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Abstract: Nurse practitioners (NPs) take on diverse and essential roles. In an exclusive interview, Representative Tarik Khan, PhD, FNP-BC, highlights the impact NPs can have in the political arena. Transitioning from an NP to a legislator in Pennsylvania, Dr. Khan's journey reflects his commitment to health care reform, driven by hospital closures, lack of patient care access, and the COVID-19 pandemic. Elected in 2022, Dr. Khan leverages his health care background to address a wide range of legislative issues, passing significant bills. He advocates for NPs to engage politically, emphasizing their unique perspective and problem-solving skills. Dr. Khan's story underscores the transformative potential of NPs in shaping public policy and advancing systemic change., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2024 American Association of Nurse Practitioners.)

Incremental health system transformations towards universal health coverage run the risk of losing sight of the overarching objectives and can lose momentum in the implementation process. Argentina's Programa Sumar is a program born out of response to both urgent and long-standing health challenges. Starting with a relatively small share of the government's budget for health, the Program over the last 20 years has gradually expanded in pursuit of increasing access to quality health care, fostering coherence through policy alignment and coordination in a highly decentralized system, and achieving its performance objectives through conditional transfers linked to results. This commentary reflects on how Programa Sumar created and has sustained its approach to health system transformation and provides four lessons: 1) distribute leadership across levels of government to enhance autonomy, collaboration, and implementation; 2) expand gradually, with a clear long-term vision - Programa Sumar took an incremental approach to expansion in terms of regions, populations, services, and management capacities; 3) ensure evolution through solid and flexible design - the Program needed both the flexibility to adapt strategies to various challenges and a constancy of purpose; and 4) compromise to make progress. The Argentine experience with Programa Sumar shows that strengthening a scheme does not have to mean adopting a fragmented approach. Instead, by implementing Programa Sumar thoughtfully and collaboratively, the reform has developed a solid foundation with the flexibility to adapt across geographies and time, creating the necessary conditions for expansion to and greater coherence across the entire system.

Health financing fragmentation poses a challenge to reforms intended to address system-wide objectives vis-à-vis universal health coverage (UHC). India's experience with publicly subsidized health insurance schemes (PSHIs), such as Rashtriya Swasthya Bima Yojana (RSBY) and its state adaptations, testify to the challenges inherent in effecting objective-oriented health systems reforms, particularly owing to wide variation in programmatic and operational design. Recent efforts to defragment PSHIs under the aegis of a new government initiative called Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) using, inter alia, a unified information and communication technology (ICT) interface provide important policy lessons. This paper presents a theory of change for the role that ICT systems can play in promoting the objectives of UHC and highlights the early effects of ICT reforms in India on UHC. Holistic and defragmented ICT systems have a positive effect on the processes and operations of government health programs, according to the literature reviewed. Streamlined ICT systems promote equity through the introduction of portability modules, which increase access to services and facilitate stronger transparency and accountability measures by using big data and machine learning for fraud detection. Although reliability issues persist on certain fronts, India's experience with homegrown, incremental reforms to defragment ICT systems for health financing have proven of paramount importance for progressing toward UHC.

South Korea is one of the few countries that has successfully consolidated its national risk pools into a single-payer health insurance system. This study analyzes national health insurance (NHI) consolidation in South Korea between 1980 and 2003, drawing lessons for countries seeking to consolidate their risk pools. The paper contextualizes the development of the South Korean national health insurance system and the consolidation of its risk pools in the changes in the political environment, particularly the processes of political democratization. It examines how these processes have affected the societal meanings and roles of the health insurance system. The paper focuses on two policy stages. During the agenda-setting stage, the government and employers emphasized the efficiency of the health insurance system. This emphasis contributed to the failure of a consolidation plan that emphasized equity over efficiency. However, as democratization expanded, the power of civil society movements and the popular demand for equity grew stronger. During the policy adoption phase, consolidation of health insurance trusts in South Korea was achieved through social and political processes that influenced public opinion, expanded civil society participation in decision-making, and worked with the government to integrate health insurance organizations and funds.

Background: This paper is one of a collection on challenges facing health systems in the future. One obvious challenge is how to transform to meet changing health needs and take advantage of emerging treatment opportunities. However, we argue that effective transformations are only possible if there is trust in the health system., Main Body: We focus on three of the many relationships that require trust in health systems, trust by patients and the public, by health workers, and by politicians. Unfortunately, we are seeing a concerning loss of trust in these relationships and, for too long, the importance of trust to health policymaking and health system functioning has been overlooked and under-valued. We contend that trust must be given the attention, time, and resources it warrants as an indispensable element of any health system and, in this paper, we review why trust is so important in health systems, how trust has been thought about by scholars from different disciplines, what we know about its place in health systems, and how we can give it greater prominence in research and policy., Conclusion: Trust is essential if health systems are to meet the challenges of the 21st century but it is too often overlooked or, in some cases, undermined., (© 2024. The Author(s).)

