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From September 21-24, 2021, the SP4PHC team in Indonesia will present four abstracts at the Indonesian Health Economics Association (InaHEA)’s seventh biennial scientific meeting in Bandung, Indonesia. This year’s meeting is entitled “Protecting People: Indonesia’s Lessons from the COVID-19 Pandemic, Health Economic Point of Views.” The abstracts include:

  • How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia; presented by Nirwan Maulana, Senior Analyst at ThinkWell Indonesia.
  • How is the disease that JKN “purchased” compatible with the Doctor’s Clinical Practice Guide at Primary Health Care; presented by Halimah Mardani, Senior Analyst at ThinkWell Indonesia.
  • Assessing the readiness of Puskesmas in the completion of disease management; presented by ThinkWell partner Harimat Hendrawan, Researcher at the National Institute of Health Research and Development within the Ministry of Health.
  • The effect of JKN coverage on paying OOP for family planning services in Indonesia; presented by Nadhila Adani, Data Analyst at ThinkWell Indonesia.

Stay tuned to learn more about the key takeaways.

SP4PHC at the 2021 International Health Economics Association (iHEA) Congress

ThinkWell staff working on the SP4PHC project joined several sessions at the iHEA Congress in July. See below for more information about two organized sessions.

Health Financing in Devolved Contexts and Its Implications for Progress Towards Universal Health Coverage

We chaired and participated in the session, “Health Financing in Devolved Contexts and Its Implications for Progress Towards Universal Health Coverage” on July 13, 2021. It was jointly organized by ThinkWell and the World Health Organization (WHO). You can read more about the session here. View our flier here.

Are Public Facilities Set up to Respond to Strategic Purchasing Signals: Insights from East Africa

Several of our team members and learning partner colleagues led the session, “Are Public Facilities Set up to Respond to Strategic Purchasing Signals: Insights from East Africa” on July 13, 2021. It was jointly organized by ThinkWell and the World Health Organization (WHO). You can read more about the session here. View our flier here.

Latest Learning Products

Our teams across the five countries continuously contribute to global learning on the Covid-19 pandemic and strategic purchasing. Please find the latest SP4PHC learning products, including reports, briefs, and blogs below. For a full list of published products related to the coronavirus, visit our Covid-19 page.

National Health Insurance in sub-Saharan Africa: Insights for Uganda

Following advances of the 2019 National Health Insurance Scheme (NHIS) Bill through Parliament in early 2021, Uganda is now pushing forward on the design of the scheme to support progress towards Universal Health Coverage. This study draws on the experiences of six sub-Saharan African (SSA) countries that have achieved the highest levels of population coverage—namely Rwanda, Ghana, Gabon, Tanzania, Ethiopia, and Kenya—to highlight insights and lessons learned for Uganda in the core areas of enrollment, benefits package design, financing, and implementation sequencing for the NHIS.

What can Bangladesh and Indonesia’s COVID-19 response teach us about the importance of public financial management?

In a new blog for P4H Global, ThinkWell’s teams in Bangladesh and Indonesia shine a spotlight on how upstream public financial management (PFM) obstacles restricted how front-line responders could respond to COVID-19. These insights draw from the experience of Bangladesh and Indonesia, where the authors have been working closely with their respective governments to identify and address some of these challenges.

Gratuité scheme’s routine feedback bulletin

ThinkWell supported Burkina Faso’s Technical Secretariat for Universal Health Coverage to revitalize the Gratuité program’s routine feedback bulletin. Using data from the e-Gratuité platform and reports from contracted non-governmental organizations, including those that carry out control and evaluation functions, this special edition bulletin covers the performance of the Gratuité program from January to December 2020.

Linda Mama Progress in Makueni County

Linda Mama is a publicly funded program which aims to ensure that all Kenyan pregnant women and their infants have access to quality and affordable health services. ThinkWell supported the Makueni County Government to track the implementation of Linda Mama in the county which has led to considerable improvements in the program’s performance. This brief published in August 2021 documents the progress made in fiscal year 2019/20 and discusses measures that the County Government can take to further improve claims submission and the rate of reimbursement.

Examining the Implementation of the Linda Mama Free Maternity Program in Kenya

Linda Mama is the Government of Kenya’s flagship universal entitlement program for free maternity services. Researchers from KEMRI Wellcome Trust and ThinkWell examined the implementation of the Linda Mama program. Our findings show challenges associated with its implementation, some of which are consistent with experiences from other low- and middle-income countries. This article in the International Journal of Health Planning and Management highlights the need for programs’ process evaluation to track implementation, ensure continuous learning, and provide opportunities for course correction.

Impact of Free Maternity Policies in Kenya: An Interrupted Time-Series Analysis

In sub-Saharan Africa, one in 37 women die from preventable causes related to pregnancy and childbirth. To help women equitably access maternal health care, Kenya instituted the Linda Mama free maternity program. An evaluation by researchers from KEMRI Wellcome Trust and ThinkWell found that the policy yielded mixed results in increasing access to maternal health services. This article in BMJ Global Health underscores the need for coupling user fee removal policies with measures to improve service readiness.

Examining Health Facility Financing in Kenya in the Context of Devolution

Financing arrangements for public health facilities in Kenya changed drastically in 2013 when the country embarked on a process of devolution. Anecdotal evidence suggests that the evolution of health financing policies as well as the shift to devolution resulted in considerable variation across counties and level of care. A study by researchers from KEMRI Wellcome Trust and ThinkWell found that planning and budgeting processes for hospitals and health centers were not standardized across counties. Hospitals and health centers relied on revenue from user fees and donor funds, respectively. Health facilities spent over 80% of their funds on staff salaries leaving insufficient funds for commodities and other expenditures.

