Community-Based Health Insurance： An Evolutionary Approach to Achieving Universal Coverage in Low-Income Countries

The WHO World Health Assembly, and the most recent WHO World Health Report, have called for all health systems to move toward universal coverage. However, low-income countries have made little progress in this respect. We use existing evidence to describe the evolution of community-based health insurance in low-income countries through the three stages of basic model, enhanced model, and nationwide model. We have concluded that community-based health insurance development is a potential strategy to meet the urgent need for health financing in low-income countries. With careful planning and implementation, it is possible to adopt such evolutionary approach to achieve universal coverage by extending tax-based financing/social insurance characteristics to community-based health insurance schemes.

Universal Health Coverage in Somalia: Charting the Path to Equitable Healthcare Financing and Governance

Somalia is a country facing numerous challenges in achieving universal health coverage (UHC) and ensuring adequate healthcare financing, This article explores the complexities and obstacles that Somalia must overcome in its pursuit of UHC, the paper begins by providing an overview of the current healthcare landscape in Somalia, highlighting the lack of infrastructure, political instability, and limited financial resources that hinder the establishment of a comprehensive and equitable healthcare system. It then examines the role of international aid and non-governmental organizations (NGOs) in filling the healthcare gap, while emphasizing the need for a more sustainable, domestically financed solution. Drawing on a range of data sources and case studies, the article proposes a multi-faceted approach to strengthen healthcare governance, improve resource allocation, and foster local capacity building, the study delves into the unique obstacles that Somalia faces, including a lack of infrastructure, political instability, and limited financial resources, which hinder the establishment of a comprehensive and equitable healthcare system. The paper also examines the role of international aid and non-governmental organizations (NGOs) in filling the healthcare gap, while highlighting the need for a more sustainable, domestically financed solution. The findings underscore the importance of political commitment, international cooperation, and innovative financing mechanisms in advancing towards UHC in Somalia, providing valuable insights for other low resource, conflict affected settings.

Challenges faced by community health nurses to achieve universal health coverage in Myanmar:A mixed methods study

Objective:This study aimed to identify the challenges of community health nurses(CHNs)in delivering effective community health care to achieve universal health coverage(UHC)in Myanmar.Methods:A total of 30 CHNs from township health centers in the northeastern,southern,and western parts of Myanmar were purposefully recruited for quantitative and qualitative interviews.Quantitative data were processed using Microsoft Excel software,and qualitative data were analyzed using thematic analysis.This study is registered with researchregistry6201.Results:Around the country,30 CHNs uncovered their hardships in implementing primary health care to achieve UHC.Over 90%of the participants agreed to the problem of inadequate health infrastructure,while half of them felt unmotivated when they encountered role conflicts among various cadres of healthcare providers and poor opportunities for career promotion.Major problems arose from the lack of standard professional education at the entry point to community settings because most CHNs did not achieve specialized training in providing public health services.Complications are incapable of evaluating health services for policy-making and the inability to conduct health research to develop evidencebased practices.Insecure work and living conditions,unsupportive community relationships,and undereducation in professional practices were supportive major themes explored by CHNs to achieve a deeper understanding of the barriers to UHC.Not only the health system itself but also the population and other geographical factors have contributed to many challenges to CHNs.Conclusion:Myanmar’s CHNs face many challenges in achieving UHC.These challenges are not confined to the health sector.Some situations,such as geographical barriers and transportation problems,remain persistent challenges for healthcare providers.This study highlights the fact that current health systems should be strengthened by qualified healthcare providers and sufficient infrastructure.Meanwhile,public empowerment plays a critical role in promoting health development.