While South Africa has some experience in various forms of health technology assessment (HTA), it is currently fragmented across numerous players. Additionally, there is a lack of systematic and consistently applied HTA processes that inform priority-setting and budget allocations. To address this, the country is journeying toward more institutionalized use of HTA. This will begin with the establishment of a Ministerial Advisory Committee on HTA for National Health Insurance (NHI) and will gradually embed HTA processes in decision-making. The goal is to create an independent HTA agency. Although these reforms will be intrinsically linked to the wider health financing reforms envisaged under NHI, such as formulating the benefits package, they will also assist in strengthening South Africa's health system. As a country facing a highly constrained fiscal environment, with limited space for additional funding for the health sector, evidence-based priority-setting will be critical to ensure that value for money is achieved in the government's investments in health care services in NHI.

China's health system is facing severe challenges from social transition and the double burden of population aging and non-communicable diseases. Addressing the tension between the public's increasing demand for health services and the limited availability of medical resources has become a critical issue for health care policymakers and medical insurance fund administrators. In promoting its medical insurance system reform, China is actively developing health technology assessment (HTA) with principles and applications adapted to the Chinese context. This study aims to analyze the evolution of HTA in China with a focus on context, actors, process, content, and challenges encountered through applying a modified verson of Walt and Gilson's policy triangle framework. Currently, HTA plays an indispensable part in the reform of China's health care and medical insurance system, especially in the formulation and adjustment of the National Reimbursement Drug List (NRDL). While HTA is increasingly used in China, there remain challenges, such as the slow development of HTA related disciplines, lack of an independent national HTA authority, and limited scope in the use of HTA. Despite the identified challenges, HTA has the potential to support a wide range of applications in China's health care sector, building on the progress achieved over the last three decades.

The introduction of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) scheme in India was a significant step toward universal health coverage. The PM-JAY scheme has made notable progress since its inception, including increasing the number of people covered and expanding the range of services provided under the health benefit package (HBP). The creation of the Health Financing and Technology Assessment (HeFTA) unit within the National Health Authority (NHA) further enhanced evidence-based decision-making processes. We outline the journey of HeFTA and highlight significant cost savings to the PM-JAY as a result of health technology assessment (HTA). Our paper also discusses the application of HTA evidence for decisions related to inclusions or exclusions in HBP, framing standard treatment guidelines as well as other policies. We recommend that future financing reforms for strategic purchasing should strengthen strategic purchasing arrangements and adopt value-based pricing (VBP). Integrating HTA and VBP is a progressive approach toward health care financing reforms for large government-funded schemes like the PM-JAY.

The COVID-19 pandemic has revealed major weaknesses in primary health care (PHC), and how such weaknesses pose a catastrophic threat to humanity. As a result, strengthening PHC has re-emerged as a global health priority and will take centre stage at the 2023 United Nations High Level Meeting (UNHLM) on Universal Health Coverage (UHC). In this analysis, we examine why, despite its fundamental importance and incredible promise, the momentum for PHC has been lost over the years. The portrayal of PHC itself (policy image) and the dominance of global interests has undermined the attractiveness of intended PHC reforms, leading to legacy historical policy choices (critical junctures) that have become extremely difficult to dismantle, even when it is clear that such choices were a mistake. PHC has been a subject of several political declarations, but post-declarative action has been weak. The COVID-19 provides a momentous opportunity under which the image of PHC has been reconstructed in the context of health security, breaking away from the dominant social justice paradigms. However, we posit that effective PHC investments are those that are done under calm conditions, particularly through political choices that prioritise the needs of the poor who continue to face a crisis even in non-pandemic situations. In the aftermath of the 2023 UNHLM on UHC, country commitment should be evaluated based on the technical and financial resources allocated to PHC and tangible deliverables as opposed to the formulation of documents or convening of a gathering that simply (re) endorses the concept., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

