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Aims We examined the extent to which associations between education and cardiovascular disease (CVD) morbidity and mortality are attributable to income and work stress. Methods and results We included all employed Danish residents aged 30–59 years in 2000. Cardiovascular disease morbidity analyses included 1 638 270 individuals, free of cardiometabolic disease (CVD or diabetes). Mortality analyses included 41 944 individuals with cardiometabolic disease. We assessed education and income annually from population registers and work stress, defined as job strain, with a job-exposure matrix. Outcomes were ascertained until 2014 from health registers and risk was estimated using Cox regression. During 10 957 399 (men) and 10 776 516 person-years (women), we identified 51 585 and 24 075 incident CVD cases, respectively. For men with low education, risk of CVD was 1.62 [95% confidence interval (CI) 1.58–1.66] before and 1.46 (95% CI 1.42–1.50) after adjustment for income and job strain (25% reduction). In women, estimates were 1.66 (95% CI 1.61–1.72) and 1.53 (95% CI 1.47–1.58) (21% reduction). Of individuals with cardiometabolic disease, 1736 men (362 234 person-years) and 341 women (179 402 person-years) died from CVD. Education predicted CVD mortality in both sexes. Estimates were reduced with 54% (men) and 33% (women) after adjustment for income and job strain. Conclusion Low education predicted incident CVD in initially healthy individuals and CVD mortality in individuals with prevalent cardiometabolic disease. In men with cardiometabolic disease, income and job strain explained half of the higher CVD mortality in the low education group. In healthy men and in women regardless of cardiometabolic disease, these factors explained 21–33% of the higher CVD morbidity and mortality. Open in new tab Download slide Open in new tab Download slide [ABSTRACT FROM AUTHOR]

Timely access to effective contraception reduces the incidence of unintended pregnancy. Cost is a significant barrier to using contraception for youth in Canada. Many must pay out-of-pocket because they have no pharmaceutical insurance, their insurance does not cover the contraceptives they desire, or they wish to obtain contraceptives without their parents' knowledge. To address these barriers and reduce rates of unintended pregnancy, this statement recommends that all youth should have confidential access to contraception, at no cost, until the age of 25. The statement also recommends measures to help achieve this goal across Canada. [ABSTRACT FROM AUTHOR]

L'accès opportun à une contraception efficace réduit l'incidence de grossesses non désirées. Le coût est un obstacle important à la contraception chez les jeunes du Canada. Bon nombre doivent payer leur contraception de leur poche puisqu'ils n'ont pas d'assurance médicaments, que leur assurance ne rembourse pas les contraceptifs qu'ils souhaitent prendre ou qu'ils désirent se procurer des contraceptifs à l'insu de leurs parents. Pour corriger ces obstacles et réduire le taux de grossesses non désirées, le présent document de principes recommande que tous les jeunes aient accès à la contraception confidentiellement et sans frais jusqu'à l'âge de 25 ans et présente des mesures pour réaliser cet objectif partout au Canada. [ABSTRACT FROM AUTHOR]

The past two decades have witnessed unprecedented policy effort to improve access to medical services and strengthen financial protection from catastrophic healthcare expenditure. Despite billions of dollars in health spending, many – especially across the developing world – continue to remain vulnerable to financial impoverishment. What accounts for this poor performance? To respond to this question, we turn to the design literature in public policy, which emphasises the role of policy tools or combination of tools in addressing a social problem. In this paper, we focus on two inter-related aspects of the design orientation to explain outcomes: a) the appropriateness of the policy tool and b) the capacity of government agencies. We apply a framework, which integrates vital questions on both these aspects along three common dimensions (analytical, operational and political) to assess healthcare reforms in India and Thailand. The case studies illustrate the importance of both these aspects of the design orientation in explaining outcomes, and show how they are commonly overlooked in the health and social policy literatures, and in reforms underway. [ABSTRACT FROM AUTHOR]