Assessment of Health Purchasing Functions for Universal Health Coverage in Nigeria: Evidence from Grey Literature and Key Informant Interviews

Objective: Out of pocket expenditure is the primary means of financing healthcare in middle and low-income countries. The 2021 government health expenditure in Nigeria at 4.52% falls short of the 15% recommendation of the 2001 Abuja Declaration. This paper examines healthcare purchasing in Nigeria, in order to explore how resources were allocated and create better insight into healthcare purchasing for universal health coverage. Data Source/Study Setting: The study was conducted in the Federal Capital Territory and three states—Lagos, Enugu and Sokoto. Study Design: A cross sectional method was used to examine health purchasing functions in Nigeria. Key informant interviews and review of grey and published literature on health financing in the selected study areas. Data Collection Methods: Primary data were collected from relevant stakeholders across the selected study areas, using a structured interview guide. A search of grey and published literature gave a total of 57 references. Principal Findings: The NHIS has a clearly articulated benefit package, for its formal sector and pro-poor BHCPF program. NHIS covers only about 5% of the Nigerian population. BHCPF (SOML) program targets the bottom 40% of Nigerians on paper, but there is no specific design for reaching them. The NHIS uses both public and private sector providers. It is not clear which providers are used for the BHCPF (SOML) program. The NHIS uses actuarially calculated capitations for primary care services and market-based fee-for-service rates for reimbursing secondary and tertiary care. BHCPF (SOML) uses a macroscale pay-for-performance mechanism to reward states achieving specific health outcomes. Conclusion: Health purchasing functions have serious implication for UHC. However, health care provision in Nigeria is not pro-poor and government efforts do not promote efficiency. Available option is prioritization of health initiatives that ensure value for money through performance-based financing and partnering with the private sector.

Rethinking Strategies to Address Inequity in Immunization Services towards Achieving Universal Immunization Coverage (UIC) in Karachi, Pakistan

Karachi, the largest city in Pakistan, having high population growth and a complex health care environment, has highest density of unimmunized (zero dose) and under-immunized children. The main reasons of low immunization coverage in Karachi were lack of governance and accountability in a duplicative and fragmented health management structure, weak and inequitable immunization services, and lack of demand and trust among people for immunization services. The Expanded Programme on Immunization (EPI), Ministry of Health (MOH) in Sindh Province spearheaded a structured and collaborative process to develop strategies for addressing inequity in immunization services towards achieving Universal Immunization Coverage (UIC) in Karachi. The process included a situation analysis with gathering quantitative and qualitative information on the root causes of zero-dose and inequity of the immunization services. The strategies and interventions were developed with multi-layer input and feedback of the stakeholders and partners, and focusing primarily to address gaps in three program areas: governance, leadership and accountability;immunization service delivery;and building demand and trust among the people. The interventions were further prioritized for high-risk areas;identified based on maximum number zero-dose children, presence of large slum areas, measles outbreak and on-going circulation of wild poliovirus. Finally, costing for the Roadmap activities was done through consultation with partners and aligning domestic and external (donor) resources. In this paper, we have highlighted the unique process the Sindh Government undertook in collaboration with the stakeholders and partners to develop strategies and interventions for addressing inequity in urban immunization services in Karachi towards achieving Universal Immunization Coverage (UIC). Similar processes can be adapted, as a potential model, for developing strategies to achieve universal health coverage in the cities of Pakistan and in other countries.

Advancing the National Immunization Program in an era of achieving universal vaccine coverage in China and beyond