It is now widely accepted that there is a growing discrepancy between demand and access to adequate treatment for behavioral or mental health conditions in the United States. This results in immense personal, societal, and economic costs. One rapidly growing method of addressing this discrepancy is to integrate mental health services into the primary care setting, which has become the de facto service provider for these conditions. In this paper, we describe the development and implementation of a novel integrated care program in a large mid-western university-based healthcare system, drawn from the collaborative care model, and describe the benefits in terms of both health care utilization and depression outcomes. Limitations and proposed future directions are discussed., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Abstract: COVID-19 has accelerated the dialogue surrounding access to health insurance, including the potential for a public option, "Medicare for All," or modification of the 2010 Affordable Care Act. A dizzying array of terms and assertions surround these health policy discussions, as well as misrepresentation and lack of specificity. This article offers a primer on contemporary reform terms and options that are likely to be prominent over the next several years and outlines some health care-related elements of the American Rescue Plan Act, a massive COVID-relief act passed in March 2021. The aim of this nonpartisan overview is to enhance nurses' understanding of these terms as a basis for effective participation in public policy and patient advocacy., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Hospital-physician integration increased rapidly in the past decade, threatening the affordability of care with minimal gains in quality. Medicare recently reformed its facility fee payments to hospitals for office consultations delivered by hospital-integrated physicians. This policy reform, affecting 200 million office visits annually, may have inadvertently encouraged hospitals to integrate with certain primary care physicians., Objective: The objective of this study was to determine whether the policy reform was associated with hospital-primary care integration., Research Design: I used a large sample of primary care physicians (n=98,884) drawn from Medicare claims data. I estimated cross-sectional multivariable linear probability models to measure whether the change in physicians' value-to-hospitals was associated with integration., Results: The reform created heterogenous results: some physicians' value-to-hospitals decreased, while others increased (first percentile to 99th percentile, -$16,000 to $47,000). This change in value had a small association with integration: for every $10,000 increase, a physician was about 0.34 percentage points (95% confidence interval: 0.16-0.52) more likely to become integrated. Among high-volume physicians, the reform had larger effects: physicians whose value-to-hospitals grew by $20,000 or more were nearly 3 percentage points more likely to become integrated. Changes in value had no effect in concentrated hospital markets and rural areas., Conclusions: Effects of Medicare's site-based payments on hospital-primary care integration were concentrated among a small subset of physicians. Reforms to Medicare payment policy could influence integration among this group., Competing Interests: The author declares no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following. The article was supported by a grant from the Bill and Melinda Gates Foundation. AB worked for the Foundation for Innovative New Diagnostics before her current position; SM has received research grants from the WHO Regional Office for Europe and the Global Preparedness Monitoring Board.

Background: The healthcare system in Iran has undergone several reforms to achieve the objectives of universal health coverage (UHC). Some reforms have delivered positive benefits, however, still many challenges remain. Hence, the current study assessed the progress and outcomes of these reforms over the past three decades., Methods: The present nationwide macro-qualitative study was conducted in Iran during 2016-2017. Data were collected through 32 in-depth interviews with 30 high-ranking policymakers and healthcare providers at the national and provincial levels to identify their experiences and perceptions of the reforms. The data were analyzed using the constant comparative analysis method., Results: Analysis of the interview data resulted in two main themes, six categories, and 18 sub-categories. The extracted themes were adverse situational context and the chaotic healthcare system. The results showed that the Iranian healthcare system reforms could be characterized as incoherent and passive, and that these were the main reasons for not achieving the objectives of UHC reforms. It was revealed that the implemented reforms lacked a comprehensive approach and at times were counterproductive. Moreover, the situational context adversely hindered the successful implementation of the reforms., Conclusion: Despite many efforts to improve the Iranian healthcare system through reforms, the situational context and organizational factors have prevented achieving the main objectives. Iran's health policymakers should consider a phased implementation of small-scale reforms based on a comprehensive master plan that takes social, political, and economic factors into account. This approach would minimize potential risks and encourages the cooperation of the main stakeholders., (Copyright: © Iranian Journal of Medical Sciences.)

The purpose of this study was to investigate the effect of the Health Evolution Plan (HEP) on Health System Responsiveness (HSR) in hospitals of Hamadan, Iran. Data were collected before and after the implementation of the HEP by interviewing hospital inpatient referrals about factors relating to responsiveness. The difference between the mean responsiveness scores before (2014) and after (2018) implementation of the HEP was not significant. The study findings demonstrate that, even though one of the most important goals of the HEP was the improvement of HSR, the responsiveness of hospitals was unchanged.

Objective: Identify the lessons learned in the Greater Maghreb, during the first semester of the fight against the COVID-19 pandemic, in the field of response., Methods: During the first week of May 2020, a consultation of experts was conducted, using the "Delphi" technique, through an email asking each of them, the drafting of a good practice recommendation for "Public health". The Group coordinator finalized the text of the lessons, later validated by the signatories of the manuscript., Results: Five lessons of good «response» against epidemics have been deduced and approved by Maghreb experts, linked to the following aspects: 1. Total reservation of hospital beds for patients; 2. Clinical management of the response; 3. Discreet conflict of interest; 4. Community participation in the response; 5. Contextualization of the global fight strategy., Conclusion: Based on the finding of low relevance of the Maghreb response against COVID-19, this list of lessons would help support the performance of Maghreb health systems in the management of epidemics.

