in the informal sector and lack the option of working from home – are facing extreme economic hardship.

As Joe Kutzin and his colleagues wrote in a recent blog on health financing priorities in the age of COVID 19, “the choice is not between health security and UHC” and that investments in core health system functions solves for both. We urge Government of Kenya to stay the course on its UHC agenda, removing financial barriers to healthcare services, now and forever.

Written by Nirmala Ravishankar (ThinkWell) and Edwine Barasa (KEMRI Wellcome Trust) 

[1] Ministry of Health, Government of Kenya. 2018. Kenya Household Health Expenditure and Utilization Survey.Nairobi: Government of Kenya.

This piece originally appeared on P4H

MAKING PURCHASING FIT FOR PURPOSE

In the Philippines, the COVID-19 response has called for rapid adaptation of purchasing arrangements. In early 2019, the Philippines passed a Universal Health Care (UHC) Law that envisions the national health insurance agency PhilHealth as the dominant strategic purchaser of individual-based health services while the Department of Health (DOH) pays for population-based health services. Health emergencies present a particularly interesting situation, where services are delivered to individuals, but require significant system-wide mobilization and a consolidated, well-orchestrated response. Existing rules put the response to public health emergencies and disasters under the umbrella of population-based health service and, as such, in DOH’s wheelhouse. However, the COVID-19 response challenges this role delineation. The surge of the disease has demanded the engagement of different types of health care providers, particularly those from the private sector that comprise 65% of providers in the country. To finance services through the greatest number of health providers, PhilHealth was called to step up.

PHILHEALTH’S RESPONSE: BUILDING THE SHIP AS IT SAILS

PhilHealth responded in record time to remove financial barriers to COVID-19 testing and treatment for nearly 93% of the country’s population. As early as February 2020, PhilHealth announced case rates for services related to hospital isolation and for those who develop more severe clinical presentations. In response to the Bayanihan to Heal As One Act enacted in March, PhilHealth declared that it would cover all medical expenses for public and private health workers in case of COVID-19 exposure or any work-related injury or disease during the emergency. In April, PhilHealth released an advisory stating that it will cover the full cost of treatment for COVID-19 patients. Later in April, it released enhanced benefit packages covering COVID-19 services for testingcommunity isolation and inpatient care. PhilHealth had to work through several thorny issues to roll these packages out, and it envisions more course corrections in the future.

Fragmented and uncoordinated financing of inputs for COVID-19 was one of the main challenges encountered. The Bayanihan Act mandates DOH to procure needed inputs to maximize efficiency and avoid “competition” among healthcare providers. Both public and private facilities are also individually receiving donations from various local entities. Resources pouring in from different channels has made it difficult to monitor who gets what and who needs more. For PhilHealth, this increased the risk that it could be paying for items that have been paid by another entity.

To address this issue, government has required donations for COVID-19 health services to be routed through them. PhilHealth then stratified the rates for testing, deducting the estimated amount of test kits received from DOH and donations. While this was not done for the benefit package for community isolation and hospitals, it represents a good first attempt to streamline payments, which can be improved going forward.

Policies, standards, and treatment guidelines surrounding COVID-19 are changing continuously, which makes it challenging to set the appropriate rate and enforce a standard level of care. PhilHealth opted to pay for its COVID-19 benefit packages via case rates which is its dominant provider payment mechanism. However, the benefit policy explicitly states that the package inclusions and rates shall be regularly reviewed based on regularly collected cost and clinical data.

The inflexibility of payment and contracting mechanisms of PhilHealth also pose another challenge. PhilHealth mainly pays its providers retrospectively through case rates after health services have already been delivered. PhilHealth was already crafting a global budget policy as well as exploring other contracting and prospective payment options before COVID 19 happened. These could have facilitated great support for facilities through upfront payments, while ensuring inputs, processes, and performance are up to standards. Additionally, the benefit packages that have been designed continue to be operated by a mix of paper-based and IT-based systems.  The circumstances brought by the pandemic demands quick turnarounds and lean processes considering the skeletal workforce onsite. These tedious requirements can be an actual disincentive to participate. Although PhilHealth relaxed some of these requirements in their COVID-19 benefits, operationalization may still prove to be challenging.

LESSONS FROM THE COVID-19 RESPONSE FOR THE JOURNEY TOWARDS UHC

The ongoing response is revealing the great benefit the country can derive from DOH and PhilHealth working together while exploiting their comparative advantage. As a strategic purchaser, PhilHealth has the capacity to work with a diverse array of providers and clout to shape their behaviour. The capacity of DOH as a national agency to leverage better procurement prices as well as address supply chains is apparent. Bringing together a stronger purchasing role and economies of scale through centralized procurement presents a great opportunity to improve access and rationalize the cost of services in the country. This joint action can build a more resilient health system that can deliver UHC under both normal conditions and during health emergencies like COVID 19.

Written by Christian Edward L. Nuevo (ThinkWell, Philippines) with Pura Angela Wee Co (ThinkWell, Philippines), Maria Eufemia C. Yap (ThinkWell, Philippines), and Nirmala Ravishankar (ThinkWell, USA)

References:

1.    PhilHealth. Circular No. 2020-0004: Enhancement Of Packages Related To Coronavirus Infection. 21 Feb 2020 (cited 30 Apr 2020). Available: https://www.philhealth.gov.ph/circulars/2020/circ2020-0004.pdf

2.    PhilHealth. Advisory No 2020-022. 2 Apri 2020 (cited 30 Apr 2020). Available:https://www.philhealth.gov.ph/advisories/2020/adv2020-0022.pdf

3.     PhilHealth. Circular No. 2020-0009: Benefit Packages For Inpatient Care Of Probable And Confirmed COVID-19 Developing Severe Illness/Outcomes. 14 Apr 2020 (cited 30 Apr 2020). Available: https://www.philhealth.gov.ph/circulars/2020/circ2020-0009.pdf

4.     PhilHealth. Circular No. 2020-0010: Benefit Package For Testing For SARS-CoV-2. 14 Apr 2020 (cited 30 Apr 2020). Available: https://www.philhealth.gov.ph/circulars/2020/circ2020-0010.pdf

5.     PhilHealth. Circular No. 2020-0011: Full Financial Risk Protection For Filipino Health Workers And Patients Against Coronavirus Disease (COVID-19). 14 Apr 2020 (cited 30 Apr 2020). Available: https://www.philhealth.gov.ph/circulars/2020/circ2020-0011.pdf

6.     PhilHealth. Circular No. 2020-0012: Guidelines On The COVID-19 Community Isolation enefit package (CCIBP). 14 Apr 2020 (cited 30 Apr 2020). Available: https://www.philhealth.gov.ph/circulars/2020/circ2020-0012.pdf

This piece originally appeared on P4H

Governments around the world are scrambling to get their hands on personal protective equipment, test kits, ventilators and oxygen. But on the frontlines of service delivery in Kenya, we are also hearing about local health officials and facility managers needing money for more mundane things like fuel for ambulances and airtime for mobile phone communication to coordinate the response. Even as the Government of Kenya reallocates existing funds and mobilizes additional resources to address the pandemic, it is imperative that the funds flow down to health facilities. And that health facilities have the authority to spend those funds to cover basic costs. That this is not happening highlights underlying health systems challenges that existed before COVID-19.

Recent commentary has started exploring the health financing dimensions of the COVID 19 response. Some have offered estimates of how much additional funding LMICs need to respond to the pandemic, and compared that need against available domestic financing. Others have provided insight into ways countries can maneuver within existing public financial management (PFM) systems to increase the budget for health as well as guidance on key health financing decisions countries need to focus on in order to respond coherently to the pandemic. We offer reflections from Kenya to explore how some of these processes are playing out in practice, focusing on the flow of funds from the National Government to county governments, and from county governments to health facilities.

Ability of county governments to allocate resources to the response

Kenya’s PFM law (section 110 -115) allows county governments to set up an emergency fund, which can be activated during a disaster without any further legislative action. While some counties have activated such funds, many have not. To spend beyond those contingency funds, county assemblies need to pass supplementary budgets. This has faced delays, in part due to the national curfew, ban on meetings, travel restrictions, and physical distancing measures. Regardless of whether counties set out to draw from their emergency funds or newly appropriated funds, they are all reliant on transfers from the national government to finance their budgets. Given the history of delayed disbursements, counties have called upon Treasury to ensure timely transfers.

Flow of funds to health providers

The county having funds to spend on the COVID response does not guarantee that the funds flows down to healthcare facilities. Kenya shifted to a devolved system of government in 2013. The newly formed county governments control all primary and secondary health facilities in the public sector. According to the PFM law (section 109), all funds collected by public facilities are to be remitted to the county government unless the county passes legislation allowing facilities to receive and retain funds. Before devolution, health facilities collected revenue from user fees and insurance reimbursements, which they used to pay for costs like casual workers, facility maintenance, and commodities during stock-outs. Their operating budgets also financed the activities of health facility management teams and community outreach efforts. Post-devolution, most counties moved to centralize all revenue in the county coffers at the expense of health facilities, especially hospitals. While the county government is meant to pay for facility costs directly, this is unreliable and slow in practice. Some counties have enacted legislation to create “facility improvements funds” where facility revenue is collected, and then used by facilities. But the counties that have these arrangements are the exception rather than the norm. Majority of public health facilities in Kenya are dependent on county governments to pay for the most basic of needs.

Both of us authors of this blog are associated with programs of work for strengthening health purchasing at the county-level in Kenya. At their core, these efforts are about making counties better at spending money for health and linking their allocations to the performance of providers. It has increasingly also become about advocating for county governments to grant public facilities greater financial autonomy. COVID 19 further underscores the need for Kenya to strengthen purchasing arrangements such that, among other things, they allow public facilities to spend funds quickly (but with accountability) on things they need to deliver health services effectively, under normal circumstances and during COVID 19!

Written by Nirmala Ravishankar (ThinkWell, USA) and Edwine Barasa (KEMRI Wellcome Trust, Kenya). The authors thank Boniface Mbuthia, Shano Guyo, Daniel Koech, and Felix Murira for their inputs.

Now more than ever, the spotlight is shining on the entrenched relationship between health and food. The COVID-19 pandemic has moved dozens of health systems to the brink in low-, middle- and even in high-income countries, and threatens to undermine food systems around the world. If more corrective action is not taken, we are at risk of losing many gains made to improve health and well-being.

Even in the best of times, the systems that deliver our food and healthcare are seldom effective in working together to deliver sustained good health. Having worked for nine years in food and nutrition and another nine in health, I see several ways practitioners across health systems and food systems can greatly improve collaboration. Here I touch on the relationship between food and health and COVID-19, summarize lessons learned from the crisis, and propose three trans-sectoral solutions that can help sustain the delivery of quality healthcare and nutritious foods.

Food systems and COVID-19

Intuitively we get it: a nutritious diet is critical to good health.

However, is it widely known that a suboptimal diet is responsible for more deaths than any other risk globally, including tobacco? Earlier this month, a systematic analysis confirmed this following a review of the health effects of dietary risks in 195 countries.

Worldwide obesity has nearly tripled since 1975. Approximately two billion adults are overweight, and of these over 650 million are obese. Forty-eight countries now face a crisis with a coexistence of high levels of undernutrition and overweight and obesity.

How is this relevant to COVID-19?

We’ve known for some time that there is a strong association between obesity and Acute Respiratory Distress Syndrome (ARDS). This holds true for COVID-19 as highlighted by a number of recent studies including this study led by Imperial College London. It showed that following age, obesity is the single biggest risk factor associated with serious illness related to the virus.  This commentary in Nature notes that patients with type 2 diabetes may have up to 10 times greater risk of death when contracting COVID-19. Without even considering the costs associated with COVID-19, preventing obesity and diabetes makes economic sense. The per capita healthcare costs of treating obesity in the United States alone is shown to be over 80% higher for severely or morbidly obese adults than for adults with a healthy weight.

COVID-19 is poised to significantly increase the number of malnourished individuals globally. COVID-19 has laid bare the dearth of available and affordable nutritious foods in many countries, a lack of sufficient food system capacity to respond to the crisis; and the inability in many countries to collect and analyze up-to-date data on who needs immediate support.

To cite a few examples, food availability has become an issue in the US, a country known for its abundance; in Germany, food banks have temporarily stopped operating depriving many of essential food supplies; and some 300 million primary school children – many in LMIC – no longer have access to their regular (sometimes only) nutritious meal at school due to school closures.

Bangladesh school children

Health Systems and COVID-19

The significant strain COVID-19 is placing on health systems is widely known. Many countries’ health systems – including seven LMIC with which ThinkWell works – are scrambling to respond using already limited resources. This is creating risk that other essential health services do not get the attention they need now and in the future. For example, there has already been a deferral of measles immunization campaigns in 25 countries including countries experiencing a measles outbreak.

“Let food be thy medicine.” – Hippocrates

The current situation points to a key opportunity, to an imperative.

Considering the lessons learned, solutions are urgently needed which are trans-sectoral, that incentivize healthy eating, and which make certain that resources are available within systems to deliver quality healthcare and nutritious food even during crises. Such solutions include food ‘sin’ taxes and subsidies, value-based health insurance programs, and dynamic fiscal management for health and food systems.

1. Food ‘sin’ taxes and subsidies: A 2016 systematic review showed that these two fiscal instruments can result in a decrease in the purchase of products high in salt, fat or sugar; and an increase in the purchase of healthier foods, respectively. Since 2011, when the UN recommended ‘fiscal measures’ as an approach to improve diets, momentum has been growing to use these instruments in national health plans. Some countries earmark revenue generated from sin taxes for health systems. One model estimates that nutritious food subsidies in the US alone could save US$39 billion in healthcare costs by preventing hundreds of thousands of cases of heart disease and diabetes.

Despite the evidence of impact, food taxes and subsidies are vastly underutilized. Only 39 countries report using fiscal policies to improve dietary intake (Figure 1), and only 30 jurisdictions have sugar-sweetened beverage taxes (Figure 2).

Figure 1: Type of fiscal policies influencing foods and beverages (F&B) among 39 countries reportingFigure 1: Type of fiscal policies influencing foods and beverages (F&B) among 39 countries reporting

Figure 2: 30 jurisdictions have existing (dark grey) or forthcoming (light grey) sugar-sweetened beverage taxesFigure 2: 30 jurisdictions have existing (dark grey) or forthcoming (light grey) sugar-sweetened beverage taxes

2. Value-based health insurance: Health insurance typically covers essential medical procedures, prescriptions and provider visits. However, value-based, food-sensitive insurance programs are rare. Where deployed, they incentivize healthy eating, and stem rising healthcare costs by improving individual and community health.

Both in Germany and in Switzerland, public and private health insurance programs offer bonuses or discounts, respectively, for those who follow a healthy diet. In Pennsylvania, USA, Geisinger’s Fresh Food Farmacy (FFF), offers 22,000 pre-diabetic and diabetic residents diabetes education and healthy, subsidized food rather than diabetes drugs. The clinical results are compelling. While medications typically offer a 0.5-1.0 point reduction in HBA1C levels, patients in the FFF program have average reductions of 2.0 points after six months. The economics are also persuasive. It costs just US$3K a year to manage one patient enrolled in FFF compared to US$48K a year for traditional programs.

Value-based, food-sensitive health insurance programs represent a step in the right direction for health systems. As their evidence of impact increases, they should be rolled out to improve prevention and treatment, and link food systems and health systems.

3. Dynamic fiscal management for health and food crises: In response to COVID-19, WHO reports that dozens of countries have now enacted new budget laws that give leaders authority to quickly reallocate budgets or to release supplementary funds. The shared feature in each case has been the declaration of a state of emergency creating the space for increased and faster spending. However, there has been an absence of a concurrent deliberation looking at the fiscal space for food systems and food delivery. Budget measures during emergencies must consider both accelerated health system spending as well as food system expenditure, and this dynamic fiscal management should be institutionalized so that countries can expand both healthcare and strengthen food supply chains in times of crisis.

COVID-19 and Beyond

While the current pandemic may be exploiting weaknesses in our health and food systems it has also helped shine a light on the opportunity to bridge divides. The three solutions summarized here – food sin taxes and subsidies, value-based health insurance, and dynamic fiscal management – are inherently trans-sectoral, requiring an engagement with practitioners and experts across health systems and food systems. They can help incentivize better diets and improve the delivery of quality healthcare and nutritious food sustainably in normal times and in times of crisis.

Written by Greg S. Garrett, Director, Strategy and Design 

Greg has worked on policy and financing to improve health and food systems for the past 18 years. Before joining ThinkWell in 2019, Greg worked for eight years at the Global Alliance for Improved Nutrition (GAIN) as Director of Policy & Finance and Head of GAIN Switzerland. During this time, he supported food system change in over 30 countries by forging private public partnerships, established GAIN’s Innovative Finance Program, directed a credit revolving fund for African businesses, and led GAIN’s largest portfolio — food fortification — helping 12 countries enact legislation and reach hundreds of millions with better nutrition.

Greg previously held senior management positions at Abt Associates and Futures Group (now Palladium), spent seven years working in Africa and Asia, and started his career in international health with Mercy Ships in 1995. Mr Garrett serves on the Board of the Iodine Global Network (IGN), is well published and is frequently asked to speak at international conferences. Greg holds a BA and an MSc in International Development from the University of Bath, UK.

The cord might be around her neck, so we will need to schedule a C-section. How does next Wednesday sound?” My obstetrician smiled reassuringly. It was 1992 in Brazil. My first C-section. Not medically necessary I’ve come to learn. Brazil offers a cautionary tale of C-section rates over 50% of all births, well above the suggested 15%. Similar increasing trends are already emerging in some other low and middle-income countries (LMICs) as they make welcome strides to improve access to basic and emergency obstetric care.

C-sections can save lives. This is especially true in LMICs where C-section rates are low (below 5%). But at the same time, unnecessary C-sections are bad. The World Health Organization has warned, “Rising C-section rates have not been accompanied by significant maternal or perinatal benefits. On the contrary, there is evidence that, beyond a certain threshold, increasing caesarean section rates may be associated with increased maternal and perinatal morbidity…[and] substantial health-care costs.” As a surgical procedure, a C-section exposes the mother and baby to risk of complications, injury, and infection.

In Kenya, there are urban settings where we are doing too many C-sections, yet in the rural areas we don’t have enough to save women’s lives.– Marleen Temmerman, Professor of Obstetrics and Gynaecology, Aga Khan University

LMICs may face the dual dilemma of:

  • Too little, too late for poor and/or rural women who cannot access safe C-sections when medically necessary because the surgical facilities and staff are lacking or because they cannot afford the hospitals that offer safe C-sections
  • Too much, too soon for wealthier urban women who opt for a C-section that is not medically necessary for a variety of reasons, such as doctor recommendation, convenience, fear of pain, or to be “modern”

Both contribute to poor outcomes, including disproportionally high C-section deaths in LMICs, especially in sub-Saharan Africa.

Source: Soha Sobhy et al. 2019

The drivers of C-sections are varied and complex. High and middle-income countries are trying to address the problem with mixed results. What can LMICs learn from these countries? Can they save lives and money in the process? Stakeholders from around the world convened for a two-day workshop in December that was titled, “Averting an Impending Cesarean Section Disaster in LMICs.” I was honored to join more than 30 experts who shared the evidence on C-sections, necessary and unnecessary, in LMICs and their heroic efforts to address a growing crisis.

I joined the workshop to share information on how financial incentives for C-section provision influence the health care provider. Paying providers a higher fee for a C-section compared to a normal delivery does contribute to higher C-section rates. Yet this is common practice in many countries. National health insurers in Kenya, Indonesia, and Philippines are alarmed at rising C-section rates among their beneficiaries. All three pay more for C-sections.

Country Payer Rate by type of delivery C-section incentive
Kenya National Hospital Insurance Fund Normal         KES 10,000

C-section      KES 30,000

3 times more
Indonesia National Health Insurance JKN Normal        Rp 1.5M-4.7M

C-section     Rp 5.2M – 14.5M

3 to 3.5 times more
Philippines PhilHealth Normal             P 9,700

C-section        P 19,000

2 times more

While financial incentives are just one driver of rising C-section rates, they may represent one lever to prevent or contain the impending disaster. Countries need financial incentives to be working with, not against, the other efforts to promote cost-effective, quality maternal and neonatal care. ThinkWell is supporting these three countries and others to align financial incentives for improved primary health care through Strategic Purchasing for Primary Health Care (SP4PHC), a project funded by a grant from the Bill & Melinda Gates Foundation.

A few months ago, my husband and I received the joyous news that we would be grandparents. My Brazilian husband asked if it would be a normal delivery. He meant a C-section! Let’s not wait until it’s too late, when C-sections become the ‘normal’ in countries that can ill afford the costs and risks to mothers and babies.

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