This paper seeks to systematically describe the length and content of quality checklists used in performance-based financing programmes, their similarities and differences, and how checklists have evolved over time. We compiled a list of supply-side, health facility-based performance-based financing (PBF) programmes in low- and lower middle-income countries based on a document review. We then solicited PBF manuals and quality checklists from implementers and donors of these PBF mechanisms. We entered each indicator from each quality checklist into a database verbatim in English, and translated into English from French where appropriate, and categorized each indicator according to the Donabedian framework and an author-derived categorization. We extracted 8,490 quality indicators from 68 quality checklists across 32 PBF implementations in 28 countries. On average, checklists contained 125 indicators; within the same program, checklists tend to grow as they are updated. Using the Donabedian framework, 80% of indicators were structure-type, 19% process-type, and less than 1% outcome-type. The author-derived categorization showed that 57% of indicators relate to availability of resources, 24% to managing the facility and 17% assess knowledge and effort. There is a high degree of similarity in a narrow set of indicators used in checklists for common service types such as maternal, neonatal and child health. We conclude that performance-based financing offers an appealing approach to targeting specific quality shortfalls and advancing toward the Sustainable Development Goals of high quality coverage. Currently most indicators focus on structural issues and resource availability. There is scope to rationalize and evolve the quality checklists of these programs to help achieve national and global goals to improve quality of care. [ABSTRACT FROM AUTHOR]

Background: Primary health care (PHC) renewal processes are currently ongoing in South America (SA), but their characteristics have not been systematically described.Objective: The study aimed to describe and contrast the PHC approaches being implemented in SA to provide knowledge of current conceptions, models and challenges.Methods: This multiple case study used a qualitative approach with technical visits to health ministries in order to apply key-informant interviews of 129 PHC national policy makers and 53 local managers, as well as field observation of 57 selected PHC providers and document analysis, using a common matrix for data collection and analysis. PHC approaches were analysed by triangulating sources using the following categories: PHC philosophy and conception, service provision organization, intersectoral collaboration and social participation.Results: Primary health care models were identified in association with existing health system types and the dynamics of PHC renewal in each country. A neo-selective model was found in three countries where coverage is segmented by private and public regimes; here, individual and collective care are separated. A comprehensive approach similar to the Alma-Ata model was found in seven countries where the public sector predominates and individual, family and community care are coordinated under the responsibility of the same health care team.Conclusions: The process of implementing a renewed PHC approach is affected by how health systems are funded and organized. Both models face many obstacles. In addition, care system organization, intersectoral coordination and social participation are weak in most of the countries. [ABSTRACT FROM AUTHOR]

Objective The objective of this article is to assess the impact of the new health financing reform in Georgia--'medical insurance for the poor (MIP)'--which uses private insurance companies and delivers state-subsidized health benefits to the poorest groups of the Georgian population. Methods To evaluate the reform we looked at access to health care services and financial protection against health care costs, which are two key dimensions proposed for the universal coverage plans. The data from two nationally representative Health Utilization and Expenditure Surveys (2007 and 2010) were used, and a difference-in- difference method of evaluation was applied. Findings The MIP was not found to have a significant impact on service utilization growth nationwide, but in the capital city the MIP insured were 12% more likely to use formal health services and 7.6% more likely to use hospitals as compared with other areas of the country. The MIP impact on out-of-pocket health expenditures was greater in reducing costs of accessing services. The cost reductions were sizable and more pronounced among the poorest. Finally, the MIP significantly increased the odds of obtaining free benefits by insured individuals as compared with the control group. Such an increase was most noticeable for the poorest third of the population. Conclusions Marginal changes in access to services and the geographically diverse impact of the MIP on service utilization points to other factors affecting health-seeking behaviour of the insured. These other factors include private insurer behaviour that may have used strategies for reducing claims and managing utilization. Equity impact of the MIP and improved financial protection, especially for the poor, are benefits to be retained by government policies when universal health coverage is rolled out nationwide and all citizens will be covered. The role of private insurance companies as financial intermediaries of the publicly funded programme needs further evaluation before moving forward. [ABSTRACT FROM AUTHOR]