Background Immunization is a cornerstone of public health.Despite great success,China’s National Immunization Program(NIP)faces challenges,such as the integration of several World Health Organization-recommended vaccines and other systemic issues.The Innovation Laboratory for Vaccine Delivery Research(VaxLab),supported by the Bill&Melinda Gates Foundation and established in 2021 at Duke Kunshan University,focuses on enhancing China’s NIP through research and policy advocacy.This editorial aims to summarize the key findings of the manuscripts published in the collection contributed by VaxLab team and set the future research agenda.Key findings The collection contains eleven manuscripts discussing China’s immunization landscape and strategies to improve coverage,particularly for non-NIP vaccines like human papillomavirus vaccine(HPV),pneumococcal conjugate vaccine(PCV),Haemophilus influenzae type b vaccine(Hib),and rotavirus vaccines.Key findings include:(i)The COVID-19 vaccination campaign demonstrated China’s capacity for rapid,large-scale immunization efforts,suggesting potential for broader vaccine coverage improvements;(ii)Efforts in combating cervical cancer through the HPV vaccine indicate progress but also highlight challenges like vaccine supply and equitable access;(iii)The lag in adopting higher-valent paediatric combination vaccines in China needs attention to address regulatory and health system hurdles;(iv)Disparities in access to non-NIP vaccines underscore the need for government initiatives to improve vaccine coverage,especially for remote areas and marginalized populations;(v)Original studies emphasize the influence of caregivers’knowledge,health workers’financial incentives,and concerns about vaccine efficacy on immunization rates;(vi)Case studies from the Weifang City of China and Indonesia to introduce PCV offer insights on successful vaccine introduction strategies and the impact of innovative financing and government support.Conclusion The articles emphasize the need for government leadership,strategic policymaking,and public awareness to enhance vaccine coverage and equity.The VaxLab will continue strengthening China’s NIP by focusing on vaccine financing,emphasizing diversity,equity,and inclusion,and improving maternal vaccination coverage.Research will extend to Southeast Asian and Western Pacific regions,especially in middle-income countries facing challenges in vaccine financing and delivery.The collective efforts outlined in this collection show a commitment to evolving and adapting immunization strategies to meet global health goals and to provide equitable access to vaccines for all.

Non-inclusion of certified herbal medicines in the National Health Insurance Scheme affects patient utilization of the integrated herbal medicine services in Ghana

Background:In 2011,Ghana piloted the integration of herbal medicine services into mainstream health care delivery in selected government hospitals across the country.To date,however,no single certified herbal drug is generally covered by the national health insurance scheme.This study evaluated the implications of out-of-pocket payment for prescriptions on the patronage of herbal medicine units in 3 selected government hospitals within Kumasi Metropolis.Methods:A cross-sectional study on 413 participants was performed using a semi-structured questionnaire.Results:The majority of study respondents were female(54%),and the median age was 35 years.Most participants(83.1%)were aware that herbal medicine was integrated in the mainstream health care system of the country.Regarding the costs of certified herbal drugs,51.5%of respondents considered them very expensive;72.1%of the respondents believed that the costs of certified herbal drugs adversely affected the utilization of herbal units at government hospitals,which produced a positive correlation(r=0.5498).A total of 99.5%of the respondents recommended the inclusion of certified herbal drugs on the national health insurance drug list.Conclusion:This study revealed that the costs of certified herbal medicines negatively affect utilization of herbal units at government hospitals.To improve the utilization of herbal units,certified herbal drugs dispensed at these units must thus be included in the national health insurance drug list.

How to Integrate Palliative Care Into Primary Health Care

Integration of Palliative Care into Primary Health Care will have a substantial amount of positive impact on Health Care in Nakuru County,Kenya.Consequently,all aspects of Palliative Care should be given to more than 2/3 population that suffer from cancers and chronic illnesses which sometimes overflow to some acute conditions.While Palliative Care focuses on Holistic Care encompassing physical,psychological,social,and spiritual aspects to adults and children,Primary Health Care operates on the principles of equity,solidarity,universal access to services,multisectoral action,social justice,centralization,and community participation.Thus,there are similarities in Palliative Care and Primary Health Care putting into consideration that the latter is based on practical,scientifically sound and socially accepted methods and technology.It is affordable,universally accessible to individuals and families in the community.Universal Health Coverage ensures that all people and communities have access to promotive,preventive,curative,rehabilitative,and palliative health services they need,of sufficient quality to be effective while also ensuring that the use of these services does not expose the users to financial hardships.The 60%of the Nakuru County population are in need of Palliative Care services,but only about 20%access these services.They suffer from cancers,non-communicable diseases,dementia,and frailty.Geographical challenges,staff shortages,and lack of Palliative Care knowledge are the main barriers to provision of care.

