Purchasing Pharmaceuticals (Health, Nutrition and Population (HNP) Discussion Paper)

This paper discusses the purchasing of pharmaceuticals as a key component of costeffective and equitable healthcare delivery. Pharmaceuticals account for a high, sometimes the dominant share of health expenditures in developing countries, but the desired health outcomes can only be achieved if the adequate medicines reach the right people and are used in the correct way. This requires purchasing arrangements that take into account the information asymmetry between patients and providers, ensure selection of effective, safe and affordable medicines and set economic incentives in a way that encourages rational drug use. The organizational and institutional frameworks define the roles of the various public and private stakeholders and establish the rules and regulations for registration, import, prescription and distribution of pharmaceuticals within which active purchasing can take place. While there is a trend towards more active purchasing arrangements for pharmaceuticals, the move from passive to active purchasing, using up-to-date information systems to link inputs and outcomes, and pooled purchasing arrangements to optimize the use of limited resources, has been slow.https://digitalcommons.chapman.edu/pharmacy_books/1019/thumbnail.jp

Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?

BACKGROUND: Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. METHODS: The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. RESULTS: Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. CONCLUSION: Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage

Does the National Health Insurance Scheme provide financial protection to households in Ghana?

BACKGROUND: Excessive healthcare payments can impede access to health services and also disrupt the welfare of households with no financial protection. Health insurance is expected to offer financial protection against health shocks. Ghana began the implementation of its National Health Insurance Scheme (NHIS) in 2004. The NHIS is aimed at removing the financial barrier to healthcare by limiting direct out-of-pocket health expenditures (OOPHE). The study examines the effect of the NHIS on OOPHE and how it protects households against catastrophic health expenditures. METHODS: Data was obtained from a cross-sectional representative household survey involving 2,430 households from three districts across Ghana. All OOPHE associated with treatment seeking for reported illness in the household in the last 4 weeks preceding the survey were analysed and compared between insured and uninsured persons. The incidence and intensity of catastrophic health expenditures (CHE) among households were measured by the catastrophic health payment method. The relative effect of NHIS on the incidence of CHE in the household was estimated by multiple logistic regression analysis. RESULTS: About 36% of households reported at least one illness during the 4 weeks period. Insured patients had significantly lower direct OOPHE for out-patient and in-patient care compared to the uninsured. On financial protection, the incidence of CHE was lower among insured households (2.9%) compared to the partially insured (3.7%) and the uninsured (4.0%) at the 40% threshold. The incidence of CHE was however significantly lower among fully insured households (6.0%) which sought healthcare from NHIS accredited health facilities compared to the partially insured (10.1%) and the uninsured households (23.2%). The likelihood of a household incurring CHE was 4.2 times less likely for fully insured and 2.9 times less likely for partially insured households relative to being uninsured. The NHIS has however not completely eliminated OOPHE for the insured and their households. CONCLUSION: The NHIS has significant effect in reducing OOPHE and offers financial protection against CHE for insured individuals and their households though they still made some out-of-pocket payments. Efforts should aim at eliminating OOPHE for the insured if the objective for establishing the NHIS is to be achieved

Inclusion of the value of herd immunity in economic evaluations of vaccines. A systematic review of methods used.

OBJECTIVE: The objectives of this review were to identify vaccine economic evaluations that include herd immunity and describe the methodological approaches used. METHODS: We used Kim and Goldie's search strategy from a systematic review (1976-2007) of modelling approaches used in vaccine economic evaluations and additionally searched PubMed/MEDLINE and Embase for 2007-2015. Studies were classified according to modelling approach used. Methods for estimating herd immunity effects were described, in particular for the static models. RESULTS: We identified 625 economic evaluations of vaccines against human-transmissible diseases from 1976 to 2015. Of these, 172 (28%) included herd immunity. While 4% of studies included herd immunity in 2001, 53% of those published in 2015 did this. Pneumococcal, human papilloma and rotavirus vaccines represented the majority of studies (63%) considering herd immunity. Ninety-five of the 172 studies utilised a static model, 59 applied a dynamic model, eight a hybrid model and ten did not clearly state which method was used. Relatively crude methods and assumptions were used in the majority of the static model studies. CONCLUSION: The proportion of economic evaluations using a dynamic model has increased in recent years. However, 55% of the included studies used a static model for estimating herd immunity. Values from a static model can only be considered reliable if high quality surveillance data are incorporated into the analysis. Without this, the results are questionable and they should only be included in sensitivity analysis