Maintaining Essential Services During the Covid-19 Pandemic in Indonesia

How did the Government of Indonesia try to maintain essential health services (EHS) in the midst of a pandemic? This policy brief focuses on how upstream financing challenges at the national and district levels affected frontline providers to effectively respond to Covid-19 and maintain routine EHS for Indonesians. The brief also offers policy recommendations on improving these processes for inevitable future crises.

How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia

While the Government of Indonesia introduced a national health insurance scheme (JKN) in 2014 and coverage has grown to over 80% of the population, Indonesians still spend significant sums out-of-pocket (OOP) for their health care – over 30% of current health expenditure. This study aims to better understand how JKN is influencing OOP payments, especially among the poor and rural, at the range of public and private PHC and referral-level providers across the country.

 

Examining the Level and Inequality in Health Insurance Coverage in 36 Sub-Saharan African Countries

This journal article authored by members of our local learning partner Kemri Wellcome Trust led by Edwine Barasa and also co-authored by Nirmala Ravishankar of the SP4PHC project found that after assessing health insurance coverage in 36 low/middle income countries in sub-Saharan Africa, coverage is low and pro-rich. The four countries that had health insurance coverage levels greater than 20% were all characterized by substantial funding from tax revenues. The other countries featured predominantly voluntary mechanisms. The study finds that in a context of high informality of labor markets, sub-Saharan Africa and other low/middle income countries should rethink the role of voluntary contributory health insurance and instead embrace tax funding as a sustainable and feasible mechanism for mobilizing resources for the health sector. Read more to review the insights from this fascinating piece of research!

Overview of Health Financing Flows in Uganda

This report documents the nature and magnitude of financial flows to Uganda’s health sector and the purchase of primary health care services. Against international benchmark estimates that $86 per person is required to deliver essential health services in low- and middle-income countries, this study documents that the current level of government funding to primary health care services are below levels needed if Uganda is to achieve its universal health coverage goals.

Ensuring Equitable Population Coverage: Immediate Eligibility to PhilHealth Benefits

Over the years, PhilHealth introduced several programs to expand population coverage, especially for vulnerable groups. However, there are still gaps in access to and utilization of health services among the poor. The UHC Law enacted in 2019 aims to ensure that all Filipinos are guaranteed equitable access to quality and affordable health care service without suffering from financial hardship. This brief published in March 2021 describes how PhilHealth population coverage improved over time and how the UHC Law aims to sustain and further increase these gains.

Country-specific Factsheets on FP, MNCH, and Health Purchasing

SP4PHC works to improve how family planning (FP), maternal, newborn, and child health (MNCH) services, and other services are purchased. As a reference for the latest data and our strategies, each SP4PHC team published country-specific factsheets on our three topic areas. You can find these factsheets within each SP4PHC country’s webpage: Burkina Faso, Indonesia, Kenya, Philippines, and Uganda.

SP4PHC’s July – September 2021 Newsletter

The question of whether user fees in public facilities reduce healthcare utilization and worsen health outcomes, which was vigorously debated by health financing experts in the past, has largely been settled; they do. The focus of discussion has shifted instead to user fee removal policies introduced by low- and middle-income countries.

In 2013, Kenya introduced a free maternity policy abolishing all charges for childbirths at public facilities. At first, the Ministry of Health (MOH) started reimbursing health facilities directly, but later transferred the program to the National Hospital Insurance Fund (NHIF). Under the renamed Linda Mama program, women who register with the NHIF are meant to have access to an expanded package of maternal and newborn health services free of charge from NHIF-contracted public and private providers, and the MOH is supposed to provide funding to the NHIF to reimburse the facilities.

In two recent journal articles, KEMRI Wellcome Trust and ThinkWell share findings from a survey of facilities and program beneficiaries that shows that the impact of Linda Mama on healthcare utilization has been mixed and the program faces many implementation challenges. Most troubling is the fact that program beneficiaries are still incurring out-of-pocket charges. This is in part due to the unavailability of essential commodities and supplies at public facilities that then force mothers to buy them elsewhere. Another reason is that providers are not being reimbursed for all the services that are in the expanded benefits package, forcing them to charge patients and undermine the intention behind the free maternity policy. Facilities face other challenges too. Some smaller facilities lack the staff and infrastructure to submit claims to the NHIF and payments from the NHIF are frequently delayed, often because the MOH has not provided the necessary funds to the NHIF.

Such implementation challenges are not uncommon for a large program of this kind; however, it is imperative that the NHIF work with the MOH, county governments, and facilities to address them quickly. One county’s ongoing efforts to improve uptake of the Linda Mama program, which are described in a recent project brief, show that progress is possible. The NHIF undertaking analysis of claims and payment data on a routine basis and sharing results with program stakeholders would go a long way in improving the performance of the Linda Mama program nationwide.

To receive updates like this about the work our country teams are leading as part of the SP4PHC project, please sign up for the quarterly newsletter by clicking here.

SP4PHC aims to improve how governments purchase primary health care services, with a focus on family planning and maternal, newborn, and child health. SP4PHC is supported by a grant from the Bill & Melinda Gates Foundation.

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