What you need to know:
- Currently, NHIF enrolment is mandatory among workers in the formal sector
- The informal sector employs over 80 per cent of Kenyans
This piece originally appeared in P4H here. It was written by Christian Edward Nuevo, Maria Eufemia Yap, Matt Boxshall, and Nirmala Ravishankar.
Primary health care (PHC), first introduced through the Alma Ata Declaration of 1978, emphasizes that addressing health needs should be people-centered and multi-sectoral in approach. The recently passed Universal Health Care (UHC) Law in the Philippines puts PHC center stage through reforms aimed to improve health system performance. While the vision is laudable, making it happen is challenging. This article offers early learnings from the implementation of the UHC Law drawn from ThinkWell Philippines’ program of technical assistance and policy research to support the Department of Health (DOH) and the Philippine Health Insurance Corporation (PhilHealth)¹. We identified key opportunities and challenges created by the UHC Law against the three main pillars of strengthening PHC . The UHC vision will have to be progressively realized through paradigm shifts, communication interventions, and a clear and strategic roll out plan.
Health sector reform in the Philippines has been accelerated by the passage of Republic Act 11223, more commonly known as the UHC Law . This landmark piece of legislation seeks to revitalize health care through a whole-of-system, whole-of-government, whole-of-society, people-centered approach. It recognizes that health systems are naturally complex, dynamic, and adaptive. The legislation acknowledges that improving health system performance requires sustainable, wholesale changes . The pillars of PHC underpin the entire UHC reform .
The 2030 Agenda for Sustainable Development as well as other landmark resolutions  all champion the crucial role of PHC in achieving responsive and resilient country health systems . The UHC Law is anchored on the three main pillars of PHC  in the following way:
One of the biggest prerequisites in this reform process is a shift in governance paradigms. The UHC reform requires provincial governments to be more accountable for care of their constituents and management of their health systems. They must reduce dependence on current national government support on personnel deployment, commodities, and infrastructure investments. Provincial governments must work to contextualize the benefits of integrating into province-wide health systems and health care provider networks, and rally support from people and providers within their jurisdiction. Central offices, on the other hand, should pivot back to their role of being technical stewards of the health sector, crafting strong policies, standards, and regulatory thrusts. These transitions from old to new ways need to be championed by the Department of Health, generating buy-in from other government agencies to ensure a genuine whole-of-government approach.
As new policies and guidelines are formulated, strong communication and promotion interventions must be pursued by both the national and local governments. Patients need to be informed of all their entitlements, and the merits of living healthy lifestyles. Likewise, health care providers must understand the need for instituting strong gatekeeping mechanisms and facilitating synergistic relationships between primary and specialty practitioners. By engaging various stakeholders and communicating a compelling value proposition, key players will better understand their respective roles, leading to greater alignment with the UHC agenda.
Finally, a clear, strategic, year-on-year rollout chronology towards achieving the vision for UHC should be laid out in a transparent manner. Sequencing of reforms should start with generating clear demand for primary care through patient empowerment and incentive schemes for providers. This can drive the necessary motivation for the public sector to build capacity, and similarly attract the private sector to participate and coordinate. By committing to a clear plan of action, the Philippines DOH can build confidence amongst all stakeholders, public and private, local and national, and across government. Clarity of vision will be essential to deliver on the promise of UHC in the Philippines.
¹ These activities are part of the Strategic Purchasing for Primary Health Care project supported by the Bill & Melinda Gates Foundation and implemented by ThinkWell. For more information, please visit our website. For questions, please write to us at firstname.lastname@example.org.
² An expanded primary care benefit package known as PhilHealth Konsulta (PhilHealth Konsultasyong Sulit at Tama) to cover all Filipinos and to ensure access to essential, preventive, promotive, and curative services.
This piece originally appeared in P4H here. It was written by Dredge, R., Nuevo, C. E., and Paterno, A. R.
The Philippine Universal Health Care (UHC) Law of 2019 introduced system-level reforms on health financing, particularly for the provider payment mechanisms of the Philippine Health Insurance Corporation (PhilHealth). PhilHealth is the implementer of the National Health Insurance Program, with the goal of ensuring financial risk protection for all Filipinos when accessing the health care they need. The recently passed Philippine UHC Law aims to revitalize and strengthen PhilHealth as part of the overall agenda of health systems reform. In order to become the national strategic purchaser of health services, PhilHealth plans to shift its provider payment mechanism towards a blend of diagnosis-related groups (DRGs) and prospective global budget payments, supported by proper costing methodologies and explicit co-payment rules. Primary care is also a key area of focus – the development of a comprehensive outpatient benefit package will have gatekeeping and patient navigation features to integrate care across a contracted network of health care providers. Through these provider payment reforms, PhilHealth aims to improve cost-effective purchasing of health services that would lead to better health outcomes.
These complex and interlinked reforms require careful coordination across several policy strands and it is essential that they coordinate their research, data, technical and policies activities to facilitate true integrated care. Costing, DRGs, global budget payment, primary care, and co-payments all work together as distinct but complementary portfolios of the provider payment reform. This scale of policy reform has not been pursued in recent years by PhilHealth. In fact, previous reforms of provider payment (such as bundled payments for outpatient and catastrophic conditions, or the shift from fee-for-service to the case-based payments through the All Case Rates) were introduced separately and individually. Simultaneously setting into motion changes across different and interconnected facets of provider payment requires significant technical work, analysis, and policy development, as well as coordination with internal and external stakeholders. Understandably, this presents a formidable challenge for PhilHealth, and much help is needed to carry things forward.
