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Thinkwell

Shaping health economics in a time of global change: ThinkWell at the 2021 iHEA Congress

25 June 2021

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. 

Be sure to take a look at the full program. You can register here until July 5. We hope to see you there to untangle challenges and seek innovative solutions in health financing! 

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.

SESSIONS 

Institutional Arrangements for Increasing Facility Autonomy and Their Effect on Performance: Insights from Kenya  

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. 

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

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. 

How Devolution Has Shaped Health Financing Arrangements: A Case Study of the Philippines 

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.    

How Does Devolution Affect Health Financing? A Synthesis of Findings from Seven Country Case Studies 

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.  

Challenges and Opportunities for Health Financing Reforms in the Age of Devolution: A Perspective from Kenya 

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). 

A Rapid Situational Assessment of the Impacts of the COVID-19 Pandemic on the Provision and Utilization of Essential Health Services in Bangladesh 

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. 

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

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.

Flow of Funds to the Frontlines: Insights from Uganda 

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. 

Econometrics of Acute Cardiovascular Services: Analyzing Pre- and Hospital Delays Among Acute Coronary Syndrome Patients in Jakarta, Indonesia 

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. 

Sustainable Health Financing: Lessons from the USAID Health Financing Activity in Indonesia 

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.  

The Cost of COVID-19 Management in Secondary and Tertiary Settings 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. 

The Cost of Integrated Immunization Campaigns: Findings from Sierra Leone and Nigeria 

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. 

POSTERS 

Patterns of Health Care Utilization and Referrals Amongst HIV Patients in Indonesia: Cross-Sectional Analysis of National Health Insurance Claims Data 

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. 

Applied Stakeholder Analysis in Mapping Political Actors Involved in the Implementation of Universal Health Care in 25 Provinces in the Philippines   

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. 

The Impact of Indonesia’s Social Health Insurance on Out-of-Pocket Health Expenditures: Financial Risk Protection, and Its Potential for Stimulating Macroeconomic Growth 

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. 

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

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. 

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