Prevalence and risk distribution of schistosomiasis among adults in Madagascar:a cross-sectional study

Background The goal to eliminate the parasitic disease of poverty schistosomiasis as a public health problem is aligned with the 2030 United Nations agenda for sustainable development goals,including universal health coverage(UHC).Current control strategies focus on school-aged children,systematically neglecting adults.We aimed at providing evidence for the need of shifting the paradigm of schistosomiasis control programs from targeted to generalized approaches as key element for both the elimination of schistosomiasis as a public health problem and the promotion of UHC.Methods In a cross-sectional study performed between March 2020 and January 2021 at three primary health care centers in Andina,Tsiroanomandidy and Ankazomborona in Madagascar,we determined prevalence and risk factors for schistosomiasis by a semi-quantitative PCR assay from specimens collected from 1482 adult participants.Univariable and multivariable logistic regression were performed to evaluate odd ratios.Results The highest prevalence of S.mansoni,S.haematobium and co-infection of both species was 59.5%,61.3%and 3.3%,in Andina and Ankazomborona respectively.Higher prevalence was observed among males(52.4%)and main contributors to the family income(68.1%).Not working as a farmer and higher age were found to be protective factors for infection.Conclusions Our findings provide evidence that adults are a high-risk group for schistosomiasis.Our data suggests that,for ensuring basic health as a human right,current public health strategies for schistosomiasis prevention and control need to be re-addressed towards more context specific,holistic and integrated approaches.

Malaria: Global progress 2000-2015 and future challenges

Background:2015 was the target year for malaria goals set by the World Health Assembly and other international institutions to reduce malaria incidence and mortality.A review of progress indicates that malaria programme financing and coverage have been transformed since the beginning of the millennium,and have contributed to substantial reductions in the burden of disease.Findings:Investments in malaria programmes increased by more than 2.5 times between 2005 and 2014 from US$960 million to US$2.5 billion,allowing an expansion in malaria prevention,diagnostic testing and treatment programmes.In 2015 more than half of the population of sub-Saharan Africa slept under insecticide-treated mosquito nets,compared to just 2%in 2000.Increased availability of rapid diagnostic tests and antimalarial medicines has allowed many more people to access timely and appropriate treatment.Malaria incidence rates have decreased by 37%globally and mortality rates by 60%since 2000.It is estimated that 70%of the reductions in numbers of cases in sub-Saharan Africa can be attributed to malaria interventions.Conclusions:Reductions in malaria incidence and mortality rates have been made in every WHO region and almost every country.However,decreases in malaria case incidence and mortality rates were slowest in countries that had the largest numbers of malaria cases and deaths in 2000;reductions in incidence need to be greatly accelerated in these countries to achieve future malaria targets.Progress is made challenging because malaria is concentrated in countries and areas with the least resourced health systems and the least ability to pay for system improvements.Malaria interventions are nevertheless highly cost-effective and have not only led to significant reductions in the incidence of the disease but are estimated to have saved about US$900 million in malaria case management costs to public providers in sub-Saharan Africa between 2000 and 2014.Investments in malaria programmes can not only reduce malaria morbidity and mortality,thereby contributing to the health targets of the Sustainable Development Goals,but they can also transform the well-being and livelihood of some of the poorest communities across the globe.