At the same time as stewarding these reforms, PhilHealth has to contend with daily operational matters, including persisting issues of the prevailing payment system. PhilHealth has faced heavy criticism over the years for inefficient payment mechanisms, inadequate package rates, lack of transparency, and even poor technical capacity to fulfill its function. This has derailed the full materialization of its mandate to ensure financial risk protection. In 2019, the share of PhilHealth in the current health expenditure (CHE) of the country remains low at only 18.8%, while out-of-pocket spending continues to be the primary source of financing at 47.9% of CHE. While the UHC Law provides the policy direction to revitalize PhilHealth’s financing mechanisms, this will not happen immediately. The current system must still be developed, and its challenges and shortfalls demand attention.
ThinkWell provided support to PhilHealth in the form of learning sessions that allowed technical teams and senior figures from many stakeholders to be introduced to global best practices, and to discuss ongoing work with subject matter experts. These one-and-a-half hour learning sessions were either of two platforms: 1) conceptual discussion with PhilHealth on provider payment and global best practices which would aid the reforms; or 2) a policy consultation for PhilHealth where they present and solicit feedback on ongoing analytics and draft policies on the provider payment reforms. Though the nature and subject of each session varied, the main objective remains the same: to provide a platform for technical discourse to allow PhilHealth to benchmark and review their current courses of action and policy directions with that of global best practices. A total of around 60 technical staff at the central and regional offices, as well as representatives from senior management (Senior Managers; Regional and Senior Vice Presidents) participated in the sessions that resulted in holistic discussions touching on high-level policy questions, as well as operational and implementation considerations.
Cabalfin MR. 2016. “Health Financing for the Poor in the Philippines: Final Report,” Discussion Papers DP 2016-37, Philippine Institute for Development Studies.
Congress of the Philippines. 1995. Republic Act No. 7875. An Act Instituting A National Health Insurance Program For All Filipinos And Establishing the Philippine Health Insurance Corporation for the Purpose.
Congress of the Philippines. 2012. Republic Act No. 10606. An Act Amending Republic Act No. 7875, Otherwise Known as the “National Health Insurance Act of 1995”, As Amended, And For Other Purposes.
Congress of the Philippines. 2019. Republic Act No. 11223. An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating Funds Therefor.
Picazo OF, Ulep VGT, Pantig IM, and Ho BL. 2015. A Critical Analysis of Purchasing of Health Services in the Philippines: A Case Study of PhilHealth. Philippine Institute for Development Studies.
Philippine Statistics Authority. 2020. Health Spending Grew by 10.9 Percent in 2019. https://psa.gov.ph/pnha-press-release/node/163258. Accessed Apr 2021.
On July 15, the 2021 International Health Economics Association (iHEA) Congress came to a close. After four busy days of health economists and health system leaders exchanging bold ideas, five ThinkWell attendees shared their main take-aways from the conference.
With vaccination on top of everyone’s mind more than ever these days, the Immunization Economics Special Interest Group, of which ThinkWell is an active member, has been in the spotlight this year. The Group’s session at iHEA confirmed the value of vaccination and the high return on investment of immunization, while demonstrating that much remains to be done to ensure these benefits are equitably distributed. Researchers also added to the tremendous body of research on the cost and cost-effectiveness of delivering immunization services. We presented novel findings on the cost of integrated immunization campaigns during an engaging session that also discussed the important role of labor in delivering immunization, an analysis of the impact of campaign-like routine delivery of vaccines on other essential health services, and an efficiency assessment of reduced scope costing studies. Looking beyond this year’s iHEA congress, we are excited to continue and keep on filling remaining critical evidence gaps, particularly on what it costs to deliver interventions to hard-to-reach populations, and further explore efficiency and equity tradeoffs.
In the session “Digital Technologies for Health Financing: What Are the Benefits and Risks,” the presenters shared how few experiences with digital technologies for health financing have been evaluated in the peer-reviewed and grey literatures. There is a sense among practitioners and experts that digital technologies have the potential to revolutionize the use of data in health systems.
In the Philippines, PhilHealth has introduced a fraud detection process using machine learning and artificial intelligence that helps to flag suspicious claims for further scrutiny prior to payment. The savings are substantial relative to the upfront and recurrent costs of the system, although the upfront investment was large and required considerable advocacy to secure support from senior decision-makers. Ongoing challenges include information security and privacy; and the possibility that providers, faced with higher legal costs to contest fraud findings, could pass costs on to patients (i.e., increased out-of-pocket costs).
Indonesia’s single-payer national health insurance scheme (Jaminan Kesehatan Nasional), has explored digital technologies, including an online ticketing system for complaints and a mobile app to help members access information, communicate with providers, and more. There’s been modest uptake, and disparities in access to technology, connectivity, comfort, etc. with technology have hindered utility, especially for the poor, whose needs require other (typically non-digital) solutions.
