31 JANUARY 2020

SESSION 1

15:10-15:20

Human Resource for Health Planning in Tribal Populated districts for Comprehensive Primary Health Care

Presenter : Narayan Tripathi
Abstract ID : A271
POSTER
Background: In India, National Health Policy 2017 includes Comprehensive Primary Health Care (CPHC) as a key intervention for achieving Universal Health Coverage. The operationalization of CPHC part of this is based on making available at Sub-centre level, a Mid-level Health Provider (MLHP) who has requisite skills for primary health care. Methods: This study applied mixed methods, using review of secondary data available, primary data collection from health facilities and qualitative findings from the in-depth interview of district health officials and health care staff. Purpose of this study was to develop a comprehensive human resource for health plan for most remote and southern three districts of Chhattisgarh i.e. Bijapur, Dantewada and Sukma. Result: Analysis of labor market in these three districts shows that there is enough availability of primary health care staff i.e. staff nurse and midwives. The major challenge is department capacity to recruit them. Recruitment is mostly centralized and most of the seats filled in urban areas based on merit list. We recommend having district wise quota in recruitment of paramedical staff this measure can ensure that enough local candidates get recruited from the concerned district. Paramedical staffs are more interested in assured permanent job as compare to contract nature of job as it has more stability and salary as compare to later one. Discussion: There are enough registered nurses who belong to the three districts. In addition to above, greater publicity and communication effort be exercised about the job opportunity. Higher salary, good residential facility, Jobs for spouse, flexibility in sanctioning leave and quality of leadership at facility and district level can help retention.

Poster Slot

A01

15:10-15:20

Challenges of anti-corruption research in LMICs: innovative approaches to research in Bangladesh

Presenter : Nahitun Naher
Abstract ID : A139
POSTER
Introduction The health systems in the LMICs of Southeast Asia face critical challenges related to corruption—representing a major challenge to progress to UHC. Despite commitment by policy makers, regulatory measures, and other innovations, efforts remain fragmented and corruption is on rise. Research within the Anti-corruption Evidence (SOAS-ACE) consortium in Bangladesh, has investigated the nature of corruption and identified policies and practices that can potentially reduce the incentives for corrupt behavior. Method We report experiences from applying a sequence of methods: literature review, consensus building workshop, in-depth interviews, a discrete choice experiment (DCE) and a survey with providers. Findings Each method faced unique challenges: limited access to analyses on corruption; corruption seen as contested terminology by the authorities and framed as ‘transparency, accountability & good governance’ or ‘irregularities’; reluctance to discuss openly incidences and characteristics of corruption; delay in securing approval from authorities for data collection from public facilities due to sensitivities. Thus, the study of absenteeism focused on health workers who are present at the time of the study and locating those who are absent in order to understand their perspectives was difficult. Respondents were reticent in sharing sensitive information given perceived career risks. A sequences of questions was needed to overcome tendency for abstract responses; doctors being unfamiliar with the DCE method, and expressing concerns and negative attitudes, refusal of access to health workers by hospitals. We suggest ways in which these challenges can be overcome, exploring different approaches for data collection(individual/group) that are culturally and health systems-appropriate, local adaptation of tools, iterative cycles involving local and international teams, and policy engagement. Conclusion While research on corruption is predictably sensitive, it has elicited fundamental issues related to power and hierarchies. Close coordination and ownership by policymakers, and locating research into overall strategies to promote UHC, is essential.

Poster Slot

B01

15:10-15:20

Friends, not foes: public-private co-design in Senegal in pursuit of UHC

Presenter : Isseu Toure
Abstract ID : A121
POSTER

Poster Slot

C01

15:10-15:20

10 years of China's comprehensive health reform: a systems perspective towards universal health coverage

Presenter : Jin Xu
Abstract ID : A299
POSTER

Poster Slot

D01

15:10-15:20

National Health Insurance in Lao PDR: accelerating progress toward Universal Health Coverage

Presenter : Dasavanh Manivong
Abstract ID : A159
POSTER

Poster Slot

E01

15:10-15:20

Rethinking and re-measuring what causes health inequities and how to act: now and in the future

Presenter : Jessica Shearer
Abstract ID : A217
POSTER

Poster Slot

F01

15:20-15:30

Health Systems Convergence and Universal Health Coverage: Role of Health Information Systems and lessons learned from conflict-affected areas in Myanmar

Presenter : Zaw Toe Myint
Abstract ID : A250
POSTER
Background Over six decades of armed conflict between the Government of Myanmar (GoM) and Ethnic Armed Organizations (EAOs) has impeded equitable access to healthcare in historically underserved and conflict-affected communities. Ethnic and community-based health organizations (ECBHOs), some of which are affiliated with EAOs, developed as parallel providers to fill gaps in primary healthcare coverage. Longstanding clashes perpetuated an atmosphere of mistrust and sensitivity around sharing data for effective planning and delivery of healthcare services between GoM and ECBHOs. However, the signing of a nationwide ceasefire agreement between GoM and EAOs in 2015 paved the way towards convergence between state and non-state actors to move towards Universal Health Coverage (UHC) by 2030, including the alignment of health management information systems (HMIS) for effective, efficient, and coordinated planning. Objectives Describe lessons learned related to HMIS needs in conflict-affected settings to promote health systems convergence. Approach and lessons learned In December 2017, five in-depth interviews with HMIS managers and field staff from four ECBHOs were conducted and reviewed HMIS documents. Key informants identified the two most significant barriers to HIS convergence between EHO and GoM health systems as 1) inconsistent definitions of health indicators, and 2) software interoperability that prevented seamless uploading of EHO program data into national databases. Other prerequisites for HMIS convergence included: adequate and routine training related to HMIS at all capacity levels, investment in infrastructure (e.g., servers), user-friendly data management software, clear HMIS workflows, data confidentiality and security policies, built-in data quality assurance mechanisms through information technology, and effective utilization of data for decision-making. These findings suggest a roadmap for engaging HMIS managers in the Ministry of Health and Sports (MOHS) and ECBHOs, as well as a prioritized agenda for upgrading and aligning HMIS systems to accelerate the progress towards UHC in contested areas of Myanmar.

Poster Slot

A02

15:20-15:30

Demand and supply-side barriers and challenges in providing sexual and reproductive health services to Rohingya refugee women and adolescent girls in Bangladesh

Presenter : Nadia Farnaz
Abstract ID : A232
POSTER

Poster Slot

B02

15:20-15:30

Do rising administration costs threaten future shifts to private health insurance risk-pooling in Hong Kong?

Presenter : Jianchao Quan
Abstract ID : A280
POSTER
Hong Kong has achieved good health outcomes at low cost (health care spending at 6.2% of GDP). However, Hong Kong’s tax-financed revenue pool accounted for only half of total health care expenditure (51.6%) in 2016/17. There is no mandatory health insurance scheme or specific health-related tax. Pooling through health insurance is limited to one-quarter of the population, with out-of-pocket payments (34% of total expenditure) well over the WHO recommended threshold of 20%. The insurance system is fragmented with many small pools that varies greatly in price and coverage. A government-regulated voluntary private health insurance scheme was established in 2019 to improve scheme quality and provide subsidies to incentivize uptake. Analysis of the Hong Kong domestic health accounts showed administration costs represented 5.7% (USD 1.09 billion) of total health care spending in 2016/17. Administration costs are substantial and were greater than spending on preventive care (2.7%) and long-term care (5.4%). Administration costs grew from 3.5% of private expenditure in 1989/90 to 9.9% in 2016/17; but fell from 2.7% to just 1.5% of public expenditure. The distribution of administration costs is skewed: voluntary health insurance plays a relatively minor role at 16.2% of total health expenditure in Hong Kong, yet it accounted for 86% of total administration costs. These costs represented 42% of total private insurance expenditure, compared to 17.8% in employer-based insurance schemes, and just 0.1% of household out-of-pocket expenditure. Administration costs are often overlooked when considering the efficiency of these health financing polices. The rapid growth of administration spend is concerning as future public funds are diverted to subsidize uptake of voluntary private insurance, with potential negative effects on efficiency and equity.