Background: Medical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending., Objective: To assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services., Methods: We conducted a retrospective analysis of deidentified claims for 18-64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011-2013) and after implementation (2014-2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index., Results: Global budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of -0.002 points (95%CI, -0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses., Conclusions: We did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care., (Published by Elsevier Inc.)

The course of HIV research has led to a multitude of interventions to prevent and treat HIV. With the arrival of more effective interventions comes the need to end, or de-implement, less effective interventions. PURPOSE OF REVIEW: To describe the state of de-implementation research in HIV and provide a rationale for expanded research in this area. RECENT FINDINGS: Existing studies have identified a set of HIV-specific interventions appropriate for de-implementing and described the persistence of interventions that should be ended. However, to our knowledge, strategies to successfully promote appropriate de-implementation of HIV-specific interventions have not been examined. De-implementing interventions that are no longer needed is an opportunity to improve the quality and effectiveness of HIV services. Opportunities to expand this field of research abound.

The current coronavirus disease 2019 (COVID-19) pandemic is testing healthcare systems like never before and all efforts are now being put into controlling the COVID-19 crisis. We witness increasing morbidity, delivery systems that sometimes are on the brink of collapse, and some shameless rent seeking. However, besides all the challenges, there are also possibilities that are opening up. In this perspective, we focus on lessons from COVID-19 to increase the sustainability of health systems. If we catch the opportunities, the crisis might very well be a policy window for positive reforms. We describe the positive opportunities that the COVID-19 crisis has opened to reduce the sources of waste for our health systems: failures of care delivery, failures of care coordination, overtreatment or low-value care, administrative complexity, pricing failures and fraud and abuse. We argue that current events can canalize some very needy reforms to make our systems more sustainable. As always, political policy windows are temporarily open, and so swift action is needed, otherwise the opportunity will pass and the vested interests will come back to pursue their own agendas. Professionals can play a key role in this as well., (© 2020 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency-and the sitting president-have endorsed health reforms that would radically transition US health care away from the current system upon which the ACA was built. Few opinion surveys to date have captured dominant preferences among alternative health reform policies or characterized attitudes and experiences that might be associated with policy preferences. Using a 2019 nationally representative telephone survey, this article considers how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor Medicare for All over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who would favor replacing it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA, and reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs., (Copyright © 2020 by Duke University Press.)

Health care is most effective when a patient's basic primary care needs are met as close to home as possible, with advanced care accessible when needed. In Ifanadiana District, Madagascar, a collaboration between the Ministry of Public Health (MoPH) and PIVOT, a non-governmental organization (NGO), fosters Networks of Care (NOC) to support high-quality, patient-centered care. The district's health system has three levels of care: community, health center, district hospital; a regional hospital is available for tertiary care services. We explore the MoPH/PIVOT collaboration through a case study which focuses on noteworthy elements of the collaboration across the four NOC domains: (I) agreement and enabling environment, (II) operational standards, (III) quality, efficiency, and responsibility, (IV) learning and adaptation. Under Domain I, we describe formal agreements between the MoPH and PIVOT and the process for engaging communities in creating effective NOC. Domain II discusses patient referral across levels of the health system and improvements to facility readiness and service availability. Under Domain III the collaboration prioritizes communication and supervision to support clinical quality, and social support for patients. Domain IV focuses on evaluation, research, and the use of data to modify programs to better meet community needs. The case study, organized by the domains of the NOC framework, demonstrates that a collaboration between the MoPH and an NGO can create effective NOC in a remote district with limited accessibility and advance the country's agenda to achieve universal health coverage.

Background: Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum., Methods: A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria., Results: A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities., Conclusions: Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Different forms of public/private mix have become a central mode of the privatization of healthcare, in both financing and provision. The present article compares the processes of these public/private amalgams in healthcare in Spain and Israel in order to better understand current developments in the privatization of healthcare., Main Text: While in both Spain and Israel combinations between the public and the private sectors have become the main forms of privatization, the concrete institutional forms differ. In Spain, these institutional forms maintain relatively clear boundaries between the private and the public sectors. In Israel, the main forms of public/private mix have blurred such boundaries: nonprofit health funds sell private insurance; public nonprofit health funds own private for-profit hospitals; and public hospitals sell private services., Conclusions: Comparison of the processes of privatization of healthcare in Spain and Israel shows their variegated characters. It reveals the active role played by national and regional state apparatuses as initiators and supporters of healthcare reforms that have adopted different forms of public/private mix. While in Israel, until recently, these processes have been perceived as mainly technical, in Spain they have created deep political rifts within both the medical community and the public. The present article contains lessons each country can learn from the other, to be adapted in each one's local context: The failure of the Alzira model in Spain warns us of the problems of for-profit HMOs and the Israeli private private/public mix shows the risk of eroding trust in the public system, thus reinforcing market failures and inefficient medical systems.