In the session “Are public facilities set up to respond to strategic purchasing signals: insights from East Africa,” panelists shared how health facilities’ level of financial autonomy in Kenya, Tanzania, and Uganda affects how the facilities respond to purchasing signals sent from the central and district level.
Tanzanian panelists described how recent reforms that allow for direct financing to health facilities has improved the predictability of funds, reduced stock-outs, and enhanced accountability at health facilities. Kenyan panelists discussed how health facilities with less autonomy had more frequent stockouts and delays in decision-making. Ugandan panelists shared how health facility autonomy is operationalized across districts and discussed authority issues across central and district purchasing.
The panelists described three common challenges across the countries. First, local governments are often conflated with health providers; these are two distinct groups who have different responsibilities. Second, in Kenya, Uganda, and Tanzania, health authority has been decentralized to the districts, but recent health reforms have recentralized much of how health services are purchased and where decisions are ultimately made. Third, a misalignment of rules and regulations for public financial management often does not adequately recognize the planning and budgeting functions for health facilities. Clear communication and alignment of signals to health providers is critical to improve service delivery.
The session “Health Financing in Devolved Contexts and Its Implications for Progress Towards Universal Health Coverage,” which Nirmala Ravishankar from ThinkWell chaired, explored the linkages between devolution and health financing. Dr. Inke Mathauer opened the session by sharing insights from a study implemented by ThinkWell and the World Health Organization that explored how devolved government structures shape the design and execution of health financing functions. She noted how local governments are responsible for a large share of health spending but depend on transfers from central governments to finance their budgets. She hypothesized that earmarked health grants could reconcile decentralized decision making to enhance resource allocation to health. She also explored how devolution can result in fragmented pooling and purchasing arrangements. Dr. Marife Yap discussed the Philippines’s experience, focusing on how the country’s UHC law is (re)defining the roles of local governments, provincial governments, and national health agencies. Reflecting on Kenya’s experience with devolution, Boniface Mbuthia emphasized the importance of aligning public financial management rules and processes so local governments can become strategic purchasers of health services while granting financial autonomy to public health providers. Finally, we heard from Dr. Mulwa and Dr. Castroverde, who work at the sub-national level in Kenya and the Philippines. They reflected on the politics of health financing reforms in devolved government systems. The session underscored the need for more disaggregated data on health budget allocations and spending at the subnational level, as well as the importance of more learning on the topic.
First, it’s easy to get sucked into the weeds of implementing programs—program implementers constantly think about contextual and political challenges. IHEA reminded program implementers to take a step back and reflect on health economics concepts and principles from a high-level. It’s important to always have an ear to the ground when you’re implementing health systems programs, but it’s also important to keep the main goals and big picture concepts in mind.
Second, ThinkWell’s Health Financing Activity is currently working on a health facility readiness assessment for HIV to understand whether health facilities in Indonesia have the needed supplies and resources to treat HIV. At iHEA, a session shared how if you have a robust health facility readiness assessment framework, you can apply that same framework to different regions or to different health areas, like maternal and child health.
Finally, in the field of health economics, it’s nice to have a community with which you can exchange knowledge and ask questions. IHEA provides that chance to connect with health economists from around the world.
The Kenyan government has identified universal health coverage (UHC) as part of its Big Four development agenda, with the National Hospital Insurance Fund (NHIF) at the center of this plan.
Countries face significant challenges as they develop and implement UHC strategies. Many low- and middle-income countries, including Kenya, are opting to introduce or expand national health insurance as a way to progress towards UHC.
Providing health insurance coverage for people outside the formal employment sector poses a key hurdle for this approach. It is administratively difficult to collect premiums from the informal sector as it is not organized, and many rely on low and irregular sources of income.
The informal sector employs over 80 percent of Kenyans in jobs that often expose them to hazards and illness, thereby increasing their need for healthcare.
Currently, NHIF enrolment is mandatory among workers in the formal sector, but voluntary for the informal sector.
The question, therefore is, how will the government extend coverage to the informal sector? Two main options have been discussed to date: Collect contributions to NHIF from the informal sector enrollees, which could either be voluntary or mandatory, or use general government taxes to provide full or partial subsidies to informal sector households.
What happens if we go with the first method?
World over, voluntary contributions lead to low coverage. Many are more likely to pay for NHIF when they are sick leading to adverse selection. Mobilizing resources from the informal sector through mandatory NHIF enrolment would increase coverage and revenues.
Other concerns regard equity in contributions: Is it fair to charge the same flat rate to all informal sector households? Kenya can learn from countries such as Rwanda, where Ubudehe, a socio-economic stratification system is used. The wealthier pay higher health insurance premiums compared to the poor.
The other option to expand informal sector NHIF coverage is using government revenues to subsidize NHIF enrolment. Countries that have financed informal-sector health coverage from general revenues have high coverage rates.
A tax financing approach requires significant resources and commitment.
One of the other ways of increasing fiscal space to finance UHC would be introduction of special “sin” taxes to earmark funds for UHC.
The ideal scenario would involve government using tax revenues to subsidize enrolment for the informal sector. However, due to the current fiscal landscape, the government should consider a phased approach and a mix of financing approaches.
