Health Care Financing for the Poor in Lao PDR

As in many other developing countries, an official policy of user fees was adopted for the Lao health system in the 1990s. In principle, the poor were to be exempted from paying user fees at public health providers. This study aimed to contribute to policy on financial protection of the poor by (1) improving understanding of health care utilization and strategies adopted by households to deal with costs of Illness; (2) examining attitudes of policy makers and actual practice of public health care providers on fee exemptions of the poor; and (3) proposing better ways of protecting the poor. Both quantitative and qualitative methods were employed. Data were collected from 172 households of 4 villages in Savannakhet Province; 26 public providers in Savannakhet Province and 3 public providers in Vientiane capital; and 22 policy makers in Vientiane capital, between October 2005 and July 2006. The exemption policy has been ineffectively implemented. In practice, criteria for identifying the poor were not specified and no budget was provided to hospitals to finance exemptions. Providers preserved exemptions for 'the destitute'. The payment of user fees could be delayed without interest when 'the poor' had insufficient cash. Villagers strongly believed in the principle of paying user fees to providers either at the point of service or through delayed payment, even though they lived In difficult conditions and their average consumption was below $US1.00 a day. Importantly, they did not perceive exemption from fees to be possible for 'the poor'. The majority of households did not access health care services when III for reasons such as financial and geographical barriers; some of them suffered adverse health consequences as a result such as death or disability. The better the socio-economic group, the better was access to health care services. Among a total of 172 sampled households, twelve households were faced with catastrophic health expenditure, most from the middle and poorest socio-economic group. The villagers managed health crises themselves mainly through drawing on social networks within the community in order to sell assets, borrow, and get other forms of support from neighbours. Although the study of households was small in scale, it was likely to echo households' difficulties elsewhere as the studied villages were similar to other rural areas without roads of Lao PDR. This study suggests that there is an urgent need for the government to improve two main areas: accessibility to adequate health care for everyone, everywhere; and reform of the nationwide policy on health financial risk protection for the poor and the less-poor in order to reduce catastrophic health expenditure

An evaluation of health systems equity in Indonesia: Study protocol

© 2018 The Author(s). Background: Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia's national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms. Methods: Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken. Discussion: As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach - are not excluded. The results of this study will not only help track Indonesia's progress to universalism but also reveal what the UHC-reforms mean to the poor

Influencing policy change: the experience of health think tanks in low- and middle-income countries

In recent years there has been a growth in the number of independent health policy analysis institutes in low- and middle-income countries which has occurred in response to the limitation of government analytical capacity and pressures associated with democratization. This study aimed to: (i) investigate the contribution made by health policy analysis institutes in low- and middle-income countries to health policy agenda setting, formulation, implementation and monitoring and evaluation; and (ii) assess which factors, including organizational form and structure, support the role of health policy analysis institutes in low- and middle-income countries in terms of positively contributing to health policy. Six case studies of health policy analysis institutes in Bangladesh, Ghana, India, South Africa, Uganda and Vietnam were conducted including two NGOs, two university and two government-owned policy analysis institutes. Case studies drew on document review, analysis of financial information, semi-structured interviews with staff and other stakeholders, and iterative feedback of draft findings. Some of the institutes had made major contributions to policy development in their respective countries. All of the institutes were actively engaged in providing policy advice and most undertook policy-relevant research. Relatively few were engaged in conducting policy dialogues, or systematic reviews, or commissioning research. Much of the work undertaken by institutes was driven by requests from government or donors, and the primary outputs for most institutes were research reports, frequently combined with verbal briefings. Several factors were critical in supporting effective policy engagement. These included a supportive policy environment, some degree of independence in governance and financing, and strong links to policy makers that facilitate trust and influence. While the formal relationship of the institute to government was not found to be critical, units within government faced considerable difficulties

Multisectoral actions for health: challenges and opportunities in complex policy environments

Abstract Multisectoral actions for health, defined as actions undertaken by non-health sectors to protect the health of the population, are essential in the context of inter-linkages between three dimensions of sustainable development: economic, social, and environmental. These multisectoral actions can address the social and economic factors that influence the health of a population at the local, national, and global levels. This editorial identifies the challenges, opportunities and capacity development for effective multisectoral actions for health in a complex policy environment. The root causes of the challenges lie in poor governance such as entrenched political and administrative corruption, widespread clientelism, lack of citizen voice, weak social capital, lack of trust and lack of respect for human rights. This is further complicated by the lack of government effectiveness caused by poor capacity for strong public financial management and low levels of transparency and accountability which leads to corruption. The absence of or rapid changes in government policies, and low salary in relation to living standards result in migration out of qualified staff. Tobacco, alcohol and sugary drink industries are major risk factors for non-communicable diseases (NCDs) and had interfered with health policy through regulatory capture and potential law suits against the government. Opportunities still exist. Some World Health Assembly (WHA) and United Nations General Assembly (UNGA) resolutions are both considered as external driving forces for intersectoral actions for health. In addition, Thailand National Health Assembly under the National Health Act is another tool providing opportunity to form trust among stakeholders from different sectors. Capacity development at individual, institutional and system level to generate evidence and ensure it is used by multisectoral agencies is as critical as strengthening the health literacy of people and the overall good governance of a country