Background: The use of the performance management (PM) system is highly contested by public servants in South Africa, although its value as essential to the appraisal and management of staff is undeniable., Objectives: The aim of this study was to explore nurses' perceptions and experiences of the PM system at primary healthcare (PHC) facilities in relation to the current health system's reforms., Method: An exploratory, descriptive and qualitative design was utilised. Participants were selected through purposive sampling. A semi-structured interview tool was used to collect data from 18 nurses in four sub-districts of Dr. Kenneth Kaunda district in the North West province. Data were analysed through thematic analysis., Results: The findings of this study confirmed that PM is implemented to some extent. However, various loopholes in its implementation threaten the accuracy and transparency of the system and leave it vulnerable to perceived organisational injustice and unfairness, with the objectivity of the system questioned. The limitations of the current PM system revealed by this study include (1) the lack of alignment with current health system reforms towards comprehensive and integrated care that demands person-centred care; (2) the system's usefulness for career progression, performance improvement and rewarding exceptional performance., Conclusion: Performance management is inadequately applied in PHC facilities at district level and needs to be realigned to include the appraisal of key attributes required for the current health system's reforms towards comprehensive and integrated care, including the provision of person-centred care, which is central for responding adequately to South Africa's changing disease profile towards multi-morbidity.

This study critically evaluates the adoption of a universal healthcare system recently introduced by the Indonesian government in 2014. Our study is driven by the lack of critical analysis of social and political factors and unintended consequences of New Public Management, which is evident in the healthcare sector reforms in emerging economies. This study not only examines the impact of economic and political forces surrounding the introduction of a universal health insurance programme in the country but also offers insights into the critical challenges and undesirable outcomes of a fundamental reform of the healthcare sector in Indonesia. Through a systematic and detailed review of prior studies, legal sources and reports from government and media organizations about the implementation and progress of an UHC health insurance programme in Indonesia, the authors find that a more democratic political system that emerged in 1998 created the opportunity for politicians and international financial aid agencies to introduce a universal social security administration agency called Badan Penyelenggara Jaminan Sosial (BPJS). Despite the introduction of BPJS to expand the health services' coverage, this effort faces critical challenges and unintended outcomes including: (1) increased financial deficits, (2) resistance from medical professionals and (3) politicians' tendency to blame BPJS's management for failing to pay healthcare services costs. We argue that the adoption of the insurance system was primarily motivated by politicians' own interests and those of international agencies at the expense of a sustainable national healthcare system. This study contributes to the healthcare industry policy literature by showing that a poorly designed UHC system could and will undermine the core values of healthcare services. It will also threaten the sustainability of the medical profession in Indonesia. The authors offer several suggestions for devising better policies in this sector in the developing nations., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In 2012, The Netherlands established the so-called "free market experiment", which allowed providers of dental care to set the prices for their dental services themselves. The introduction of market mechanisms is intended to improve the quality of care and to contribute to cost containment, but increasing health expenditures for citizens have been observed in this context. Using large-volume health insurance claims data and exploiting the 2012 experiment in Dutch dental care, we identified the effects of a liberalization of service prices. Using pooled regression with individual fixed effects, we analyzed changes in utilization patterns of prevention-oriented dental services in response to the experiment as well as the elasticities in demand in response to variations in out-of-pocket (OOP) prices. We found substantial increases in prices and patients' OOP contributions for dental services following the liberalization with differences in increases between types of services. In response to the experiment, the proportion of treatment sessions containing preventive-oriented services decreased significantly by 3.4% among adults and by 5.3% for children and adolescents. Estimates of short-run price elasticities of demand for different services point towards differences in price sensitivity. One potential explanation for the observed variations in prices and utilization could be different extents of asymmetric information for first-stage and follow-on services. Price liberalization seems to have affected the composition of treatment sessions towards a decreasing use of preventive services, suggesting a shift in the reason for seeing a dental care provider from a regular-preventive perspective to a symptom-based restorative approach.

In the context of addressing the pressing health needs for the global population, the World Health Organization has repeatedly called for universal health coverage (UHC) to be prioritised by its member countries. This is to be achieved through a high-quality primary health care (PHC) approach that provides comprehensive and integrated generalist care as close to where people live as well as links the clinical care to health promotion and disease prevention. In this paper, we argue for the introduction of family medicines as a critical player in the healthcare system of Tanzania to strengthen the strategies towards UHC. The paper reviews how PHC is understood, the context of family medicine in sub-Saharan Africa and makes a case for how family medicine can assist in addressing the current burden of disease in Tanzania.