Having a single flat premium for the contributing informal sector will still not be equitable, but if all the poor are covered, this is a way to strike a compromise in the short term.
From July 12-15, ThinkWell will virtually join health economists and health system leaders at the 2021 International Health Economics Association (iHEA) Congress to discuss bold, creative, and practical solutions that actually work.
In twelve organized sessions and four poster sessions, we will showcase transformative work from the Strategic Purchasing for Primary Health Care (SP4PHC), USAID Health Financing Activity, and Immunization Costing Action Network (ICAN) programs.
ThinkWell’s sessions and posters that will be featured at iHEA are briefly summarized below. The titles link to iHEA’s more detailed session descriptions.
Tuesday, July 13, 2021
6:45 AM – 7:45 AM GMT
Ensuring that facilities have funds that they can use flexibly and account for them is critical for improving service delivery in the public sector in Kenya. When Kenya transitioned to a devolved system of government in 2013, newly formed county governments required all public hospitals, which generate considerable own-source revenue from user fees and insurance reimbursements, to remit the funds to the county treasury. In contrast, some counties transferred funds they received from the national government through earmarked conditional grants to primary health care centers. In more recent years, counties have embarked on reforms to grant greater financial autonomy to public facilities. Against this backdrop, we undertook a study to explore the effect of facility autonomy on performance by comparing three counties: one with no facility autonomy, one with modest facility autonomy, and one with extensive facility autonomy. This session will discuss the study’s findings.
Tuesday, July 13, 2021
7:45 AM – 8:45 AM GMT
This session focuses on health financing in devolved settings and explores how a devolved setting affects the health financing functions of revenue raising, pooling, and purchasing, and what this implies for progress towards universal health coverage (UHC) objectives. This draws on a multi-country study undertaken by the World Health Organization (WHO) and ThinkWell in Kenya, Uganda, Burkina Faso, Mozambique, Nigeria, the Philippines, and Indonesia, following an analytical framework developed for that purpose. The session will include a “real life” perspective from two sub-national government health officials from Kenya and the Philippines, who will respond to the country case studies and offer reflections from a local perspective.
Tuesday, July 13, 2021
7:45 AM – 8:45 AM GMT
The Local Government Code of 1991 reshaped the centralized health system of the Philippines into a highly decentralized system. Several major policy reforms have since been enacted to better facilitate the flow of money for health across the different levels of governance. Even with these changes, financing of health services continues to face considerable challenges brought about by the devolved structure. This session will explore how devolution has affected overall spending on health, equitable resource distribution and redistributive capacity, as well as strategic purchasing in the country as part of a World Health Organization (WHO) and ThinkWell multi-country study.
Tuesday, July 13, 2021
7:45 AM – 8:45 AM
Over the past decades, countries around the world have devolved decision-making authority to sub-national government units in various sectors including health. In parallel, countries have also initiated health financing reforms for achieving the goal of universal health coverage. While national governments exercise a high degree of control over the design of health financing reforms, their implementation is heavily influenced by the devolved institutional setup. Against this backdrop, the World Health Organization (WHO) and ThinkWell launched a multi-country study to explore how devolution has affected overall spending on health, equitable resource distribution and redistributive capacity, as well as local purchasers’ ability to make purchasing more strategic. This session will explore the countries’ findings.
Tuesday, July 13, 2021
7:45 AM – 8:45 AM GMT
Kenya’s transition to a devolved system of government in 2013 fundamentally transformed the organization of health financing functions. While the national government continues to mobilize the bulk of public funds for health, over half of the funds are pooled at the county-level. Moreover, counties are the main purchasers of primary and secondary care services in the country. This session will discuss acase study that provides a detailed analysis of how devolution has impacted the three functions of health financing: revenue raising, pooling and purchasing. The session will also explore implications for the country’s strategy for achieving universal health coverage (UHC).
You can view the presentation deck here
Tuesday, July 13, 2021
12:15 PM – 1:15 PM GMT
Despite early anecdotal evidence of significant reductions in health service utilization related to the COVID-19 outbreak in Bangladesh, the scale, incidence, and drivers of health service impacts were poorly understood. The Government of Bangladesh (GOB) has committed to maintain the provision of essential health services as a component of the National COVID-19 Preparedness and Response Plan. However, a lack of evidence on the scale of service impacts, as well as the drivers and root causes of these impacts, meant that the GOB lacked an evidence-base for important decisions on health service strategy, planning, and resource allocation. This session will share the results of a rapid situational assessment that revealed several important drivers of COVID-mediated health service and health financing disruptions with the potential to inform better strategy and planning in Bangladesh.
Tuesday, July 13, 2021
1:45 PM – 2:45 PM GMT
In this session, we will explore approaches for enhancing facility autonomy and whether they increase the marginal productivity of public facilities, drawing on evidence and insights from Kenya, Tanzania, and Uganda. Panelists from these three neighboring countries in East Africa will share information on ongoing public financial management reforms to enhance facility autonomy, such as initiating direct transfers of earmarked allocations to facilities, the inclusion of public facilities in the chart of accounts, and legal amendments to allow facilities to collect appropriations in aid. They will then share findings on the effect of these reforms, reflecting on the mechanisms through which facility autonomy boosts facility performance as well as the enabling factors that are necessary for improved facility autonomy.