Poster Slot

C02

15:20-15:30

Impact of Free Annual Health Assessment to Improve Health Outcomes, Health-Related Quality of Life and Fill Preventive Care Service Gap of Working Poor in Hong Kong

Presenter : Caitlin Hon Ning Yeung
Abstract ID : A194
POSTER
Introduction: Individuals of low socioeconomic status (SES) experience poorer health. This study aimed to determine whether a community-based health empowerment programme (HEP) could improve self-care and health outcomes among adults of low SES. Methods: This longitudinal study included participants enrolled in the HEP where they received free annual health assessments and health enablement programmes (intervention group) and those with a similar socioeconomic background (control group). Inclusion criteria were: 1) at least one working family member; 2) at least one child studying in grade 1-3; and 3) a monthly household of <75% Hong Kong’s median monthly household income. The primary outcome was self-care enablement, measured using the Patient Enablement Instrument (PEI). Secondary outcomes included Health-Related Quality-of-Life (HRQoL) measured by Short-Form 12 Health Survey Version 2(SF-12v2)) and allostatic load assessed by waist-to-hip-ratio (WHR), total-cholesterol to high-density-lipoprotein-cholesterol (TC:HDLC) ratio, triglycerides and blood pressure. Results: 229 intervention adults and 167 control adults were included (mean follow-up: 4 years). Both intervention and control groups reported increases in mean PEI-total scores between baseline and follow-up, with significantly greater increases in the intervention group than control group (p<0.001). The change in mean SF-12v2 mental component scores were also significantly greater for the intervention group (p<0.001). No statistically significant differences were found between groups for changes in mean SF-12v2 physical component scores. For allostatic load, the intervention group showed significant increases in the proportion achieving optimal TC:HDL-C ratio and blood pressure, whereas significant decreases were found in the control group (all p<0.001). Both groups showed significant increases in WHR and triglycerides, however, such increases were higher among control group participants. Conclusion: Our findings support the implementation of community-based health empowerment programmes to build self-care capacity among individuals of low SES and ultimately improve self-care enablement, mental wellbeing and allostatic load.

Poster Slot

D02

15:20-15:30

Expanding Social Health Protection in Cambodia: An assessment of the current coverage potential and gaps, and social equity considerations

Presenter : Robert Kolesar
Abstract ID : A265
POSTER
The Royal Government of Cambodia recently launched its National Social Protection Policy Framework that includes expansion of health insurance schemes to achieve universal health coverage. The U.S. Agency for International Development (USAID)-funded Health Policy Plus (HP+) project is supporting an evidence-to-action process to answer key questions and inform decision making on coverage expansion. We examined data from a 2016 Cambodia socioeconomic survey and administrative data from 2019 to assess the coverage potential of existing schemes, estimate gaps, and compare equitable contribution rates. Current expansion efforts focus on the formal employee scheme (National Social Security Fund, or NSSF-F) in which only 51 percent of eligible beneficiaries are estimated to be enrolled, primarily benefiting individuals from higher-income households. Recent expansion to some informal workers leaves significant gaps in coverage. Lower-wealth-quintile individuals are financially vulnerable to health shocks, as out-of-pocket health care expenditure (OOPE) comprises an excessive share of (effective) income. Average OOPE for the second and third wealth quintiles reduces income below the threshold of the poorest quintile. Applying a 2.6 percent contribution rate to the average effective income by wealth quintile yields the proportional contribution rate. Weighting these rates by the proportional share of total income by wealth quintile yields a progressive, or equitable, contribution rate. Using these approaches reveals severely limited potential for revenue generation among the lower three quintiles. Population coverage expansion should align with Cambodia’s National Social Protection Policy Framework’s fundamental principle of social equity, ensuring that costs are fairly distributed and do not present an undue burden on enrollees. Therefore, we recommend that vulnerable groups, including the financially vulnerable second- and third-income quintiles, should be exempted from contribution payments as social health protection is expanded.

Poster Slot

E02

15:20-15:30

Strengthening health systems and preparing for pandemics in Ukraine through clinical decision support and online learning.

Presenter : Lalitha Bhagavatheeswaran
Abstract ID : A167
POSTER

Poster Slot

F02

1 FEBRUARY 2020

SESSION 2

10:10-10:20

Community Engagement and Capacity Development of Stakeholders in Enabling Access to PHC Services by Rural Community People in Sudan

Presenter : Kei Yoshidome
Abstract ID : A208
POSTER
<Background> Sudan had 4 times higher MMR (311) compared to the average MMR (70) of Northern Africa (Trends in Maternal Mortality, 2015) and 71 percent home delivery (MICS, 2014). Enhancing skills of Community Midwives (CMW) is critical to save lives of women and newborns. Community Health Committees (CHC) were neither existing nor functioning. Capacity of Health Administrators in planning and implementing PHC programs responding to the needs of communities was insufficient. JICA PHC Expansion Project has been implemented from 2016 to 2019 with the Government of Sudan in 2 localities in Gezira State. This paper presents some factors identified as effective to vitalize the existing health system. <Implementation> Capacity development of Health Administers on leadership, data collection & analysis, planning and M&E based on reviewed roles and responsibility, (2) Upgrading service skills and knowledge of 611 CMWs, (3) Providing CHCs with skills for action-oriented planning and communication strategy development with monitoring by health administrators. <Methodologies> Output 1: Desk Review of Health Administrative Reports Output 2: Comparative Before and After Study using pre and post test results Output 3: Community Survey and Desk review of CAP Reports by CHCs Project Purpose Indicators: House to House Survey <Results> Clients per trained CMWs increased, especially PNC (3.74 to 5.03) comparing before and after the in-service training. CHCs and CMWs are capacitated to operate emergency referral system and community people are motivated to take initiative in improving environmental sanitation with technical support of Health Administrators. CHCs with written plans increased from 0 to 100%, and 84.6% of planned activities were implemented. <Conclusion> Capacity building of key stakeholders of community health contributed to (1) strengthening roles of each stakeholder, (2) strengthening ownership about their roles, (3) strategically collaborating, (4) gaining trust from community, and (5) mobilizing existing community resources.

Poster Slot

B03

10:10-10:20

Using HBM and TRA model to predict intention to buy Social Health Insurance and to prevent boycott from Independent Workers in Depok City, Indonesia

Presenter : Dwi Oktiana Irawati
Abstract ID : A200
POSTER
Since launched in 2014, the members of Indonesian Social Health Insurance have reached 213 million people. Among those, there are 36 million (>15%) from Independent workers and Not a Worker (entrepreneur, business owner, etc) sector. Although the benefit package is quite generous, as predicted before its implementation, moral hazard and adverse selection happened during the 5 years of implementation especially from independent workers due to some problems in supply side such as drugs availability. This study aims to determine the factors that affect the motivation of individuals to purchase health insurance by using a Health Belief Model and the Theory of Planned Behaviour. The variables used to construct prediction of intention to buy are perceived susceptibility, perceived benefits, and perceived behavioral control. The attributes as follow: financial risks, health risks, access to the utilization of insurance benefit package, contribution prices, access of contribution purchases, and individual characteristics. The method used to multiple regression test to determine the association between variables and descriptive analysis to explain managerial implications. The sampling technique is nonprobability sampling, approach technique is convenience sampling. The number of samples is 180. The study found that variables directly attributed to the intention to buy health insurance are 1) perceived benefit that is benefit package and access to utilization. Other is perceived behavioural control that is the availability of procedure to utilize the insurance, various methods of purchase and monthly payment methods, as well as easy to use the health insurance. Payment contribution has been developed through several channels such as minimarket, online, atm. Unfortunately lack of benefit package such as drugs availability is challenging to keep the independent workers from boycotting their monthly contribution. If this condition exist, SHI in Indonesia is too big to be fall.

Poster Slot

C03

10:10-10:20

Sub-national experiments in strategic health purchasing: lessons from county governments in Kenya

Presenter : Joanne Ondera
Abstract ID : A186
POSTER

Poster Slot

D03

10:10-10:20

The limitation of insurance-based system towards UHC and SDG: The case of Unintentional Contributions Arrears (UCAs) under the South Korean NHI system

Presenter : Sun Kim
Abstract ID : A278
POSTER
WHO regarded Korea as an exemplary case which achieved UHC in a short period with its NHI system. But it has never been highlighted that almost 10% of the Korean population is failing to pay the contributions and 60% of them just can’t pay the arrears. Many of them cannot access to healthcare and social services and are even being punished by the government for their arrears through disposition. This study explored the case of UCAs under the Korean NHI system to show the fundamental limitation of the insurance-based system towards UHC and SDG, so that provides lessons for other countries. First, we analyzed the personal histories of people who were in arrears with their NHI contributions to identify the factors that made them fail to pay, as well as the results of their UCAs. Second, we analyzed the institutional arrangements of the Korean NHI system, in terms of the prevention or resolution of UCAs. These were compared with the insurance-based systems in other countries including in Taiwan and Japan. People in arrears with their NHI contributions showed frequent changes and short durations in their NHI entitlements, which reflected their unstable employment and fragile family relationships. The Korean government has implemented only patch-work policies or programs to prevent or deal with UCAs. As a result, the most vulnerable people have failed to pay their contributions, and their vulnerabilities were aggravated due to the arrears. We could find similar problems in Taiwan and Japan. Insurance-based systems only cover the entitled people as defined by the law, and among them, those who have paid their contributions. This principle has a fundamental limitation towards UHC, as illustrated in the case of UCAs under the Korean NHI system. To achieve the goals of Inclusive Societies as well as UHC, we need a tax-based, non-contributory system, with robust public provisioning of healthcare which is free at the point of use, that will ensure universal health care, without any exclusion of the vulnerable population.

Poster Slot

E03

10:10-10:20

Broadening UHC beyond national boundaries: a prerequisite to addressing the challenge of Tuberculosis and Migration.

Presenter : Wirun Limsawart
Abstract ID : A273
POSTER
Background: Ending the global epidemics of tuberculosis (TB) is one of the global ambitions in achieving Sustainable Development Goals (SDG). The universal health coverage (UHC) is stressed as a prerequisite of TB control as UHC ensures access to curative care that is the critical success factor of TB control. Nevertheless, the problem of TB in migrants places a significant challenge to the promise of UHC on universal health security as national UHC schemes are usually provided TB care only for the citizen. Therefore, it is a need to redesign the health care system that can address this problem. Thailand has implemented UHC for two decades, but it is still one of the countries that have the highest burden of TB in the world. Thailand is, thus, a useful case to understand the relationship between UHC and TB control and find ways to design the healthcare system that can ensure health security from TB for everyone. Methods and Findings: This analysis based on fourteen months of ethnographic research in Umphang, a borderland between Thailand and Myanmar. The key finding is that, as UHC is developed by focusing mainly on citizens, non-citizens, including migrants, lack access to TB care because of many factors, including lack of health insurance, legal status. And their mobility, complicated by the historical and sociocultural context of the national boundaries, makes it challenging to access and adhere to the curative treatment for TB that requires at least six months of continuity of chemotherapy. Conclusions: There is a need to broaden the scope of “universal health coverage” beyond a national population if the security of the community is to be ensured.

Poster Slot

F03

10:20-10:30

Access to Essential Medicines for UHC: Results of a study on availability of medicines in public health facilities in Central India

Presenter : Narayan Tripathi
Abstract ID : A252
POSTER
Background: Access to medicines has been listed as one of the six health systems building blocks, and rational drug use is a key ingredient of desirable healthcare policies. In India, access to essential medicines is below 35% with several barriers that aggravate this situation. A dedicated autonomous institution to strengthen procurement and supply as well as rational use of medicines has been suggested as a solution. In 2011, a Medical Services Corporation was set up to ensure availability of essential medicines in Chhattisgarh state. Free generic medicines based on the State Essential Drug List have been guaranteed by the state to all patients in public health facilities. This study was done to evaluate the implementation of this scheme. Methods: Prescription-analysis and exit interviews of patients utilizing public facilities were carried out. In facilities, frequency of stock-outs and reasons were assessed. Results: In 2015, 69% of the medicines prescribed by physicians in public facilities were generic. Out of the prescribed medicines, 58% were made available free of cost to patients. The above proportions did not increase significantly by 2018. Average Out of pocket spending per patient at Primary Health Centers was found to be 128 Indian Rupees on medicines. It drove a proportion of users to unqualified informal providers. Prescription of branded drugs increased at tertiary care level. Around 40% of the essential medicines faced frequent stock-outs. Gaps identified ranged from errors in forecasting quantities required to poor capacity in procurement. Part of the budget allocation remained unutilized. Unsubstantiated adverse perceptions about quality of drugs undermined the efforts to improve procurement. Conclusion: Gaps in access to essential medicines continue to hamper the public health system in many states of India. UHC cannot be realized without paying greater attention to strengthening capacities for medicine procurement and logistics.

Poster Slot

A04

10:20-10:30

Lessons from the field: Recasting Primary Health Care (PHC) – A Primary Health Care framework and roadmap design to strengthen local health systems to achieve Universal Health Care (UHC) in Northern Samar, the Philippines

Presenter : Marie T. Benner
Abstract ID : A037
POSTER
Background Although PHC is one of the main strategies for achieving Universal Health Care (UHC), still many countries face difficulties to provide appropriate and needed health services affordable for the poorest and marginalized. The Philippines health sector is fragmented and challenging with an overemphasis on secondary and tertiary care. The overall goal of this PHC framework was to demonstrate how functional PHC system and services can be designed and reorganized within a service delivery network (SDN) to ensure people-centred and integrated health services. The Implementing Rules and Regulations of the recently passed Universal Health Care Law has been developed and signed, with particular emphasis on strengthening Primary Health Care in the country. Methods Policy documents, epidemiological statistics, reports were analyzed. Multiple field visits, workshops and meetings with health service providers, national health insurance company, universities, policy makers at the pilot area, regional and national level were carried out; communities in the pilot area were included and participated in workshops. Results With information and data gathered, we developed a specific PHC framework for the province prioritizing maternal health, immunization and malnutrition aspects. Five essential elements evolved with ten relevant activities to re-cast PHC efficiently and effectively to ensure a people centred and integrated health service within a service delivery network. Conclusion The driving element for a successful PHC framework is one that is owned by the communities and is supported by the national, regional, provincial health authorities and by the governor. Listening to people’s needs and concerns was critical. Prioritizing ‘low hanging fruits’, has been vital in this pilot design to ensure commitment. The communication strategy helped inform the population on the planned PHC strategy. The steps in this PHC framework can be scaled up and applied in other areas of the Philippines as the country prepares implementing the UHC Law.

Poster Slot

B04

10:20-10:30

Who is using PhilHealth? Using segmentation to track social health insurance resources to broad patient populations

Presenter : Celina Ysabel Gacias
Abstract ID : A088
POSTER
BACKGROUND | In light of the passage of the Universal Health Care (UHC) Law in the Philippines in early 2019, policy actors must understand the heterogeneous demands for care among Filipinos in order to deepen financial coverage. This segmentation study was conducted in order to gain an initial understanding of the populations utilizing the PhilHealth fund and characterize the groups to be targeted for preventive action. METHOD | A k-means cluster analysis was performed on a patient-level transformation of the 2016 PhilHealth claims database, grouping patients together based on age, number of days spent in inpatient admission, and payouts for broad categories of conditions and procedures. Cluster analysis was done separately for maternal beneficiaries. FINDINGS | More than 7.2 million patients were estimated to have utilized PhilHealth benefits in 2016, 39.6% of whom were indigent. Twelve segments across seven age groups were identified for the 6 million non-maternal beneficiaries. Among these, the largest segment in both beneficiaries and payouts was of children below 10 years of age, 70% of whom had claims for communicable diseases. The segment with the greatest average payouts per patient was for adults and elderly utilizing either hemodialysis or chemotherapy packages, a group comprising only 0.6% of all beneficiaries but 8.7% of total payouts. It is also the only group where indigents are the minority. For the 1.27 million maternal beneficiaries, a higher-cost segment was composed of mothers who had availed of c-sections. RECOMMENDATIONS | It is recommended that PhilHealth share its store of information with the DOH to improve upon existing evidence for preventive efforts across all segments, with focus on children with communicable diseases and patients at risk of cancers and kidney diseases. PhilHealth should collect actual diagnoses and further sociodemographic data on its members to facilitate deeper understanding of these beneficiary groups.

Poster Slot

C04

10:20-10:30

Purchasing Arrangements for Healthcare through Publicly Funded Health Insurance and Contracting in India - Understanding Design Challenges and Implementation Processes

Presenter : Samir Garg
Abstract ID : A239
POSTER
WHO has advocated greater use of Strategic Purchasing by LMICs in order to attain progress towards UHC. The recently unveiled National Health Policy (2017) of India also emphasizes the role of Strategic Purchasing. Public Funded Insurance and Contracting have been two important forms of purchasing healthcare in India. The study examines the implementation processes, arrangements and experience of purchasing hospital-care in one state of India. Improving access of the poor to private-sector care was a stated objective from beginning and aligning private-sector growth with public-health goals was added subsequently. The analysis of programme data and guidelines showed some clear patterns. The state chose to focus the benefit package on secondary care and gradually added some primary-care. The utilisation was concentrated on a small number of procedures despite an extensive list included in benefit-package. Costs of insurance premium grew over years and formed a substantial part of state’s finances. Incentives were poorly implemented in public sector. Some services shifted from public sector to private sector under purchasing. Vulnerable remote populations were enrolled but services could not be made available to them through purchasing. A mix of payment mechanisms did not give coherent results. Providers did not respond to demand stimulus in case of some crucial unmet needs, while some services like caesarean deliveries were over-supplied in urban areas. Monitoring and ensuring adherence to contracts involved several challenges including prohibitive costs. Measures for quality promotion and performance measurement were difficult to design. Incentives encouraged selective care and extra-billing. The qualitative analysis of stakeholder-interviews was used to explain the key findings. The processes and experience of implementation were compared with the theoretical assumptions of Strategic Purchasing. The study, one of the first on Strategic Purchasing in Indian health system, provides insight into this complex phenomenon and offers suggestions for future research.

Poster Slot

D04

10:20-10:30

The National Health Insurance Fund of Sudan: Sustainable Financing for Expanding & Deepening UHC

Presenter : Basit Yousif Ibrahim Salih
Abstract ID : A255
POSTER
Abstract: The National Health Insurance Fund, of Sudan (NHIF), was established in 1995 to provide financial risk protection to Sudanese people against catastrophic out-of-pocket health spending. This direction was supported, among others, by UHC Committee, endorsement of Health Financing Policy 2016, and approval of NHIF Act 2016. The National Board of Directors (BOD) for NHIF was endorsed to ensure using unified policies and strategies for implementation at state level. NHIF is compulsory depending mostly on premiums. For the formal sector, 10% is deducted from the payroll. However, different flat-rate premiums are charged from other sectors. For more revenues, earmark taxation and sin taxes have been adopted in many states. Besides, partnership with national and international organizations increased coverage of the poor and refugees. Currently, 66% of Sudanese population (26 million subscribers) are covered and 89% of the poor (3 million families) are fully covered by the Government and Zakat Chamber. To overcome fragmentation, NHIF has improved pooling mechanisms through central collection of premiums at source. Partial Zakat resources as well as free care funds of under-five children in 6 states have been shifted to NHIF. Besides, efforts are underway to direct international funds towards UHC objectives. The benefit package (BP), defined into basic and comprehensive, is provided by more than 3000 health facilities. The payment system is based mostly on fee-for-service. But, the strategy is to shift to capitation for PHC, which is under piloting, and the DRGs for hospitals. Bulk purchasing of medicines is well-established practice since 2012. NHIF is now shifting to be a single purchaser to ensure provision of quality healthcare. Main Challenges facing NHIF is to have government commitment to attain UHC, ensure financial sustainability and cover the informal sector.

Poster Slot

E04

10:20-10:30

Using research for action towards achieving UHC and SDGs equitably: A case study among the Baiga Particularly Vulnerable Tribal Group in India

Presenter : Sulakshana Nandi
Abstract ID : A245
POSTER
Baigas are Particularly Vulnerable Tribal Groups (PVTGs), who are among the most marginalised indigenous groups in India. Lack of evidence regarding their situation has led to their ‘invisibility’ in all programmes. This study aimed to assess their health and nutrition status and its determinants in Chhattisgarh state. The study used mixed methods, that included a quantitative household survey (among 289 Baiga households) using a structured questionnaire and an in-depth qualitative study. Verbal informed consent was taken and ethical clearance given by the Institutional Ethics Committee of PHRS. Underweight (56%) and stunting (56%) among children under five years, proportion of adults (15-49 years) (56%) with BMI under 18.5 and self-reported morbidity 15 days prior to study were much higher than state averages. Malaria and diarrhoea led to numerous deaths annually. Most went to informal private practitioners and village health workers for ambulatory care and to public sector for hospitalisations. Most incurred expenditure for healthcare. Their access to contraceptive services was restricted by a ‘ban’. Many habitations were excluded from regular health and nutrition services. Lack of potable water was a major concern. Depletion of forests and forced displacement have affected their livelihoods and diet. Baigas were worse off in terms of access to public programmes and faced discrimination, abuse and victim blaming. A policy push towards ‘assimilation’ has meant loss of their identity and culture. The determinants of health inequities included food insecurity, ‘politics of development’, culture, identity, gender, geography and social welfare programmes. There were gaps in availability, affordability and acceptability of health services. An action plan was developed at the behest of the government that included recommendations on strengthening the public health system, intersectoral convergence and provision of respectful and responsive services. The study paves the path for more rigorous work among vulnerable communities towards achieving UHC and SDGs.

Poster Slot

F04

SESSION 3

13:30-13:40

Utilization of Maternal Health Services in Humanitarian Crisis: Findings from a study on Rohingya Refugees in Cox’s Bazar, Bangladesh

Presenter : Nadia Farnaz
Abstract ID : A235
POSTER
More than half of the Rohingya refugees, residing in refugee camps in Cox’s Bazar, Bangladesh, are women and adolescent girls. Bangladesh health sector with the support from development partners is committed to providing maternal healthcare to the refugees. However, ensuring accessibility and utilization of services are challenging that affects progress towards universal health coverage. A concurrent mixed method study was conducted in refugee camps in Cox’s Bazar, Bangladesh to understand the utilization of maternal health services among Rohingya refugees. A household survey was conducted among 403 Rohingya refugee adolescent girls and women. In-depth interviews with women, adolescent girls and informal healthcare providers, and Focus Group Discussions with male Rohingya refugees were conducted. Total 129 women and adolescent girls participated in the survey experienced pregnancy in refugee camps. Among them, 82% received ANC and most of them received ANC from health facilities. Only half of the survey respondents who delivered child in refugee camps received PNC services and 78% of them received PNC from doctor/nurse. Some cultural practices, such as not allowing mothers to go out of home for 40 days after delivery, and practice of seeking healthcare only when mothers face any severe complications, were found to be the main reason for low uptake of PNC. Home delivery was very high (86%) among Rohingya refugees as they trust the local traditional birth attendants more than the skilled health providers at the health facilities. Those informal providers have a huge influence on their decision making for seeking delivery care and PNC. Many national and international organizations including the government of Bangladesh are providing maternal health services. However, the utilization of service is still limited due to different contextual and cultural factors. Community-based awareness programs are crucial for improving the utilization of maternal health care services.

Poster Slot

A05

13:30-13:40

Technology Enabled Health & Wellness Centre (s): Steering the primary healthcare systems to respond comprehensive and quality healthcare services to the last mile population in rural India towards universal health coverage

Presenter : Rajesh Singh
Abstract ID : A130
POSTER
Technology Enabled Health & Wellness Centre(s): Steering the primary healthcare systems to ensure/provide comprehensive and quality healthcare services to the last mile population in rural India towards universal health coverage. Anand Kumar Panjiyar1, Dinesh Songara1, Rajesh Ranjan Singh1 1Lords Education & Health Society/WISH Foundation India Background: India’s National Health Policy (NHP) 2017 and its flagship initiative Ayushman Bharat (Healthy India) envisage attainment of Universal Health Coverage (UHC). The realization of UHC is being ensured through availability of free quality essential primary healthcare services by transforming primary care facilities into Health & Wellness Centres and provision of financial protection for secondary & tertiary care treatment through Pradhan Mantri Jan Arogya Yojana (PMJAY). India’s 80% poor live in rural areas and have low access to basic services. Health Sub Centre (HSC), the first point of contact between rural population and public healthcare system, doesn’t have a medical doctor. Technology and innovations have potential to bridge this gap which can be leveraged by the government through public private partnerships. Methods WISH Foundation has designed Project SCALE which bolsters the government initiatives, to ensure free quality primary healthcare services to the last mile population, by leveraging healthcare technology and innovation. Project SCALE has designed and implemented a state-of-the-art; technology-enabled solution ‘Technology enabled Health and Wellness Center’ (THWC) which is efficient in providing curative care treatment through telemedicine and dispensing of medicines through automated medicine vending machine. Additionally, strong referral mechanism and health promotion activities are provided as per Indian Public Health Standards (IPHS). Result In rural Rajasthan (India), 13 HSCs have been successfully transformed into THWCs. Last mile population has been able to connect to both general practitioner as well as specialist medical services through THWCs. Policy makers have considered this model as complementary and supplementary to the Ayushman Bharat program. The government of Rajasthan has allocated additional 50 free essential medicines to the existing essential drug list through these centres. Conclusion/Way Forward: THWC is a first of its kind model. Its successful demonstration has secured recognition and rewards at various platforms across the country. Other state governments after learning about its impact and exploring possibilities of scaling up the model for masses.

Poster Slot

B05

13:30-13:40

What attitudes and beliefs do ministries of finance have towards taxing tobacco to help fund universal healthcare?

Presenter : Jean-Luc Eisel
Abstract ID : A079
POSTER

Poster Slot

C05

13:30-13:40

Access to Emergency Maternal Care Services in Backward regions – Potential of ‘Strategic Purchasing’ from Non-profit Providers to fill the gap

Presenter : Narayan Tripathi
Abstract ID : A251
POSTER
Background: Chhattisgarh, one of the EAG states, has Maternal Mortality Ratio (MMR) of 221 as per SRS bulletin 2011-13. Chhattisgarh has universal maternal and emergency transport and health insurance scheme to cover the health care expenditure, including emergency obstetric care. Yet, the access to Emergency Maternal Care services is inadequate for certain tribal regions and other under-developed geographical pockets in the state. Objective: To identify the reasons for the gap and to assess the potential of Strategic Purchasing in addressing it. Methodology: Mapping of existing facilities providing c-sections was done for Public, Private and Non-profit facilities across the state. Identification of left-out populations was done. Key informants were interviewed and field visits were made to facilities. Results: The predominant model of ‘purchasing’ services for emergency maternal care in the state is through its Universal Health Insurance Scheme that empanels both for-profit and non-profit hospitals in addition to public facilities. Public and private facilities have left out several pockets without reach to such care. Secondary data suggests that significant out of pocket expenditure persists in private facilities despite insurance cover. However, certain non-profit centers were identified where out of pocket expenditure was negligible. A significant section of such non-profit hospitals is also empanelled under health insurance and it has improved their ability to cover larger load of cases. However, they face a gap in getting timely referrals from public hospitals because state policy on referral transport restricts its use for transporting to public hospitals only. Resolving this gap will require extending the transport facility for identified genuine non-profit centers. Conclusion: Not-for-profit hospitals offer opportunity of strategic purchasing for government, in response to the critical need in emergency maternal care for specific geographies. However, ‘purchasing’ methodologies need to be developed that ensure selection of genuine non-profits for this role.

Poster Slot

D05

13:30-13:40

Why do patients still incur OOPE when they use their health insurance? Lessons for Indian Government’s attempts to attain UHC through its ambitious National Health Insurance program

Presenter : Samir Garg
Abstract ID : A238
POSTER
Improving access and financial-protection for healthcare are important objectives of UHC. Publicly Funded Health Insurance (PFHI) has been adopted as a healthcare-financing measure by many LMICs to meet the above objectives. India has implemented PFHI schemes for more than a decade now. The schemes were meant to provide access to free hospital-care in the private and public sector. Indian Government has recently launched an expanded PFHI programme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) with objectives of reducing Out of Pocket Expenditure (OOPE). It is relevant to understand how the earlier schemes performed and the factors underlying their performance. Since the design of government insurance schemes varies across states, it is important to study the performance of state-specific schemes. Quantitative analysis of Household Survey data was carried out for five states. Special attention was paid to address potential selection issues in insurance enrolment. The findings showed that in none of the five states, government health insurance was effective in curtailing the size of OOPE or incidence of Catastrophic Expenditure. No increase in utilization of hospital-care was found due to insurance enrollment. A large share of utilisation was in private sector hospitals. Even when the patients used insurance, the chances of incurring catastrophic expenditure did not come down. A key reason for persistent OOPE under PFHI was the co-payments charged by private sector hospitals despite the contracts prohibiting such “double-billing”. Empanelment-contracts with hospitals were inadequate for regulation of private sector providers. The insurance benefit was appropriated by the private providers. Just increasing the vertical cover and expanding enrollment may not deliver the intended financial-protection. OOPE in public sector utilisation was several times lower than in private sector, irrespective of cover provided by PFHI. Increasing the share of public-sector in utilisation can help in bringing down the overall OOPE.

Poster Slot

E05

13:30-13:40

Deriving Lessons on Legislating Universal Health Care in the Philippines: a historical perspective

Presenter : Manuel Dayrit
Abstract ID : A127
POSTER
BACKGROUND. In February 2019, the Philippines enacted into law the Universal Health Care (UHC) Act, culminating a 40-year journey that traces its way back to the 1978 Alma Ata declaration. A historical perspective on the process of legislating the UHC Act sheds light on evolving UHC issues and on challenges in legislating health policies in the context of multiple actors. METHODS. Archival work was done to gather documents such as congress proceedings, speeches, news articles, among others. Oral histories were gathered through interviews with stakeholders. RESULTS. From the proposal to the drafting of the Implementing Rules and Regulations (IRR) of the UHC Act, lessons are learned, and challenges in the implementation of the UHC can be extrapolated. Maintaining UHC at the public and political agenda is a volatile process because it is easily manipulated in politics. Conceptualizing the UHC bill involved benchmarking from the best practices of other countries as applicable in our setting A collaborative policy community is critical in successful policy development-- evidence must be brokered by researchers in an understandable and compelling way to policymakers to ensure goals are aligned and provisions are evidence-based. The UHC law, though primarily concerned with health financing reform, must consider other health system components to truly improve health outcomes. A balance of innovation and risk management is key in crafting the IRR. Health sector reform through UHC legislation requires change management: building solidarity, managing resistance, and frontlining champions. CONCLUSION. Reviewing the country’s arduous path toward UHC provides a critical view of public health in the political context, of UHC within the wider scope of the past, and of the potential of the UHC Act as a collective action of multiple sectors. This historical inquiry creates a narrative from which developing countries can springboard towards making UHC a global reality.

Poster Slot

F05

13:40-13:50

Including all migrants in Universal Health Coverage in Thailand: the Migrant Fund (M-FUND), a private low-cost, not-for-profit health insurance

Presenter : NYUNT THEIN
Abstract ID : A125
POSTER
Background: Thailand has achieved Universal Health Coverage (UHC) for its citizens, but many migrants remain excluded from UHC. There are over three million migrants in Thailand, including one million unregistered. Registered migrants can enroll into a government Migrant Health Insurance or the Social Security Scheme, but unregistered migrants cannot. Some registered migrants are also not covered. Methods: We have initiated the Migrant Fund (M-FUND) in Tak province, a voluntary, low-cost, not-for-profit health insurance for uncovered migrants. Community workers enroll migrants using a secured application on tablets. The core plan covers outpatient consultations and inpatient admissions up to 50,000 THB/year, for a premium of 100 THB (3.1 US$)/person/month (ppm). Options can be taken to cover chronic diseases, pregnancy care, and care in seniors (>50 years old) for an additional 200, 100 and 50 THB/ppm respectively. Members receive care in a network of partner facilities who charge the M-FUND monthly. An electronic membership card with coverage details is viewed at partner facilities via scan of a QR-code given to members. Results: Enrollment started in September 2017. As of March 2019, 9,211 persons have joined, 6,564 females (71,3%), 2,647 males (28,7%), and 2,518 children (27.3%). A total of 3,065 members (33.3%) have defaulted, 6,146 (66.7%) remain actively covered, maintaining subscription. Since initiation, 2,094 members (22.7% of enrollees) have sought services, with 6,578 consultations and 1,185 admissions covered. Healthcare cost over premiums collected averages now 2.27, decreasing from 5.98 in November 2017 to 1.54 in January 2019. Satisfaction is high among migrants and partners. Lesson Learned: The M-FUND has shown early success in Tak in extending UHC to migrants uncovered by government insurance, demonstrating value in protecting health, raising awareness on health insurance among migrants, and reducing economic burden on hospitals. We are working to extend the M-FUND in new areas in Thailand.

Poster Slot

A06

13:40-13:50

Job satisfaction of the primary healthcare providers with expanded roles in the context of health service integration in rural China: a cross-sectional mixed methods study

Presenter : Yinzi Jin
Abstract ID : A054
POSTER
Objective: Expanded roles of primary healthcare providers (PCPs) under the integration of public health services and clinic services at primary healthcare (PHC) institutions is a potential challenge to China because it may have direct impact on PCPs’ workload, income and perceived work autonomy thereby influencing their job satisfaction. This study aimed to explore the association between the expanded roles and job satisfaction in the group of PCPs at rural PHC institutions. Methods: We conducted a cross-sectional mixed methods study in 47 THCs in Shandong China, extracting a sample of 1146 PCPs. By using the logistic regression, we estimated the association between the proportion of PCPs’ working time on public health services and PCPs’ self-reported job satisfaction. By conducting qualitative study, we explored the mechanisms in explaining how the expanded roles impacted PCPs’ job satisfaction. Results: 184 physicians and 146 nurses undertook increased work responsibilities, accounting for 15.91% and 12.61% of the total sample. Those with 40-60% (OR=0.199 [0.067–0.587]), 60-80% (OR=0.083 [0.025–0.276]) and more than 80% (OR=0.030 [0.007–0.130]) of working time on public health were negatively associated with job satisfaction. Qualitative analysis illustrated that majority of PCPs with expanded roles reported unsatisfied as they felt high workload, income mismatching with their workload and low work autonomy. The current public health services delivery policy and its separation from regular clinical services delivery work were the major reasons causing the increased work burden for PCPs, which remained a significant challenge for efforts to strengthen the synergy of public health services and clinical services at PHC institutions. Conclusion: Policy-makers should balance the development of clinic and public health departments at institutional level and integrate the financing and supervision mechanisms for both kinds of services at system level to strengthen the synergy of public health services package and routine clinical services.

Poster Slot

B06

13:40-13:50

Exploring Opportunities for Tobacco Tax Reform for Sustaining National Health Insurance of Indonesia

Presenter : Ryan Rachmad Nugraha
Abstract ID : A218
POSTER
Exploring Opportunities for Tobacco Tax Reform for Sustaining National Health Insurance of Indonesia. Background. Indonesia has been experiencing demographic and economic loss due to its long fight with tobacco, over 32% of adults are smokers and nearly one-fifth of children 13-15 smoke. This loss is felt heavily by the newly implemented national health insurance, which needs to cover the burden of tobacco-related disease. The Indonesian National Health Insurance, or Jaminan Kesehatan Nasional (JKN), implemented in 2014, has experienced negative cashflow, which prompts questions about its sustainability. Tobacco taxes and earmark have been regarded internationally as an effective option for controlling tobacco consumption and funding health, This capstone examines why implementation is far from target in Indonesia, and finds this is mainly due to political infeasibility and lack of commitment from stakeholders Significance. This research provides a pivotal qualitative evidence on Indonesian national tobacco tax policy towards viable policy alternatives. This evidence can be utilized to inform decision makers for roadblocks as well as opportunities for better tobacco control tax policy. Methods. This study builds upon Programmatic Qualitative Research (PQR), in which 15 respondents in government departments, academia and NGOs in Indonesia were identified for their expertise. Interviews were conducted using a structured questionnaire to analyze stakeholders’ perception on both of tobacco tax increase and earmark as policy alternatives. Findings were analyzed using a qualitative approach, in which two stage coding, both inductively and deductively, approach was applied. Moreover, framework was developed to address gaps in efforts to sustaining tobacco increase and earmark policies, based on interview results. Results. Based on findings, it is found that 80% of respondents agreed that it is important to pass tobacco tax increase policy, however, only 40% respondents responded positively to allocate the tax for national health insurance (earmark). Out of respondents who stated their agreement, 6 out of 15 respondents believe that the percentage of tobacco tax earmarked to states, as a current policy, is not ideal and somewhat arbitrary; and in fact most amounts are unabsorbed every year. In leveraging the policy to increase tobacco tax uniformly and regularly, opportunities identified include national exposure on the health insurance gaps and policy coherence on health. Threats include fundamental differences across stakeholders and lack of political will. Acknowledging the country’s unique context with regard to the tobacco industry’s influence and forming alliances within the policymaking environment to counter that influence will be important for tobacco control progress in Indonesia. Conclusions. Policy engagement have been an issue within the political environment, thus the need to alleviate the problem pertaining to the stalled of policy progress on tobacco tax must be taken. Building consensus and engaging stakeholders on viable alternatives, while acknowledging the context is pivotal to leverage the tobacco tax policy in Indonesia.

Poster Slot

C06

13:40-13:50

Facility-Based Intervention Costing for the 48 Highest Burden Diseases in the Guaranteed Health Benefits Package of the Philippine Department of Health and the Philippine Health Insurance Corporation

Presenter : Stephanie Anne Lim Co
Abstract ID : A060
POSTER
The Philippines is committed to achieving Universal Health Coverage (UHC) as best concretized by the recent signing of the UHC bill into law. A key component to meet the goals of UHC is the Guaranteed Health Benefits Package (GHBP) which covers for the treatment of the top 48 most burdensome diseases. This study, commissioned by the Department of Health and the Philippine Health Insurance Corporation, aimed to improve the package design by determining the actual direct medical and nonmedical costs per disease to help guide policymakers towards strategic purchasing of goods and services. The researchers planned to cost the provision of healthcare services in local public health facilities with different levels of care nationwide. The Joint Learning Network Step-Down Cost Accounting Model was used to estimate disease-based cost. The study was able to estimate costs per day of treatment in different levels of facilities and costs per treatment of all diseases. More importantly, the research found gaps in the current system that will prevent the government to sustain proper costing in the long run. Extremely varied methods of record-keeping and data management practices, simplification of hospital statistics forms for improved compliance at the expense of tracking pertinent data and the presence of multiple purchasers as sources funding with no clear guidelines on coverage by the national provider cause difficulty in assessing long-term resource utilization. Overall, the research provided an approximation of costs for providing healthcare services but the larger value gained were policy recommendations for action. Improvements in the regulation, standardization and harmonization of records and information systems, the development of a universal cost accounting system and persistently clear identification of cost coverage are the necessary foundations for a more continuous costing effort by the government which will ultimately be the key to long-term financing of UHC.

Poster Slot

D06

13:40-13:50

When publicly-funded health insurance schemes fail to provide financial protection: An indepth study of patients’ experiences from urban slums of Chhattisgarh, India

Presenter : Sulakshana Nandi
Abstract ID : A180
POSTER
In LMICs, state-funded health insurance schemes are increasingly being promoted as vehicles to achieve UHC. Evidence on financial risk protection through such schemes is mixed. Studies in the context of UHC have focused on utilisation and financial protection (or the affordability dimension of access), and less on how this relates to subjective dimensions (acceptability dimension). This study explores the dynamics of access under the publicly-funded universal health insurance scheme in Chhattisgarh, India and specifically the relationship between choice, affordability and acceptability. A qualitative study was undertaken of eight purposefully selected patients from the slums of Raipur City incurring significant heath expenditure despite using insurance. It examined the way these patients and their families sought to navigate and negotiate hospitalisation under the scheme. Patients were hospitalised for a range of reasons and all families, except for one, went into debt as a result of the hospitalisation and use of health insurance. Patients and their family members exercised agency to the extent that they could, engaging in constant negotiation and efforts to navigate the system, from admission to post-hospitalisation. The families faced mounting costs, and increasingly harsh interactions with providers. The research revealed the dynamics underlying failures in promoting affordability and the interactions between choice, affordability and acceptability. The outcomes were produced by a combination of failures of key regulatory mechanisms (the smart card), dominant norms of care as a market transaction (rather than a right), and wider cultural acceptance of illegal informal healthcare payments. The unfavourable normative and cultural context of the private sector provisioning in India needs to be recognised by policy makers seeking to ensure financial risk protection through publicly-funded health insurance. The insights gained from this study have relevance for other states in India and for LMICs with mixed health systems that have introduced publicly-funded health insurance programmes.

Poster Slot

E06

13:40-13:50

Transforming health service delivery models in the Philippines supporting UHC through better hospital and health facility regulation: the role of regulatory impact assessment

Presenter : Katherine Ann Reyes
Abstract ID : A035
POSTER

Poster Slot

F06

SESSION 4

15:10-15:20

Achieving universal health coverage for marginalized communities: lessons learnt from indigenous communities in south India.

Presenter : Mathew Sunil George
Abstract ID : A216
POSTER
Limited access to healthcare combined with the higher burden of disease known to be experienced by Indigenous communities significantly reduces their quality of life and well-being. Work carried out among Indigenous communities in Kerala, south India shows that financial protection and coverage of healthcare services alone will not lead to effective UHC. What is important is that local health systems meaningfully involve Indigenous communities as equal partners in the various stages of conceptualising and implementing measures to improve access to healthcare in a culturally safe environment.

Poster Slot

A07

15:10-15:20

Assessment of Policy Initiatives on Rural Health Practitioner Cadre for Primary Health Care in Chhattisgarh state of India

Presenter : Narayan Tripathi
Abstract ID : A256
POSTER
Context: WHO recommends a threshold of 4.45 physicians, nurses and midwives per 1,000 population. In India, the doctor-patient ratio was 1:2,000 in urban areas; in contrast to 1:20,000 in rural areas. Chhattisgarh state in India faced uphill challenges in convincing doctors to serve in rural areas. To fill the need of clinical care providers in rural areas, Chhattisgarh state designed a special cadre of health care providers called ‘Rural Medical Assistants’ (RMA) to provide primary care in rural Primary Health Centers (PHCs). A study was undertaken to assess the improvement in primary health care over one decade of RMA cadre serving in PHCs. Methods: RCH indicators from two rounds of National Family Health Survey were analyzed to compare the progress in state indicators as a measurement of RMA performance. Service data was analyzed from Health Management Information System. Result: More than 1200 RMAs provided clinical care in remote and rural areas. Between 2008 to 2013, coverage of outpatient cases increased 2.5 times. For ante-natal care coverage, the state climbed to second position among all states by 2016. Average out of pocket expenditure (OOPE) per delivery in Chhattisgarh was 1480 Indian Rupees in 2015-16 as compared to national average of 2905 Indian Rupees. 73% of the prescriptions written by RMAs were of generic medicines, slightly better than other providers. Assessments found that the skills of RMAs were adequate to provide primary care. Discussion: National Health Policy of India, 2017 recommends Health and Wellness Centers to strengthen primary care for UHC. The concept of a Mid-level care provider is at the core of this policy. The policy is to get nursing graduates to undergo a 6-month bridge course to become eligible to work as mid-level care providers. This component can get informed by experience gained during development of RMA cadre.

Poster Slot

B07

15:10-15:20

Better understanding the issues around out-of-pocket spending in medicines: an analysis of medicines sales data in four South East Asian countries

Presenter : Lluis Vinals Torres
Abstract ID : A098
POSTER

Poster Slot

C07

15:10-15:20

The Challenges of Producing Evidence to Guide UHC expansion: Lessons Learned from Senegal

Presenter : Sophie Faye
Abstract ID : A138
POSTER

Poster Slot

D07

15:10-15:20

Achieving the mortality reduction targets for SDG3: intervention financing and coverage requirements

Presenter : Rachel Nugent
Abstract ID : A224
POSTER

Poster Slot

E07

15:10-15:20

A Study on Factors Influencing Drug Prices Among National Public Hospitals

Presenter : Cheyenne Ariana Modina
Abstract ID : A070
POSTER
In the Philippines, the prices of essential medicines have high variability, which causes a significant portion of Filipino’s out-of-pocket expenditures for medicines. This study determines the factors associated with the variation in drug prices; it also aims to uncover the different gaps in the drug management cycle, to identify key stakeholders involved in the decision-making of drug prices, and to describe the current challenges in implementing the Drug Price Reference Index (DPRI). Two tools were adapted in this mixed-method, case-control research. These tools are based on the Management Sciences for Health (MSH)’s Rapid Pharmaceutical Management Assessment and the World Health Organization (WHO)’s Good Pharmaceutical Practices (GPP). The tool patterned from MSH is to compute for the price ratio based on the DPRI, while the WHO tool is a checklist to gauge the compliance of hospitals using the principles of good procurement practices. Results showed that compliance with the DPRI is low among hospitals given that only 44% follow the index. There are several factors behind this. First, lower drug prices are associated with the use of staff with appropriate expertise (WHO GPP 1) in the selection phase. Next, hospitals with an existing system to order drugs, a management information system, and regular reports on the purchases procure drugs cheaper than others; this principle is also known as proper procurement planning and performance monitoring (WHO GPP 3). Lastly, the use of competitive bidding as a mode of procurement is also associated to lower drug prices. Uncovering the factors that lead to high variation in drug prices promotes good governance, transparency, and accountability from the different national hospitals to DOH. Using the WHO GPP tool enables good-decision making for proper service delivery. Ultimately, equitable access and affordable drug prices are necessary for UHC and achieving the Sustainable Development Goals.

Poster Slot

F07

15:20-15:30

Affordable Essential Diagnostic Services to Achieve Universal Health Coverage: Should Governments Outsource them or Strengthen In-house Provisioning?

Presenter : Narayan Tripathi
Abstract ID : A247
POSTER
Background: Without adequate access to affordable diagnostics, rational care and hence meaningful universal coverage cannot be achieved. Chhattisgarh state in India is yet to roll out a program for universal free access to essential diagnostics. Health facilities charged user fee from patients, whereas a large part of earmarked funds from government remained un-utilized. There have been multiple attempts to outsource diagnostic services to private agencies and alongside the state has tried to strengthen in-house provisioning through public laboratories in selected districts. A study was undertaken to assess the effectiveness and challenges in both above approaches. Methodology: This study triangulated a variety of data sources including program documents, patient surveys and facility surveys. It was combined with qualitative analysis of stakeholders’ interviews. Results: Laboratory strengthening project demonstrated that with capacity building interventions; motivation and skills of laboratory human resources improved resulting in increase in outputs. Two main challenges emerged – supply-chain for reagents and governance of laboratory services. Other states in India have shown that through appropriate organization of services such challenges can be overcome. While overall availability of tests increased under outsourcing, it posed problems of existing government staff becoming redundant, unnecessary tests getting prescribed, quality becoming difficult to monitor and cost-escalation. Discussion: There is a contestation between ideas of public provisioning versus outsourcing in the domain of essential diagnostics services. The experience in Chhattisgarh shows that strengthening public provisioning can be a viable and cost-effective option but not an easy one. A mix of strategies is needed to address the systemic weaknesses –supplies, skills and leadership. The study provides lessons for this neglected but essential part of health system. Existing literature indicates better success of outsourcing for non-clinical services compared to clinical care. Diagnostics is a supportive service but is close enough to clinical care to pose similar challenges.

Poster Slot

B08

15:20-15:30

Sustainable health systems and sustainable markets: Assuring the quality of medicine in pursuit of UHC

Presenter : Steven Harsono
Abstract ID : A150
POSTER

Poster Slot

C08

15:20-15:30

Intervention Scoping Addressing the Top 48 Philippine Disease Burden

Presenter : Abigail Tan
Abstract ID : A050
POSTER
After the identification of the 48 most high burden diseases in the Philippines, the country’s Department of Health (DOH) needed a list of the most cost-effective interventions addressing them. This list of interventions would then be reviewed for inclusion in the Guaranteed Health Benefits Package (GHBP), which aims to help the country take a major step towards universal health care. “Intervention Scoping Addressing the Top 48 Philippine Disease Burden” provided a candidate list of 743 cost-effective and feasible interventions through a systematic scoping review of literature on cost-effective interventions and their respective resource requirements. In contrast to other countries who have already developed such a package, the Philippines is working towards filling gaps that have resulted from the ad hoc expansion of benefit packages, which led to increases in government expenditures but did not translate into any improvement in health outcomes. The experience of the Philippines is a lesson for other countries at a similar situation, and how they can proceed in developing those minimum guarantees. The researchers utilized a mixed methods approach, utilizing various sources in literature like the Disease Control Priorities (DCP) 2/3, the WHO CHOosing Interventions that are Cost-Effective (CHOICE), local Clinical Practice Guidelines, and expert opinion. Interventions were screened and appraised according to local applicability and quality of being evidence-based for inclusion and analysis in the study. These individual interventions categorized by life stages and by level of intervention are potential targets for the GHBP, but policymakers should still review their inclusion for reimbursement considering the following factors: the appropriateness of the context in which the cost-effectiveness study was conducted, the feasibility of conducting primary health technology assessment (HTA) locally, the local costs of the intervention, and the need to act quickly before the policy window closes.

Poster Slot

D08

15:20-15:30

Questing for Sustainable Fiscal Space of Universal Health Coverage

Presenter : Theepakorn Jithitikulchai
Abstract ID : A105
POSTER
Thailand is a champion of the universal health coverage. However, there are challenges for equitable, efficient, and sustainable universal coverage arising from demographic and epidemiological transitions and economic development. This study conducts fiscal space analysis for Thailand by looking at the public health financing levels and trends and incorporating demographic and epidemiologic trends as well as macroeconomic context. The study uses a policy approach for financing the bottom-up expansion of UHC to consider the population coverage by UHC, the risk profile of beneficiaries and their utilization rates, costs of inputs, nature and extent of benefits provided, and how the health system is organized and financed.

Poster Slot

E08

15:20-15:30

Setting performance-based financing in the health sector agenda: a case study in Cameroon.

Presenter : Isidore Sieleunou
Abstract ID : A153
POSTER
Background More than 30 countries in sub-Saharan Africa have introduced performance-based financing (PBF) in their healthcare systems. Yet, there has been little research on the process by which PBF was put on the national policy agenda in Africa. This study examines the policy process behind the introduction of PBF program in Cameroon. Methods The research is an explanatory case study using the Kingdon multiple streams framework. We conducted a document review and 25 interviews with various types of actors involved in the policy process. We conducted thematic analysis using a hybrid deductive-inductive approach for data analysis. Results By 2004, several reports and events had provided evidence on the state of the poor health outcomes and health financing in the country, thereby raising awareness of the situation. As a result, decision-makers identified the lack of a suitable health financing policy as an important issue that needed to be addressed. The change in the political discourse toward more accountability made room to test new mechanisms. A group of policy entrepreneurs from the World Bank, through numerous forms of influence (financial, ideational, network and knowledge-based) and building on several ongoing reforms, collaborated with senior government officials to place the PBF program on the agenda. The policy changes occurred as the result of two open policy windows (i.e. national and international), and in both instances, policy entrepreneurs were able to couple the policy streams to effect change. Conclusion The policy agenda of PBF in Cameroon underlined the importance of a perceived crisis in the policy reform process and the advantage of building a team to carry forward the policy process. It also highlighted the role of other sources of information alongside scientific evidence (eg.: workshop and study tour), as well as the role of previous policies and experiences, in shaping or influencing respectively the way issues are framed and reformers’ actions and choices.

Poster Slot

F08