Health care seeking behaviour and utilisation in a multiple health insurance system: does insurance affiliation matter?

BACKGROUND: Many countries striving to achieve universal health insurance coverage have done so by means of multiple health insurance funds covering different population groups. However, existence of multiple health insurance funds may also cause variation in access to health care, due to the differential revenue raising capacities and benefit packages offered by the various funds resulting in inequity and inefficiency within the health system. This paper examines how the existence of multiple health insurance funds affects health care seeking behaviour and utilisation among members of the Community Health Fund, the National Health Insurance Fund and non-members in two districts in Tanzania. METHODS: Using household survey data collected in 2011 with a sample of 3290 individuals, the study uses a multinomial logit model to examine the influence of predisposing, enabling and need characteristics on the probability of seeking care and choice of provider. RESULTS: Generally, health insurance is found to increase the probability of seeking care and reduce delays. However, the probability, timing of seeking care and choice of provider varies across the CHF and NHIF members. CONCLUSIONS: Reducing fragmentation is necessary to provide opportunities for redistribution and to promote equity in utilisation of health services. Improvement in the delivery of services is crucial for achievement of improved access and financial protection and for increased enrolment into the CHF, which is essential for broadening redistribution and cross-subsidisation to promote equity

Household perceptions towards a redistributive policy across health insurance funds in Tanzania.

BACKGROUND: The Tanzanian health insurance system comprises multiple health insurance funds targeting different population groups but which operate in parallel, with no mechanisms for redistribution across the funds. Establishing such redistributive mechanisms requires public support, which is grounded on the level of solidarity within the country. The aim of this paper is to analyse the perceptions of CHF, NHIF and non-member households towards cross-subsidisation of the poor as an indication of the level of solidarity and acceptance of redistributive mechanisms. METHODS: This study analyses data collected from a survey of 695 households relating to perceptions of household heads towards cross-subsidisation of the poor to enable them to access health services. Kruskal-Wallis test is used to compare perceptions by membership status. Generalized ordinal logistic regression models are used to identify factors associated with support for cross-subsidisation of the poor. RESULTS: Compared to CHF and NHIF households, non-member households expressed the highest support for subsidised CHF membership for the poor. The odds of expressing support for subsidised CHF membership are higher for NHIF households and non-member households, households that are wealthier, whose household heads have lower education levels, and have sick members. The majority of households support a partial rather than fully subsidised CHF membership for the poor and there were no significant differences by membership status. The odds of expressing willingness to contribute towards subsidised CHF membership are higher for households that are wealthier, with young household heads and have confidence in scheme management. CONCLUSION: The majority may support a redistributive policy, but there are indications that this support and willingness to contribute to its achievement are influenced by the perceived benefits, amount of subsidy considered, and trust in scheme management. These present important issues for consideration when designing redistributive policies

Risk distribution across multiple health insurance funds in rural Tanzania.