Tuesday, July 13, 2021
1:45 PM – 2:45 PM GMT
Decentralization in Uganda has taken a dynamic path since 1997, when the Local Government Act was passed to devolve decision-making powers and service delivery responsibilities to districts. Progressive reforms followed to channel more funds to the districts and strengthen subnational governance structures. The national government also introduced primary health care grants that flow directly to health facilities, including public health centers and hospitals under the jurisdiction of local governments. In recent years, donors have funded results-based financing programs where the national government channels additional payments to government-owned facilities based on outputs. Against this complex landscape, we undertook a study to map the flow of funds to the frontlines and explore the decision-making dynamics between local governments and health facilities to inform ongoing policy discussions around health financing reforms for making progress towards universal health coverage. The session will cover our findings.
Wednesday, July 14, 2021
5:30 AM – 6:30 AM GMT
Delay of treatments for patients with acute coronary syndrome (ACS) should be kept as short as possible to reduce complications and mortality. This session will discuss a study that investigated drivers of prehospital and hospital delays amongst ACS patients in Indonesia by determining the symptom-to-door times (prehospital) and hospital delays of ACS patients admitted at health facilities in Jakarta, Indonesia. The study also analyzed variables associated with such delays by looking at patients’ socio-demographical data, risk factors and comorbidities, and symptom characteristics. It’s critical to identify these factors for raising awareness as well as designing innovative policies.
Wednesday, July 14, 2021
8:30 AM – 9:30 AM GMT
To ensure a long-term sustainable health financing USAID Indonesia, in collaboration with the Ministry of Health’s Center for Health Financing, implements a five-year project call Health Financing Activity. The program aims to ensure sustainable health financing and strategic purchasing. This organized session will provide lessons learned from the HFA USAID Project in Indonesia.
Wednesday, July 14, 2021
4:00 AM – 5:00 AM GMT
As of mid-December 2020, Indonesia had 598,933 cases of COVID-19, posing a burden on hospitals to care for COVID-19 patients in addition to other cases. Government of Indonesia (GoI) regulation requires COVID-related costs to be covered by the MOH because it is a pandemic. Once declared endemic, treatment will be covered by the National Health Insurance. The MOH quickly established an innovative system to pay hospitals for COVID-19 treatment. The hospital is paid fee-for-service for per-diem and other costs. However, there are concerns about the cost of this payment system and its effect on the national health budget. Since COVID-19 is new, there is limited understanding of which factors drive treatment costs and no cost standards. This session will review evidence of actual costs to develop a standard cost for a COVID-19 treatment package.
You can view the presentation deck here
Wednesday, July 14, 2021
4:00 PM – 5:00 PM GMT
The COVID-19 pandemic has increased the need for integrated delivery of essential health services, including immunization, to ensure effective and efficient service delivery. Many countries have suffered from disruptions in immunization services, reductions in coverage, and have had to delay or cancel immunization campaigns, rendering populations vulnerable to outbreaks of vaccine preventable diseases. As part of catch-up vaccination strategies and while resources are particularly constrained, countries have been encouraged to explore the option of conducting multi-antigen campaigns or integrating immunization campaigns with other health services. Despite this recommendation, there is little evidence on the cost and efficiency gains of co-delivery during immunization campaigns. This session will discuss results of a study that will help global and country level decision makers in planning and budgeting for multi-antigen and co-delivery campaigns.
Tuesday, July 13, 2021
6:00 AM – 7:15 AM GMT
As of December 2019, approximately 640,443 people in Indonesia were living with HIV, but only 57% knew their status, only 127,613 (19%) were on treatment, and only 10,009 viral load tests were performed. Indonesia seeks to scale-up its HIV response and replace declining donor funding through better coverage of HIV/AIDS services by its National Health Insurance Scheme (JKN). This session will discuss a study that analyzed current patterns of service use, referral, and costs of HIV care under JKN to identify opportunities to improve coverage.
Tuesday, July 13, 2021
6:00 AM – 7:15 AM GMT
Stakeholder perceptions on health policy reforms are key for evidence-based policy development and implementation. To this end, stakeholder analysis (SHA) is a useful tool for gathering insights on stakeholders’ interests in, positions on, and power to influence health policy issues that aim to achieve universal health coverage (UHC). There is little evidence on the use of SHA in health policy development and even less in informing the politics of implementing health system reforms towards UHC. This poster summarizes a study that demonstrates the utility of SHA as a tool for evidence-based policy development for UHC, drawn from the experience of doing SHA with political actors in 25 provinces involved in the pilot implementation of the recently enacted UHC Law in the Philippines.
Tuesday, July 13, 2021
6:00 AM – 7:15 AM
Since the single payer national health insurance scheme in Indonesia (JKN) rolled out in 2014, the proportion of out-of-pocket (OOP) health expenditure in Indonesia has steadily decreased over time. The OOP health expenditure at the national level was 32% of Total Health Expenditure (THE) in 2018, a substantial decrease from 47% in 2013, prior to JKN. Public spending became the largest component of national health expenditure from 2018 onwards (54%). To better understand the root causes and characteristics of OOP at the household level, this poster summarizes a study that estimates the effect of JKN towards reducing OOP spending and how this effect changes by key sociodemographic (e.g., poverty level) and provider (e.g., type, service) characteristics.