Multi-source financing for tuberculosis treatment in China: key issues and challenges

Background:The End Tuberculosis(TB)Strategy of the World Health Organization highlights the need for patientcentered care and social protection measures that alleviate the financial hardships faced by many TB patients.In China,TB treatments are paid for by earmarked government funds,social health insurance,medical assistance for the poor,and out-of-pocket payments from patients.As part of Phase III of the China-Gates TB project,this paper introduces multi-source financing ofTB treatment in the three provinces of China and analyzes the challenges of moving towards universal coverage and its implications of multi-sectoral engagement for TB care.Main text:The new financing policies forTB treatment in the three provinces include increased reimbursement forTB outpatient care,linkage ofTB treatment with local poverty alleviation programs,and use of local government funds to cover some costs to reduce out-of-pocket expenses.However,there are several challenges in reducing the financial burdens faced byTB patients.First,medical costs must be contained by reducing the profit-maximizing behaviors of hospitals.Second,treatment forTB and multi-drug resistant TB(MDR-TB)is only available at county hospitals and city or provincial hospitals,respectively,and these hospitals have low reimbursement rates and high co-payments.Third,many patients with TB and MDR-TB are at the edge of poverty,and therefore ineligible for medical assistance,which targets extremely poor individuals.In addition,the local governments of less developed provinces often face fiscal difficulties,making it challenging to use of local government funds to provide financial support for TB patients.We suggest that stakeholders at multiple sectors should engage in transparent and responsive communications,coordinate policy developments,and integrate resources to improve the integration of social protection schemes.Conclusions:The Chinese government is examining the establishment of multi-source financing forTB treatment by mobilization of funds from the government and social protection schemes.These efforts require strengthening the cooperation of multiple sectors and improving the accountability of different government agencies.All key stakeholders must take concrete actions in the near future to assure significant progress toward the goal of alleviating the financial burden faced byTB and MDR-TB patients.

Inequity in catastrophic costs among tuberculosis-affected households in China

Background:There are limited nationally representative studies globally in the post-2015 END tuberculosis(TB)era regarding wealth related inequity in the distribution of catastrophic costs due to TB care.Under the Chinese national tuberculosis programme setting,we aimed to assess extent of equity in distribution of total TB care costs(pre-treatment,treatment and overall)and costs as a proportion of annual household income(AHI),and describe and compare equity in distribution of catastrophic costs(pre-treatment,treatment and overall)across population sub-groups.Methods:Analytical cross-seaional study using data from national TB patient cost survey carried out in 22 counties from six provinces in China in 2017.Drug-susceptible pulmonary TB registered under programme,who had received at least 2 weeks of intensive phase therapy were included.Equity was depiaed using concentration curves and concentration indices were compared using dominance test.Results:Of 1147 patients,the median cost of pre-treatment,treatment and overall care,were USD 283.5,USD 413.1 and USD 965.5,respectively.Richer quintiles incurred significantly higher pre-treatment and treatment costs compared to poorer quintiles.The distribution of costs as a proportion of AHI and catastrophic costs were significantly pro-poor overall as well as during pre-treatment and treatment phase.All the concentration curves for catastrophic costs(due to pre-treatment,treatment and overall care)stratified by region(east,middle and west),area of residence(urban,rural)and type of insurance new rural co-operative medical system[NCMS],non-NCMSalso exhibited a pro-poor pattern with statistically significant(P<0.01)concentration indices.The pro-poor distribution of the catastrophic costs due to TB treatment was significantly more inequitable among rural,compared to urban patients,and NCMS compared to non-NCMS beneficiaries.Conclusions:There is inequity in the distribution of catastrophic costs due to TB care.Universal health coverage,social protection strategies complemented by quality TB care is vital to reduce inequitable distribution of catastrophic costs due to TB care in China.

Social innovation for health: engaging communities to address infectious diseases

Universal health coverage emphasises the value of the community-based delivery of health services to ensure that underserved populations have access to care.In areas where infectious diseases are endemic,there are often few resources and limited capacity,and the introduction of effective and accessible strategies require innovation.In this special issue,the contributing authors emphasise the power of local responses to the circumstances that underpin diseases of poverty,and highlight the methodological and programme innovations necessary to support and sustain these responses.Through case studies,the authors illustrate how social innovations can address health inequities,and they identify the role of academics in the Social Innovation in Health Initiative to support this approach.