INTRODUCTION: Multiple insurance funds serving different population groups may compromise equity due to differential revenue raising capacity and an unequal distribution of high risk members among the funds. This occurs when the funds exist without mechanisms in place to promote income and risk cross-subsidisation across the funds. This paper analyses whether the risk distribution varies across the Community Health Fund (CHF) and National Health Insurance Fund (NHIF) in two districts in Tanzania. Specifically we aim to 1) identify risk factors associated with increased utilisation of health services and 2) compare the distribution of identified risk factors among the CHF, NHIF and non-member households. METHODS: Data was collected from a survey of 695 households. A multivariate logisitic regression model was used to identify risk factors for increased health care utilisation. Chi-square tests were performed to test whether the distribution of identified risk factors varied across the CHF, NHIF and non-member households. RESULTS: There was a higher concentration of identified risk factors among CHF households compared to those of the NHIF. Non-member households have a similar wealth status to CHF households, but a lower concentration of identified risk factors. CONCLUSION: Mechanisms for broader risk spreading and cross-subsidisation across the funds are necessary for the promotion of equity. These include risk equalisation to adjust for differential risk distribution and revenue raising capacity of the funds. Expansion of CHF coverage is equally important, by addressing non-financial barriers to CHF enrolment to encourage wealthy non-members to join, as well as subsidised membership for the poorest

Risk distribution across multiple health insurance funds in rural Tanzania

Introduction: multiple insurance funds serving different population groups may compromise equity due to differential revenue raising capacity and an unequal distribution of high risk members among the funds. This occurs when the funds exist without mechanisms in place to promote income and risk cross-subsidisation across the funds. This paper analyses whether the risk distribution varies across the  Community Health Fund (CHF) and National Health Insurance Fund (NHIF) in two districts in Tanzania. Specifically we aim to 1) identify risk factors associated with increased utilisation of health services and 2) compare the distribution of identified risk factors among the CHF, NHIF and non-member households. Methods: data was collected from a survey of 695 households. A multivariate logisitic regression model was used to identify risk factors for increased health care utilisation. Chi-square tests were performed to test whether the distribution of identified risk factors varied across the CHF, NHIF and non-member households.Results: there was a higher concentration of identified risk factors among CHF households compared to those of the NHIF. Non-member households have a similar wealth status to CHF households, but a lower concentration of identified risk factors.Conclusion: mechanisms for broader risk spreading  and cross-subsidisation across the funds are necessary for the promotion of equity. These include risk equalisation to adjust for differential risk distribution and revenue raising capacity of the funds. Expansion of CHF coverage is equally important, by addressing non-financial barriers to CHF enrolment to encourage wealthy non-members to join, as well as subsidised membership for the poorest.Key words: Health insurance, risk distribution, risk stratification, risk pool fragmentation, cross-subsidisation

Progress in utilization of antenatal and delivery care services in Bangladesh: Where does the equity gap lie?

Despite a central element of the Millennium Development Goals (MDGs), the progress in making pregnancy and childbearing safer for women has been slow in many developing countries. Though Bangladesh has achieved commendable progress in reducing maternal mortality in recent decades, the country faces pervasive inequity in antennal (ANC) and delivery care services. The purpose of this study is to provide recent estimates of trend in inequity in antenatal and delivery care services in Bangladesh during 2004-2011. We employ rich-poor ratio, concentration curve and concentration index to examine the trends of inequities in ANC and delivery care services using the latest three waves of Bangladesh Demographic and Health Survey. This study uses logistic regression analysis to investigate the relationship between socioeconomic factors and six indicators of ANC and delivery care. Concentration index for 4+ ANC visits dropped from 0.42 in 2004 to 0.31 in 2011 while it remained around 0.20 for receiving ANC from medically trained provider. Findings indicate that inequity in delivery at health facility and delivery by caesarean section decreased by about 33% in between 2004 and 2011. Women from the richest households were about 3 times more likely to have 4+ ANC visits (OR=2.91, 95% CI: 2.24-3.78), delivery at health facility (OR=3.16, 95% CI: 2.40-4.17), and skilled assistance at birth (OR=3.32, 95% CI: 2.51-4.38) compared to women from the poorest households. There was an overall progress in reducing inequity in utilization of maternal health care but rural area lagged behind to achieve equity compared to urban area. The evidence of inequity in maternal health care utilization highlights that the country faces not only a persistent equity gap between rich and poor women but also substantial rural-urban inequity. It is essential to design multi-sectoral and concerted interventions from an equity perspective to accelerate safe motherhood and childbirth in Bangladesh