Tuesday, July 13, 2021
6:00 AM – 7:15 AM GMT
User fees have been reported to limit access to services and increase inequities. As a result, Kenya introduced a free maternity policy in all public facilities in 2013. Subsequently in 2017, the policy was revised to the Linda Mama program to expand access to private sector, expand the benefit package, and change its management. The free maternity policies show mixed effects in increasing access to maternal health services. Emphasis on other accessibility barriers and service delivery challenges alongside user fee removal policies should be addressed to realize maximum benefits in maternal health utilization. this poster summarizes an interrupted time series analysis on facility deliveries, antenatal care and postnatal care visits data between 2012-2019 to determine the effect of the two free maternity policies.
Written by Martha Coe (Program Manager, ThinkWell) and Anupama Tantri (Executive Director, Global Vaccine Public Policy Development; Merck Sharp & Dohme Corp.)
Fifteen months into the global COVID-19 pandemic, the tie between public health and the economic value of disease prevention and immunization has never been more apparent. The world is looking to vaccination to help prevent illness, hospitalization, and death from COVID-19 as well as reopen economies.
The Asia-Pacific Economic Cooperation (APEC) Life Sciences Innovation Forum recently hosted a webinar to explore how countries can unlock and leverage funds for COVID-19 vaccination and across the life-course moving forward. ThinkWell and Merck Sharp & Dohme Corp. (MSD) were pleased to take part in the webinar and build on our ongoing work on sustainable immunization financing. Moderated by Anupama Tantri from MSD, the three expert panelists, Dr. Chunhuei Chi from Oregon State University, Dr. Mursaleena Islam from ThinkWell, and Dr. Ping-Ing Lee from National Taiwan University, provided insights and recommendations on how best to secure and leverage financing for COVID-19 and for immunizations across the life-course, including:
Availability is not the same as accessibility. At the outset, Dr. Chi noted that even if countries have procured COVID-19 vaccine doses and have them available in country, they may not be reaching all their populations in need. For example, barriers in delivery systems can postpone availability for certain geographies or hourly wage workers may need vaccination sites to be open at different hours than their work shifts in order to get vaccinated.
To ensure rapid and equitable access to COVID-19 vaccines, countries need to invest in the following three areas:
These investments can have long-serving impact beyond the pandemic to strengthen equitable access to other vaccinations across the life-course. For some countries, the pandemic has made apparent the fragility of and gaps in their public health infrastructure. Investments to respond to the pandemic provide an opportunity to have broader impact on immunization programs and public health.
Securing sufficient and sustained resources for routine immunization requires costing and budget information that is specific to the country context and use-case. Dr. Islam shared three real-world case studies, conducted by ThinkWell with country and multilateral partners, that demonstrate the criticality of contextually relevant economic evidence to secure the resources needed for both routine vaccination and COVID-19 priorities.
The full health, economic, and societal benefits of immunizations should be captured and reflected in value assessments and funding decisions. As Dr. Lee noted, many middle-income countries have gaps in the vaccines available through their public immunization programs. Immunization programs must compete for resources alongside many other health interventions, and greater awareness and evidence on the value of vaccination can help to improve the prioritization of and allocation of resources to fill these gaps. Dr. Lee noted that traditional cost-effectiveness analysis may not take into account the broader, more comprehensive benefits of vaccination. Greater awareness among policymakers, health care providers, and the public of the broad returns on investment is necessary to support resource mobilization for, as well as access to and uptake of vaccination services. A variety of channels can be used to reach these audiences including public education, the media, and medical education.
If you want to learn more about ThinkWell’s work in sustainable immunization financing, you can read about it here.
You can watch the full webinar recording below. You can view the accompanying slides here.
This blog was produced by ThinkWell in partnership with and funding from Merck Sharp & Dohme Corp. (MSD), a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA. The views and opinions expressed by the panelists are their own and do not necessarily reflect the views and opinions of ThinkWell or MSD.
This piece originally appeared on P4H here.
This blog, written by Tapley Jordanwood (ThinkWell), Aliyi Walimbwa (Ministry of Health, Uganda), Anooj Pattnaik (ThinkWell), and Angellah Nakyanzi (ThinkWell), highlights an extensive study of the latest two reproductive, maternal, and newborn health (RMNH) voucher schemes in Uganda conducted jointly by the Uganda Ministry of Health and the Strategic Purchasing for Primary Health Care project implemented by ThinkWell with support from the Bill & Melinda Gates Foundation.
With support from donors, Uganda has implemented a variety of voucher schemes, which offer more than a decade of context-specific learning on health purchasing that could inform the proposed national health insurance scheme (NHIS). The Parliament of Uganda recently passed the 2019 NHIS Bill, which now awaits Presidential approval to establish the NHIS as a new demand-side health financing mechanism. This pivotal health reform would create a purchaser-provider split, contract public and private providers, and establish a benefits package— all essential functions that the voucher programs successfully implemented at a large scale. As the last two voucher projects drew to a close, the Ugandan Ministry of Health and ThinkWell undertook a joint study and published an extensive report that documents how these voucher schemes functioned and performed to draw lessons for future demand-side financing efforts, including the planned NHIS.