The protests in Chile in October 2019 raised the issue of health reform to the public agenda again. This article reviews some of the explanations for why there was a widespread protest, including the expectations of continued progress, the emergence of a "fear-based populism" and the decline in legitimacy of most social and political actors. Using the theories of Kingdon to explain how reforms are placed on the political agenda, we describe how the protests raised health reform as a problem to be addressed, discuss the tendency toward consensus on policy options by technical health reform advocates, and examine the uncertain political processes that would be necessary for a consensus reform to be adopted and implemented. A lesson for reformers is the need to pay attention to growing signs of popular resentment over failures of health reforms to address accumulating problems and to try to address them with urgency to avoid populist crises.

Haiti announced in 2018 its aim to achieve universal health coverage. In this paper, we discuss what this objective means for the country and what next steps should be taken. To contextualize the notion, we framed Haiti en route to the 2030 goal and analyzed qualitatively the status quo in terms of geographic, financial, and service access. For each dimension, we focused on the context, the government's policies and political agendas, their implementation progress, and key influential factors. Our analysis found little progress and numerous challenges. Geographic access was limited due principally to the insufficient number of facilities, difficulties in reaching health facilities, and local customs. Financial coverage was low because of the government's insufficient budgets, inefficient budget allocation, and ineffective management. Service access also had room for significant improvement for a lack of basic infrastructure and resources, gaps between the essential service package guidelines, health professionals' skills, and the needs, as well as deficiencies in people-centered care. These factors affected not only health service coverage but also its quality. We found that the root causes of these issues were composed of unstable financing mechanisms, opportunistic resource allocation, and ineffective management control systems. We suggest that to overcome these issues and achieve universal health coverage with decent service quality, Haiti's health system needs to be reformed by implementing strategic financing, decentralized management systems, and community engagement in primary health care.

The World Health Report 2010 encourages countries to reduce wastage and increase efficiency to achieve Universal Health Coverage (UHC). This research examines the efficiency of divisions (sub-provincial geographic units) in Pakistan in moving towards UHC using Data Envelop Analysis. We have used data from the Pakistan National Accounts 2011-12 and the Pakistan Social Living and Measurement Survey 2012-13 to measure per capita pooled public health spending in the divisions as inputs, and a set of UHC indicators (health service coverage and financial protection) as outputs. Sensitivity analysis for factors outside the health sector influencing health outcomes was conducted to refine the main model specification. Spider radar graphs were generated to illustrate differences between divisions with similar public spending but different performances for UHC. Pearson product-moment correlation was used to explore the strength and direction of the associations between proxy health systems organization variables and efficiency scores.The results showed a large variation in performance of divisions for selected UHC outputs. The results of the sensitivity analysis were also similar. Overall, divisions in Sindh province were better performing and divisions in Balochistan province were the least performing. Access to health care, the responsiveness of health systems, and patients' satisfaction were found to be correlated with efficiency scores.This research suggests that progress towards UHC is possible even at relatively low levels of public spending. Given the devolution of health system responsibilities to the provinces, this analysis will be a timely reference for provinces to gauge the performance of their divisions and plan the ongoing reforms to achieve UHC.

Mexico's health system is undergoing major restructuring by the administration of President Andrés Manuel López Obrador (known as AMLO) starting in December 2018. The government has eliminated the 2003 health reform ( Seguro Popular ) from national laws and government agencies and is returning Mexico to a centralized health system with integrated public financing and delivery and reduced private participation. This article looks at the political drivers of Mexico's restructuring reform. Three main ethical principles are identified as the foundation for the government's health system vision: universality, free services, and anti-corruption. The article then compares what existed under Seguro Popular with the new system under the Instituto de Salud para el Bienestar (INSABI), which began on 1 January 2020. The analysis uses the five policy levers that shape health system performance: financing, payment, organization, regulation, and persuasion. The article concludes with five lessons about the reform process in Mexico. First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government's restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization.