Purpose Low- and middle-income countries are increasingly pursuing health financing reforms aimed at achieving universal health coverage. As these countries rapidly expand access to care, overburdened health systems may fail to deliver high-quality care, resulting in poor health outcomes. Public insurers responsible for financing coverage expansions have the financial leverage to influence the quality of care and can benefit from guidance to execute a cohesive health-care quality strategy. Data sources and selection Following a literature review, we used a cascading expert consultation and validation process to develop a conceptual framework for insurance-driven quality improvements in health care. Results of data synthesis The framework presents the strategies available to insurers to influence the quality of care within three domains: ensuring a basic standard of quality, motivating providers and professionals to improve, and activating patient and public demand for quality. By being sensitive to the local context, building will among key stakeholders and selecting context-appropriate ideas for improvement, insurers can influence the quality through four possible mechanisms: selective contracting; provider payment systems; benefit package design and investments in systems, patients and providers. Conclusion This framework is a resource for public insurers that are responsible for rapidly expanding access to care, as it places the mechanisms that insurers directly control within the context of broader strategies of improving health-care quality. The framework bridges the existing gap in the literature between broad frameworks for strategy design for system improvement and narrower discussions of the technical methods by which payers directly influence the quality. [ABSTRACT FROM PUBLISHER]

Extending coverage to the informal sector is a key challenge to achieving universal coverage through contributory health insurance schemes. Ghana introduced a mandatory National Health Insurance system in 2004 to provide financial protection for both the formal and informal sectors through a combination of taxes and annual premium payments. As part of its election promise in 2008, the current government (then in opposition) promised to make the payment of premiums ‘one-time’. This has been a very controversial policy issue in Ghana. This study sought to contribute to assessing the feasibility of the proposed policy by exploring the understandings of various stakeholders on the policy, their interests or concerns, potential positions, power and influences on it, as well as the general prospects and challenges for its implementation. Data were gathered from a review of relevant documents in the public domain, 28 key informant interviews and six focus group discussions with key stakeholders in Accra and two other districts. The results show that there is a lot of confusion in stakeholders’ understanding of the policy issue, and, because of the uncertainties surrounding it, most powerful stakeholders are yet to take clear positions on it. However, stakeholders raised concerns that revolved around issues such as: the meaning of a one-time premium within an insurance scheme context, the affordability of the one-time premium, financing sources and sustainability of the policy, as well as the likely impact of the policy on equity in access to health care. Policy-makers need to clearly explain the meaning of the one-time premium policy and how it will be funded, and critically consider the concerns raised by stakeholders before proceeding with further attempts to implement it. For other countries planning universal coverage reforms, it is important that the terminology of their reforms clearly reflects policy objectives. [ABSTRACT FROM AUTHOR]

Objective To understand the Iranian health financing system and provide lessons for policy makers about achieving universal coverage.Methods Twenty-five interviewees from seven major health insurance companies were selected for a qualitative study in 2007. Using a semi-structured interview, three main tasks of the health financing system (revenue collection, risk pooling and purchasing) were investigated. A framework method was applied for the data analysis.Results The results of the study show the following seven major obstacles to universal coverage: unknown insured rate; regressive financing and non-transparent financial flow; fragmented and non-compulsory system; non-scientifically designed benefit package; non-health-oriented and expensive payment system; uncontrolled demands; and administrative deficiency. A long-term systematic plan is required to address the above problems. [ABSTRACT FROM PUBLISHER]

In 2007, Massachusetts instituted a universal coverage health plan that requires all citizens to purchase insurance. I argue that there is nothing wrong in principle with the use of an individual mandate to force citizens to secure health insurance. I argue that state neutrality is not tenable on this issue. Then I proceed to show that even if state neutrality were viable, it is not a violation of state neutrality (thought of as neutrality of intent) to force citizens to insure themselves with the primary purpose of securing the normative good of health. I adapt recent work on universal medical coverage to demonstrate that such a mandate is in keeping with several principles of fairness shared in liberal democratic societies. This argument not only applies to the Massachusetts plan but likely to any other health care coverage schemes using individual mandates in the US political context, including recently passed federal health care reform measures. However, even though the Massachusetts plan may provide increased access to health care for many, there are still legitimate worries that it currently places disproportionate financial burdens on the working poor and thus will need refinement. [ABSTRACT FROM PUBLISHER]

This article examines barriers to and prospects for universal health coverage in the U.S. On September 22, 1993, U.S. President Bill Clinton, in a televised address, introduced the Health Security Act (HSA), which would have provided universal health care coverage. The author identifies major obstacles and possible routes to universal coverage, addresses current problems with the U.S. health care system, and discusses the debate over Medicare and Medicaid. The history of the HSA provides insight into barriers to universal coverage in the U.S. Perhaps the chief obstacle is the lack of political support for health care reformers. Another obstacle to universal coverage is opposition from powerful interest groups. A final obstacle was the lack of a crisis that would motivate people to change the health care system. The U.S. health care system continues to have serious problems, particularly in the area of coverage. First, 40.3 million people lack health insurance, and 29 million people have inadequate coverage. Second, health care costs remain a problem. And third, the U.S. faces the corporatization of health care and the subjection of medicine to the morality of the marketplace.

This article reviews the experience of British social workers with the National Health Service (NHS). In 1948 Great Britain passed major social welfare legislation, including the National Assistance Act, which laid the foundation for local welfare departments, the Children's Act, which provided comprehensive services for children needing care and the National Health Services Act, which provided universal health care for the entire population. At this time almost half of the population was covered by some health insurance. But many wives, children and older people were excluded. The NHS included hospital services, outpatient services provided by general practitioners and family doctors and aftercare services provided by local authorities. Public health services were to continue to be provided through local government authorities and medically related services such as the provision of wheelchairs, home nursing and so forth were also provided locally. From the outset, the role of central government versus the role of local government in the British health care system was vigorously debated. The role of the local authorities had major ramifications for social workers as issues of distribution of authority and responsibility and the organization of health care unfolded over several decades.

Modelling the likely financial resource requirements and potential sources of revenue for health system reform options is of great potential value to policy-makers. Models provide an indication of the financial feasibility and sustainability of such reforms and highlight the implications of alternative reform paths. There has been increasing use of financial models of health sector reform in recent years, particularly since the development of user-friendly software such as SimIns, which was developed by the World Health Organization (WHO) and Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ). This paper outlines the process of developing country-specific spreadsheet-based models to explore the financial resource requirements of health system reform options in South Africa and Tanzania. Building one's own model, although time consuming, allows for greater flexibility and forces the analysts to give careful consideration to the assumptions underlying the model. The core variables in our models are: population, health service utilization rates and unit costs. The paper outlines the types of disaggregation of these variables, the range of possible data sources, key challenges with securing accurate data for each variable, and relevant evidence on which to base key assumptions, and how we went about addressing these challenges. We also briefly review how to model the revenue-generating potential of alternative sources of health care financing. The intention of the paper is to provide guidance for analysts who wish to develop their own models, and to illustrate, with reference to the South African and Tanzanian modelling experience, how one has to adapt to data constraints and context-specific modelling requirements. [ABSTRACT FROM AUTHOR]

Stakeholder analysis is widely recommended as a tool for gathering insights on policy actor interests in, positions on, and power to influence, health policy issues. Such information is recognized to be critical in developing viable health policy proposals, and is particularly important for new health care financing proposals that aim to secure universal coverage (UC).However, there remain surprisingly few published accounts of the use of stakeholder analysis in health policy development generally, and health financing specifically, and even fewer that draw lessons from experience about how to do and how to use such analysis. This paper, therefore, aims to support those developing or researching UC reforms to think both about how to conduct stakeholder analysis, and how to use it to support evidence-informed pro-poor health policy development. It presents practical lessons and ideas drawn from experience of doing stakeholder analysis around UC reforms in South Africa and Tanzania, combined with insights from other relevant material. The paper has two parts. The first presents lessons of experience for conducting a stakeholder analysis, and the second, ideas about how to use the analysis to support policy design and the development of actor and broader political management strategies.Comparison of experience across South Africa and Tanzania shows that there are some commonalities concerning which stakeholders have general interests in UC reform. However, differences in context and in reform proposals generate differences in the particular interests of stakeholders and their likely positioning on reform proposals, as well as in their relative balance of power. It is, therefore, difficult to draw cross-national policy comparisons around these specific issues. Nonetheless, the paper shows that cross-national policy learning is possible around the approach to analysis, the factors influencing judgements and the implications for, and possible approaches to, management of policy processes. Such learning does not entail generalization about which UC reform package offers most gain in any setting, but rather about how to manage the reform process within a particular context. [ABSTRACT FROM AUTHOR]

A model was developed to assess the impact of possible moves towards universal coverage in Tanzania over a 15-year time frame. Three scenarios were considered: maintaining the current situation (‘the status quo’); expanded health insurance coverage (the estimated maximum achievable coverage in the absence of premium subsidies, coverage restricted to those who can pay); universal coverage to all (government revenues used to pay the premiums for the poor). The model estimated the costs of delivering public health services and all health services to the population as a proportion of Gross Domestic Product (GDP), and forecast revenue from user fees and insurance premiums. Under the status quo, financial protection is provided to 10% of the population through health insurance schemes, with the remaining population benefiting from subsidized user charges in public facilities. Seventy-six per cent of the population would benefit from financial protection through health insurance under the expanded coverage scenario, and 100% of the population would receive such protection through a mix of insurance cover and government funding under the universal coverage scenario. The expanded and universal coverage scenarios have a significant effect on utilization levels, especially for public outpatient care. Universal coverage would require an initial doubling in the proportion of GDP going to the public health system. Government health expenditure would increase to 18% of total government expenditure. The results are sensitive to the cost of health system strengthening, the level of real GDP growth, provider reimbursement rates and administrative costs. Promoting greater cross-subsidization between insurance schemes would provide sufficient resources to finance universal coverage. Alternately, greater tax funding for health could be generated through an increase in the rate of Value-Added Tax (VAT) or expanding the income tax base. The feasibility and sustainability of efforts to promote universal coverage will depend on the ability of the system to contain costs. [ABSTRACT FROM AUTHOR]

South Africa is considering introducing a universal health care system. A key concern for policy-makers and the general public is whether or not this reform is affordable. Modelling the resource and revenue generation requirements of alternative reform options is critical to inform decision-making. This paper considers three reform scenarios: universal coverage funded by increased allocations to health from general tax and additional dedicated taxes; an alternative reform option of extending private health insurance coverage to all formal sector workers and their dependants with the remainder using tax-funded services; and maintaining the status quo. Each scenario was modelled over a 15-year period using a spreadsheet model. Statistical analyses were also undertaken to evaluate the impact of options on the distribution of health care financing burden and benefits from using health services across socio-economic groups. Universal coverage would result in total health care spending levels equivalent to 8.6% of gross domestic product (GDP), which is comparable to current spending levels. It is lower than the status quo option (9.5% of GDP) and far lower than the option of expanding private insurance cover (over 13% of GDP). However, public funding of health services would have to increase substantially. Despite this, universal coverage would result in the most progressive financing system if the additional public funding requirements are generated through a surcharge on taxable income (but not if VAT is increased). The extended private insurance scheme option would be the least progressive and would impose a very high payment burden; total health care payments on average would be 10.7% of household consumption expenditure compared with the universal coverage (6.7%) and status quo (7.5%) options. The least pro-rich distribution of service benefits would be achieved under universal coverage. Universal coverage is affordable and would promote health system equity, but needs careful design to ensure its long-term sustainability. [ABSTRACT FROM AUTHOR]

A desire to enhance protection against health care costs and improve equity of access to health care lies at the core of many health sector financing initiatives. Until recently, international debates about financing and health equity have focused primarily on mechanisms to promote equity in relation to very specific elements of health systems. However, in recent years there has been growing interest in considering these equity challenges from a more systemic perspective. In this context, universal health coverage is becoming a rallying call, with a focus on how best universal coverage can be financed. This paper is the first in a special issue which presents a body of research whose overall aim was to critically evaluate existing inequities in health care financing and provision in Ghana, South Africa and Tanzania, and the extent to which health insurance mechanisms (broadly defined) could address financial protection and equity of access challenges. In this first paper we introduce the countries’ health systems, with a special emphasis on existing mechanisms for financial protection. We also identify in broad terms the key challenges for universal coverage, setting the scene for the subsequent papers. [ABSTRACT FROM AUTHOR]

In October 2001 Thailand introduced universal healthcare coverage (UC) financed by general tax revenue. This paper aims to assess the design and content of the UC benefit package, focusing on the part of the package concerned with sexual and reproductive health (SRH). The economic concept of need, demand and supply in the process of developing the SRH package was applied to the analysis. [ABSTRACT FROM AUTHOR]