The Ugandan voucher schemes were designed to provide rural poor pregnant women with affordable access to high-quality essential RMNH services. The latest two donor-funded voucher schemes supported over 400,000 safe deliveries in just over three years. Covering 28 (out of 135) of Uganda’s districts, the second Uganda Reproductive Health Voucher Project (URHVP-II) was financed by the World Bank through the Global Partnership on Output-Based Aid and ran from June 2016 through October 2019. The USAID-funded Uganda Voucher Plus Activity (UVPA) started slightly later in October of 2016 and ran through March 2020, covering 35 districts. Set up as independent purchasers of services, the schemes fielded teams of village-based voucher distributors who identified poor women, provided them with health education, and then sold them vouchers at highly subsidized prices. Identified women then redeemed their vouchers primarily at selectively contracted private for-profit health facilities (in addition to some public and private non-profit facilities) to access a package of RMNH services. Contracted providers were then reimbursed by the voucher schemes based on the services rendered.
Within Uganda’s fragmented health delivery system, voucher schemes pioneered service networks that integrated private, public, and non-profit facilities. Selectively contracted facilities were organized into service delivery networks to ensure affordable access, accountability, and adherence to service quality standards. A critical step forward in this effort was the successful linking of private for-profit providers to both public and private non-profit facilities in the health system. The voucher facility networks of providers facilitated cooperative actions between facilities, including improved referral systems for complications and emergencies.
Providers reinvested their revenue from the voucher schemes to increase their facility capacity and improve their quality of care. By paying facilities fair rates based on the cost of care, contracted facilities had the resources and autonomy to ensure sufficient staffing and medical supplies to meet demand. The combination of clear quality standards, regular measurement, field-based technical support, and contractual consequences led to significant improvements in quality.
The voucher schemes were vivid demonstrations of what is required to establish a demand-side financing mechanism. Establishing a new financing mechanism that will purchase service outputs requires new institutional roles, modalities, contracts, and financing systems. Examples in South Korea and Taiwan have demonstrated that years of implementing voucher programs can lay the groundwork for building an NHIS to support universal health coverage efforts. As Uganda takes its first steps to establish its own NHIS, critical choices to determine the institutional setup, initial benefit package, service delivery contracts, and claims management systems need to be made. The voucher schemes provide a large-scale demonstration of what it takes to set up a demand-side purchaser. These experiences have generated hard evidence to inform Uganda’s choices as it establishes the NHIS going forward.
One of the proposals in the 2021 National Hospital Insurance Fund (NHIF) Amendment Bill stipulates that all Kenyans must be registered under NHIF in the new Universal Health Coverage (UHC) program.
When this news broke in mid-February, the media balked. Much of the uproar was in response to mandatory NHIF enrollment. Many Kenyans believed that it’s unfair to require all households, including the poor, to pay the premium. The concerns raised by Kenyans warrant reflection.
First some background. This bill is part of a Government of Kenya (GOK) plan for achieving UHC. The goal of the UHC program is to provide health care for all based on need—not on ability to pay. It is predicated on NHIF becoming a national health insurance scheme that is mandatory for all.
Formal sector employees currently make mandatory NHIF contributions on a graduated scale, which covers them and their families. Informal sector households can sign up for NHIF by contributing Ksh 6000 per year. The “universal” part of GOK’s UHC plan is its commitment to cover the poor. The target is to eventually cover all five million poor households, but GOK has committed to start this year with covering one million poor households.
To expand NHIF’s mandate to offer UHC, the proposed bill seeks to increase the revenues raised by NHIF in three ways: 1) making NHIF mandatory for all, 2) requiring employers to match their employees’ NHIF contributions, and 3) for co-insured patients, providers will be required to bill the private insurer first before NHIF pays.
Let’s explore these three key elements of the proposed legislation that relate to the question of equity.
Mandatory NHIF membership
By explicitly including the word “mandatory,” the bill makes it clear that NHIF is mandatory. In theory, NHIF has been mandatory since the NHIF Act of 1998, which states that any “ordinary resident of Kenya,” whether “salaried or self-employed,” shall be “liable as a contributor” to NHIF. In practice, however, NHIF membership for informal sector workers—who constitute 83% of Kenya’s workforce—has remained voluntary.
Mandatory NHIF coverage would raise revenues for UHC and improve prepayment and financial protection. Currently, only about 20% of Kenyans have any form of health insurance coverage, with over 85% of them covered by NHIF. NHIF coverage among the formal sector is near universal, compared with only 15% NHIF coverage among the informal sector.
Since the informal sector is not organized, it has proven administratively difficult to recruit and collect regular contributions. Retention of informal sector workers has also proven difficult, and drop out rates among this group of members remains high.
So what might change now?
The bill gives NHIF and the Ministry of Health new powers to enforce premium collection, particulary among the informal sector. Some possible ways of enforcing NHIF enrollment would be requiring proof of NHIF membership to obtain an ID card, to enroll your child to school, or get other government licences and services.