Introduction: Rhode Island has received national recognition as a leader in statewide, multipayer, multistakeholder initiatives that focus on investments in primary care as a strategy to build a strong delivery system foundation that delivers high-quality, affordable health care., Method: For this case study we summarize key structural, process and outcomes factors and lessons learned from internal and external evaluations and project based and stakeholder-engaged quality improvement efforts that helped Rhode Island become the most improved U.S. health system over the past 5 years., Results: Rhode Island's Office of the Insurance Commissioner through a collaborative process contractually established per-member, per-month payments to practices that engaged in the statewide transformation program to the patient-centered medical home model of care and paid incentives for achieving quality, patient experience, and hospital utilization targets., Discussion: Critical lessons learned include the importance of engaging stakeholders in systems change, measuring and monitoring primary care spending, and continuous learning and best-practice sharing. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background: Health insurance literacy (HIL) is defined as a person's ability to seek, obtain, and understand health insurance plans, and once enrolled use their insurance to seek appropriate health care services., Objective: The objectives of this study were to assess sociodemographic disparities in HIL, including knowledge of health insurance terms and costs, and confidence in using insurance to access health care in a nationally representative adult sample., Methods: We conducted a secondary data analysis of the Health Reform Monitoring Survey, which included 15,168 adults age 18 years and older who responded to surveys in the third quarter of 2015 and first quarter of 2016. Rao-Scott chi-square tests and weighted logistic regression were used for analysis., Key Results: The majority of our sample (51%) reported having inadequate HIL as measured by knowledge of basic insurance terms, and close to one-half (48%) had low confidence in using their insurance to access health care. Logistic regression analysis indicated significant disparities in HIL, with multiple groups identified as being at higher risk for having inadequate HIL (as measured by both knowledge and use of health insurance). These included young adults, women, those with Hispanic ethnicity, those who were not U.S. citizens, and those who were currently unmarried. Also identified to be at risk were those who are unemployed, uninsured, and enrolled in public health insurance plans, and those with lower levels of education and income. Most had inadequate knowledge of their annual out-of-pocket costs and insurance plan's deductible amounts., Conclusions: One-half of U.S. adults rate themselves as having inadequate HIL. Sociodemographic disparities in self-reported HIL underscore the need for increased consumer education, as well as efforts to simplify the health care system by promoting value-based care, supporting delivery system reforms, and designing services to be responsive to consumer HIL needs and abilities. [ HLRP: Health Literacy Research and Practice . 2019;3(4):e250-e258.] ., Plain Language Summary: In a nationally representative sample of 15,168 adults, the majority had low knowledge about basic health insurance terms and had difficulty using health insurance to access needed health care services. These findings indicate that health insurance literacy is a major concern in our community that disproportionately affects some underserved groups more than others, including young adults, groups with low-income, and people who are uninsured., (©2019 Edward, Wiggins, Young et al.)

Background: Healthcare reform in China has attracted worldwide interest and reached a new juncture. In an attempt to improve healthcare quality and patient satisfaction, the government of Beijing introduced comprehensive reform of urban public hospitals in 2016 and implemented new policies on personnel, compensation, management, and diagnosis and treatment. As the agents of healthcare service, and a target of reform measures, healthcare workers were greatly affected by these reforms but have not been carefully studied., Methods: This study used mean value analysis, variance analysis, and qualitative content analysis to investigate the status of healthcare workers after comprehensive reform of urban public hospitals in Beijing., Results: We found a gradual but constant increase in the number of healthcare workers in poor health in Beijing public hospitals. After the reforms, this population reported high challenge stress, public service motivation, job satisfaction, job performance and quality of healthcare, moderate presenteeism, and low hindrance stress and turnover intention. The status of healthcare workers differed by subgroup and changed during the reform process., Conclusions: Our study provides data useful for policy recommendations regarding the implementation and extension of future reforms and offers important lessons for developing and developed countries that are reforming public hospitals to improve efficiency and reduce costs.

Background: The primary care reform developed in Xiamen City stood out among the dozens of pilot reforms conducted in China. The aim of this study was to investigate the effects of the reform., Methods: The data were collected from the Annual Statistical Report on Xiamen's Hospitals and face-to-face questionnaire interviews among physicians (n = 107) and community members (n = 399). Binary logistic regression was performed to analyze the factors influencing the community members' preference for treatment in community health centers (CHCs)., Results: The drug cost declined nearly 3.0% in hospitals, and outpatient visits increased more quickly (27.1%) in CHCs. A total of 86.2% of community members preferred to receive treatment for slight illness or chronic diseases in CHCs, and 77.9% of them were willing to be referred to CHCs during the recovery period. Patients who were managed by the general practice (GP) team showed higher percentages in examining and controlling blood pressure and blood glucose., Conclusion: The reform in Xiamen was easily accepted by physicians and community members. The reform had rendered initial achievements in reducing drug income in hospitals, increasing outpatient visits in CHCs, seeking health care in CHCs, and controlling blood pressure and glucose for patients with chronic diseases., (© 2019 John Wiley & Sons, Ltd.)

Aim: This study evaluates nurses' leadership in research and policy formulation in southern Nigeria., Background: In Africa and particularly in low- and middle-income countries, expected health information from nurse's leaders is sometimes not available, thereby hindering the attainment of sustainable health., Methods: This qualitative study used 12 high-ranking nurses leader from primary, secondary and tertiary health care systems in Cross River State, Nigeria. In-depth interview and focus group discussion were used to generate and validate collected data., Results: There was marginal leadership in research and policy formulation. The hindering factors were mainly individual and institutional barriers., Conclusion: Nurses effective leadership in research and policy have not yet been actualized. Suggested remedies include mentoring of the mentee in research, provision of designated grants for nursing research, acceptance of nurses as policy formulators rather than implementers among others. The small sample size informs the need for further study throughout the region., Implications for Nursing Management: Nurses have the capability to exercise influence directly or indirectly on health care goals. Dereliction in research and policy formulation could hinder the attainment of desired health care reforms due to absence of innovation in nursing practice and management., (© 2019 John Wiley & Sons Ltd.)

Background: e-Health has been expansively considered as a technological intervention for fundamental enhancement in the healthcare sector to mitigate the enormous demand and supply of healthcare in both developed and developing nations. In 2000, the Saudi government established a committee for health reform to develop an information technology strategic plan for healthcare and for deploying e-health applications within the country. The objective of e-health systems was to provide better healthcare to patients and to increase the efficiency of healthcare organizations. Despite numerous e-health interventions to provide healthcare services, very little is studied about the adoption process of e-health from users' viewpoints in Saudi Arabia. This study minimizes this knowledge gap by studying the factors affecting the adoption and acceptance of e-health in the context of Saudi Arabia. Materials and Methods: This study has combined the Technology Acceptance Model and Theory of Planned Behavior frameworks to evaluate the factors influencing the patient acceptance of e-health services in Saudi Arabia. Data were collected from patients at various private and public hospitals in Saudi Arabia. The partial least square technique based on structural equation modeling was applied to analyze the survey data. Results: The study shows the significant influence of perceived usefulness and perceived ease of use on the attitude. Furthermore, attitude and subjective norm ( p  < 0.05) significantly influence patient behavioral intention (BI) to use e-health services. However, perceived behavioral control ( p  > 0.05) had no significant influence on patient BI to use e-health services. Conclusions: The findings of this study might be useful to policymakers, the government, and healthcare service providers in Saudi Arabia and other developing countries.

This study aimed to reflect the efficiency of hospitals under the Ministry of Health (MoH) before and after the implementation of Public Hospital Associations (PHAs). This study covered 3 years before (2010-2012) and 3 years after (2013-2015) the implementation. The population of the study included 865 hospitals under the MoH providing health care services in 81 provinces. No sample was selected; all hospitals were included under the scope of study. The provinces were chosen as the decision-making unit. Changes in the efficiency values of hospitals were analyzed with the Malmquist Total Factor Efficiency Index. The results showed that, for the pre-PHAs period, 24 provinces in 2010, 27 provinces from 2010 to 2011, and 32 provinces from 2011 to 2012 were assessed as efficient. From 2012, the year of implementation, to 2013, the number of efficient provinces dropped to 16. However, 20 provinces were subsequently found to be efficient from 2013 to 2014, and 26 from 2014 to 2015. The efficiency scores average of all provinces were found to be 0.89, 0.92, 0.92, 0.82, 0.88, and 0.90, respectively. Further, the efficiency score average of the 3 years before PHAs (0.91 ± 0.09) was significantly higher than the score obtained 3 years after PHAs (0.86 ± 0.11; p < 0.05). In consideration of such finding, the PHAs established at the provinces were identified as hampering increased efficiency.

The European Network for Health Technology Assessment (EUnetHTA) was founded to support efficient production and use of health technology assessments (HTAs) across Europe by reducing redundancies through collaboration. To facilitate collaboration, a range of practical tools, methods and process definitions were developed. The article describes when and how these tools and methods are used along the HTA process with specific focus on "other technologies", that is medical devices and non-pharmaceutical procedures. EUnetHTA was able to deliver tangible achievements complying with its goals. The practical tools and the developed methods formed a basis for close collaboration among over 70 agencies at a European level. The activities of EUnetHTA laid a strong foundation for sustainable cooperation. In the long run, jointly produced assessments could realise economies of scale with improved quality, consistency and transparency for the health systems in Europe.

Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)-the individual mandate, expansion of Medicaid eligibility, and essential benefits. How these provisions affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed. We study Massachusetts health reform because it enacted these key provisions statewide in 2006. Methods We used a difference-in-differences (DD) approach to assess the impact of Massachusetts health reform on uninsurance and access to care among children 0-17 years in Massachusetts compared to children in other New England states. The National Survey of Children's Health provided the pre-reform year and two post-reform years (1 and 5 years post-reform). We analyzed outcomes for children overall and children previously and newly-eligible for Medicaid under Massachusetts health reform, adjusting for age, sex, race/ethnicity, non-English language, and having special health care needs. Results Compared to other New England states, Massachusetts's enactment of the individual mandate, Medicaid expansion, and essential benefits was associated with trends at 5 years post-reform toward lower uninsurance for children overall (DD = - 1.1, p-for-DD = 0.05), increased access to specialty care (DD = 7.7, p-for-DD = 0.06), but also with a decrease in access to preventive care (DD=-3.4, p-for-DD = 0.004). At 1 year post-reform, access to specialty care improved for children newly-Medicaid-eligible (DD = 18.3, p-for-DD = 0.03). Conclusions for Practice Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.