That may work, but it poses some risks of hurting the poor who have not yet been brought into the NHIF subsidy. During this first year of UHC implementation, the government will sponsor one million poor households, leaving about 4 million poor households without coverage. What happens to them during the period when the subsidy is not scaled up, but NHIF starts enforcing the new rules? And isn’t it unfair to the near-poor, who have to pay the same exact amount as a rich farmer or businessman?
The proposed law requires employers to match their employees’ NHIF contributions. This is a game changer that would double the premiums received by NHIF from the relatively affluent members of society, namely those employed in the formal sector. These resources would improve NHIF’s financial sustainability as well as its redistributive potential.
On the flip side, this would considerably increase the labor cost of doing business in Kenya, which is already deemed high in comparison to Kenya’s GDP, and to the labor cost in neighbouring countries. This could hurt Kenya’s competitiveness and could have a detrimental effect on the private sector, which may reduce jobs to meet these new demands or move businesses to other countries. If that happens, it could worsen the already dire unemployment situation.
Because of these reasons, this proposal is likely to be met with a lot of resistance from the private sector.
Changing how NHIF pays out
In situations where clients have both private insurance and NHIF, private insurance providers would be required to first exhaust their coverage before NHIF pays any outstanding amounts subject to the “funds applicable limits” (though NHIF would still pay the daily inpatient rebate). This is an interesting twist and a reversal of the current practice.
When NHIF expanded the benefit package in 2016 to cover outpatient, surgeries, radiology, and other services, private insurance companies quickly saw an opportunity. They stipulated that NHIF act as the primary insurer for co-insured members, thereby bearing the biggest component of medical bills. In many ways, NHIF funds were used to subsidize private insurance.
Anecdotal evidence is that the tariffs for health services, especially in the private sector, went up as “more” funds became available. NHIF also ran into solvency problems and was not able to meet claims, leading to delays in claims reimbursement.
If this bill is passed, more funds would be available for NHIF to possibly expand the benefit package and honor claims. On the flip side, it could also lead to private insurers raising their premiums or reducing their limits, forcing NHIF to pay the residual amount.
The move to provide universal health coverage is noble, but the success of the UHC program depends largely on a reformed NHIF, improved service quality, and leaving no one behind. Urgent reforms are needed that improve efficiency, transparency, and accountability at NHIF. NHIF will need to improve its engagement and communication with the public and with providers; this is one of proposals stipulated in this bill. NHIF also needs to strengthen the way it pays providers by incentivizing quality healthcare.
The GOK needs to address the coverage of the poor and vulnerable. So far, the GOK has made plans to sponsor one million poor and vulnerable households, which is roughly four million people. While this is a step in the right direction, there is still much work to do given that roughly 18 million Kenyans live below the national poverty line. If the reforms proposed in this bill see the light of day, the additional funds could go a long way towards providing UHC.
In Mozambique, management systems in high-volume health facilities are adapting slowly to demographic and epidemiologic changes and growth in patient demand. This often leaves management teams and clinical staff to implement ad-hoc adjustments to respond to patients’ needs. High patient volumes paired with clinical and administrative challenges and lack of clear national guidance can lead to critical consequences. For example, key primary healthcare professionals, including doctors, nurses, MCH nurses, clinical officers, and pharmacy and laboratory technicians, spend on average 34% of their time in non-clinical tasks—time that could be better spent with patients and addressing their needs.
As part of the project “A Comprehensive Approach to Improve Performance of Human Resources for Health in Mozambique,” ThinkWell’s Mozambique team collaborated with the Maputo Provincial Health Directorate to assess two health centers to understand formal and informal managerial and administrative systems currently in place and to identify quality improvement areas. We used a variety of methods, including semi-structured interviews, observation, and patient flow analysis, to assess performance areas, including human resources, pharmacy and laboratory services, data management, and service provision. Evidence from the assessments showed, among other challenges, inefficiencies in patient flow management, such as weak queue management procedures and peaks of patient arrivals early in the morning, long wait times, short consultations, overreliance on clinical staff for administrative tasks, and low utilization of strategic information for decision-making.
Following the principles of human-centered design, the team currently works with the health facility staff to identify and implement sustainable, practical interventions to improve their day-to-day operations and the patient experience. Examples of currently implemented interventions include tool design to speed-up the process of producing monthly data reports, the creation of a communication strategy between the health facility and the community of patients, and the design of a signage and wayfinding system to improve how patients navigate the health facility.
ThinkWell’s team has so far been successful in ensuring a high level of engagement, motivation and commitment from the health facilities’ leadership and staff in collecting data, critically analyzing strengths and weaknesses, prioritizing quality improvement areas, and designing interventions. The team effort of ThinkWell staff and the Provincial Health Directorate also resulted in a package of data collection tools that will ensure replicability of the study and comparability of results in other primary health centers.
Written by Federica Fabozzi, Program Analyst, and Toze Namalela, Senior Program Analyst
On March 31, 2021, staff from ThinkWell’s Strategic Purchasing for Primary Health Care (SP4PHC) project participated in HSR2020 session, “Public Financial Management challenges and innovations – Learning from COVID-19 health response.”
In 2020, coronavirus-affected countries explored and tested alternative modalities to formulate budgets and accelerate public spending to the frontlines.
During the session, “Public Financial Management challenges and innovations – Learning from COVID-19 health response,” participants presented and discussed: