Universal Health Coverage; Sub-Saharan Africa; Low- and Middle-Income Countries; Experts; Health Policies
Abstract :
[en] Many countries rely on standard recipes for accelerating progress toward universal health coverage (UHC). With limited generalizable empirical evidence, expert confidence and consensus plays a major role in shaping country policy choices. This article presents an exploratory attempt conducted between April and September 2016 to measure confidence and consensus among a panel of global health experts in terms of the effectiveness and feasibility of a number of policy options commonly proposed for achieving UHC in low- and middle-income countries, such as fee exemptions for certain groups of people, ring-fenced domestic health budgets, and public-private partnerships. To ensure a relative homogeneity of contexts, we focused on French-speaking sub-Saharan Africa. We initially used the Delphi method to arrive at expert consensus, but since no consensus emerged after 2 rounds, we adjusted our approach to a statistical analysis of the results from our questionnaire by measuring the degree of consensus on each policy option through 100 (signifying total consensus) minus the size of the interquartile range of the individual scores. Seventeen global health experts from various backgrounds, but with at least 20 years' experience in the broad region, participated in the 2 rounds of the study. The results provide an initial “mapping” of the opinions of a group of experts and suggest interesting lessons. For the 18 policy options proposed, consensus emerged only on strengthening the supply of quality primary health care services (judged as being effective with a confidence score of 79 and consensus score of 90), and on fee exemptions for the poorest (judged as being fairly easy to implement with a confidence score of 66 and consensus score of 85). For none of the 18 common policy options was there consensus on both potential effectiveness and feasibility, with very diverging opinions concerning 5 policy options. The lack of confidence and consensus within the panel seems to reflect the lack of consistent evidence on the proposed policy options. This suggests that experts' opinions should be framed within strengthened inclusive and “evidence-informed deliberative processes” where the trade-offs along the 3 dimensions of UHC—extending the population covered against health hazards, expanding the range of services and benefits covered, and reducing out-of-pocket expenditures—can be discussed in a transparent and contextualized setting.
Research Center/Unit :
Economie politique et économie politique
Disciplines :
Public health, health care sciences & services Special economic topics (health, labor, transportation...)
Author, co-author :
Paul, Elisabeth ; Université de Liège - ULiège > Département des sciences sociales > Economie politique et économie de la santé
Fecher-Bourgeois, Fabienne ; Université de Liège - ULiège > Département des sciences sociales > Economie politique et économie de la santé
Meloni, Remo
Van Lerberghe, Wim
Language :
English
Title :
Universal Health Coverage in Francophone Sub-Saharan Africa: Assessment of Global Health Experts' Confidence in Policy Options
World Health Organization (WHO). The World Health Report 2008: Primary Health Care, Now More than Ever. Geneva: WHO; 2008. http://www. who. int/whr/2008/en/. Accessed November 13, 2017.
World Health Organization (WHO). The World Health Report 2010: Health Systems Financing, The Path to Universal Coverage. Geneva: WHO; 2010. http://www. who. int/whr/2010/en/. Accessed November 13, 2017.
Busse R, Schreyogg J, Gericke C. Analyzing Changes in Health Financing Arrangements in High-Income Countries: A Comprehensive Framework Approach. HNP discussion paper. Washington, DC: World Bank; 2007. http://documents. worldbank. org/curated/en/162311468141575894/Analyzing-changes-inhealth-financing-arrangements-in-high-income-countries-acomprehensive-framework-approach. Accessed November 13, 2017.
Giedion U, Alfonso EA, Diaz Y. The Impact of Universal Coverage Schemes in the Developing World:A Review of the Existing Evidence. Universal Health Coverage (UNICO) Studies Series No. 25. Washington, DC: World Bank; 2013. http://documents. worldbank. org/curated/en/349621468158382497/The-impact-ofuniversal-coverage-schemes-in-the-developing-world-a-review-ofthe-existing-evidence. Accessed November 13, 2017.
Maeda A, Cashin C, Harris J, Ikegami N, Reich MR. Universal Health Coverage for Inclusive and Sustainable Development: A Synthesis of 11 Country Case Studies. Washington, DC: World Bank Group; 2014. http://documents. worldbank. org/curated/en/ 575211468278746561/Universal-health-coverage-for-inclusiveand-sustainable-development-a-synthesis-of-11-country-casestudies. Accessed November 13, 2017.
Reich MR, Harris J, Ikegami N, et al. Moving towards universal health coverage: lessons from 11 country studies. Lancet. 2016; 387(10020):811-816. CrossRef. Medline
Cotlear D, Nagpal S, Smith O, Tandon A, Cortez R. Going Universal: How 24 Developing Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up. Washington, DC: World Bank; 2015. http://documents. worldbank. org/curated/en/ 936881467992465464/pdf/99455-PUB-Box393200B-OUO-9-PUBDATE-9-28-15-DOI-10-1596-978-1-4648-0610-0-EPI-210610. pdf. Accessed November 13, 2017.
World Bank. UHC in Africa: A Framework for Action. Washington, DC: World Bank; 2016. http://documents. worldbank. org/curated/ en/735071472096342073/Main-report. Accessed November 13, 2017.
Mosley P. Aid-effectiveness: The micro-macro paradox. IDS Bull. 1986;17(2):22-27. CrossRef
Spaan E, Mathijssen J, Tromp N, McBain F, ten Have A, Baltussen R. The impact of health insurance in Africa and Asia: A systematic review. Bull World Health Organ. 2012;90(9):685-692. CrossRef. Medline
Mathauer I, Mathivet B, Kutzin J. Community based health insurance: how can it contribute to progress towards UHC Geneva: World Health Organization; 2017. http://www. who. int/health- financing/documents/community-based-health-insurance/en/. Accessed November 13, 2017.
Rayens MK, Hahn EJ. Building consensus using the policy Delphi method. Policy Polit Nurs Pract. 2000;1(4):308-315. CrossRef
Atun R, de Andrade LOM, Almeida G, et al. Health-system reform and universal health coverage in Latin America. Lancet. 2015;385 (9974):1230-1247. CrossRef
World Health Organization (WHO). Making Fair Choices on the Path to Universal Health Coverage. Final Report of the WHO Consultative Group on Equity and Universal Health Coverage. Geneva: WHO; 2014. http://www. who. int/choice/documents/ making-fair-choices/en/. Accessed November 13, 2017.
McIntyre D, Ranson MK, Aulakh BK, Honda A. Promoting universal financial protection: evidence from seven low-and middle-income countries on factors facilitating or hindering progress. Health Res Policy Syst. 2013;11(1):36. CrossRef
Rodney AM, Hill PS. Achieving equity within universal health coverage: A narrative review of progress and resources for measuring success. Int J Equity Health. 2014;13(1):72. CrossRef. Medline
Nicholson D, Yates R, WarburtonW, Fontana G. Delivering Universal Health Coverage: A Guide for Policymakers. Report of the WISH Universal Health Coverage Forum 2015. [Doha, Qatar]: World Innovation Summit for Health (WISH); 2015. https://www. imperial. Ac. uk/media/imperial-college/institute-of-global-healthinnovation/ public/Universal-health-coverage. pdf. Accessed November 13, 2017.
Kutzin J. Anything goes on the path to universal health coverage No. Bull World Health Organ. 2012;90(11):867-868. CrossRef
Kutzin J, Yip W, Cashin C. Alternative financing strategies for universal health coverage. In: Scheffler RM, ed. World Scientific Handbook of Global Health Economics and Public Policy. Hackensack, NJ: World Scientific Publishing; 2016: 267-309.
Jowett M, Kutzin J. Raising Revenues for Health in Support of UHC: Strategic Issues for Policy Makers. Geneva: World Health Organization; 2015. http://www. who. int/health-financing/ documents/revenue-raising/en/. Accessed November 13, 2017.
Lagarde M, Palmer N. The impact of user fees on health service utilization in low-and middle-income countries: how strong is the evidence Bull World Health Organ. 2008;86(11):839-848. CrossRef. Medline
Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan. 2011;26(1):1-11. CrossRef. Medline
Ridde V, Robert E, Meessen B. A literature review of the disruptive effects of user fee exemption policies on health systems. BMC Public Health. 2012;12(1):289. CrossRef
Hatt LE, Makinen M, Madhavan S, Conlon CM. Effects of user fee exemptions on the provision and use of maternal health services: A review of literature. J Health Popul Nutr. 2013;31(4 suppl 2):67-80. Medline
Richard F, Antony M, Witter S, et al. Fee exemption for maternal care in sub-Saharan Africa: A review of 11 countries and lessons for the region. Glob Health Gov. September 18, 2013. https://blogs. shu. edu/ghg/2013/09/18/fee-exemption-for-maternal-care-in-subsaharan-africa-a-review-of-11-countries-and-lessons-for-theregion/. Accessed May 3, 2108.
Dzakpasu S, Powell-Jackson T, Campbell OMR. Impact of user fees on maternal health service utilization and related health outcomes: A systematic review. Health Policy Plan. 2014;29(2):137-150. CrossRef
Crowley GR, Hoffer AJ. The effects of dedicating tax revenues. Mercat Policy. June 14, 2012. https://www. mercatus. org/ publication/effects-dedicating-tax-revenues. Accessed November 13, 2017.
Cashin C, Sparkes S, Bloom D. Earmarking for Health: From Theory to Practice. Geneva: World Health Organization; 2017. http:// www. who. int/health-financing/documents/earmarking-forhealth/ en/. Accessed November 14, 2017.
Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M, Stuckler D. Financing universal health coverage-effects of alternative tax structures on public health systems: cross-national modelling in 89 lowincome and middle-income countries. Lancet. 2015;386 (9990):274-280. CrossRef. Medline
Nakhimovsky S, Langenbrunner J, White J, Vogus A, Zelelew H, Avila C. Domestic Innovative Financing for Health: Learning From Country Experience. Bethesda, MD: Health Finance & Governance Project, Abt Associates Inc.; 2014. https://www. hfgproject. org/domestic-innovative-financing-health-learningcountry-experience/. Accessed May 3, 2018.
Cashin C. Health Financing Policy: The Macroeconomic, Fiscal, and Public Finance Context. Washington, DC: World Bank; 2016. http://documents. worldbank. org/curated/en/ 394031467990348481/Health-financing-policy-themacroeconomic-fiscal-and-public-finance-context. Accessed November 14, 2017.
Acharya A, Vellakkal S, Taylor F, et al. The Impact of Health Insurance Schemes for the Informal Sector in Low-and Middle-Income Countries: A Systematic Review. Policy Research Working Paper No. 6324. Washington, DC: World Bank; 2013. http:// documents. worldbank. org/curated/en/952181468340141917/ The-impact-of-health-insurance-schemes-for-the-informal-sector-inlow-and-middle-income-countries-a-systematic-review. Accessed November 14, 2017.
Nosratnejad S, Rashidian A, Dror DM. Systematic review of willingness to pay for health insurance in low and middle income countries. PLoS One. 2016;11(6):e0157470. CrossRef. Medline
Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W. Systematic review: effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res. 2010;10(1):247. CrossRef
Emmert M, Eijkenaar F, Kemter H, Esslinger AS, Schöffski O. Economic evaluation of pay-for-performance in health care: A systematic review. Eur J Health Econ. 2012;13(6):755-767. CrossRef
Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low-and middleincome countries. Cochrane Database Syst Rev. 2012;(2): CD007899. CrossRef. Medline
Eijkenaar F, Emmert M, Scheppach M, Schöffski O. Effects of pay for performance in health care: A systematic review of systematic reviews. Health Policy. 2013;110(2-3):115-130. CrossRef. Medline
Das A, Gopalan SS, Chandramohan D. Effect of pay for performance to improve quality of maternal and child care in low-and middle-income countries: A systematic review. BMC Public Health. 2016;16(1):321. CrossRef. Medline
Turcotte-Tremblay AM, Spagnolo J, De Allegri M, Ridde V. Does performance-based financing increase value for money in low-and middle-income countries A systematic review. Health Econ Rev. 2016;6(1):30. CrossRef. Medline
Wiysonge CS, Paulsen E, Lewin S, et al. Financial arrangements for health systems in low-income countries: An overview of systematic reviews. Cochrane Database Syst Rev. 2017;9:CD011084.
Paul E, Albert L, Bisala BNS, et al. Ridde V. Performance-based financing in low-income and middle-income countries: isn't it time for a rethink BMJ Glob Health. 2018;3:e000664. CrossRef. Medline
Roehrich JK, Lewis MA, George G. Are public-private partnerships a healthy option A systematic literature review. Soc Sci Med. 2014;113(suppl C):110-119. CrossRef. Medline
Montagu D, Goodman C. Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector Lancet. 2016;388(10044):613-621. CrossRef. Medline
Pearson M, Johnson M, Ellison R. Review of major results based aid (RBA) and results based financing (RBF) schemes: final report. London: DFID Human Development Resource Centre; 2010. https://assets. publishing. service. gov. uk/media/ 57a08afb40f0b652dd000a04/Results-Based-Financing-Schemes- Report. pdf.
Klingebiel S, Janus H. Results-based aid: potential and limits of an innovative modality in development cooperation. Int Dev Policy. 2014;5(2). CrossRef
Paul E. Performance-based aid: why it will probably not meet its promises. Dev Policy Rev. 2015;33(3):313-323. CrossRef
Clist P. Payment by results in development aid: All that glitters is not gold. World Bank Res Obs. 2016;31(2):290-319. CrossRef
Angelsen A. REDD as result-based aid: general lessons and bilateral agreements of Norway. Rev Dev Econ. 2017;21(2):237-264. CrossRef
Ekman B. Community-based health insurance in low-income countries: A systematic review of the evidence. Health Policy Plan. 2004;19(5):249-270. CrossRef
Brody CM, Bellows N, Campbell M, Potts M. The impact of vouchers on the use and quality of health care in developing countries: A systematic review. Glob Public Health. 2013;8(4):363-388. CrossRef
Bellows NM, Bellows BW, Warren C. Systematic review: The use of vouchers for reproductive health services in developing countries: systematic review. Trop Med Int Health. 2011;16(1):84-96. CrossRef
Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low-and middle-income countries: A systematic review. JAMA. 2007;298(16):1900-1910. CrossRef
Owusu-Addo E, Renzaho AMN, Smith BJ. The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: A systematic review. Health Policy Plan. March 21, 2018. CrossRef
McIntyre D, Garshong B, Mtei G, et al. Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania. Bull World Health Organ. 2008;86(11):871-876. CrossRef
YipW, Hafez R. Reforms for Improving the Efficiency of Health Systems: Lessons From 10 Country Cases. Synthesis Report. Geneva: World Health Organization; 2015. http://www. who. int/health- financing/documents/synthesis-report/en/. Accessed November 14, 2017.
Dmytraczenko T, Almeida G. Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Selected Countries. Washington, DC: World Bank; 2015. https:// openknowledge. worldbank. org/handle/10986/22026. Accessed March 22, 2018.
Chisholm D, Evans DB. Improving Health System Efficiency as a Means of Moving Towards Universal Coverage. World Health Report (2010) Background Paper No. 28. Geneva: World Health Organization; 2010. http://www. who. int/healthsystems/topics/ financing/healthreport/28UCefficiency. pdf. Accessed May 3, 2018.
Siapka M, Remme M, Obure CD, Maier CB, Dehne KL, Vassall A. Is there scope for cost savings and efficiency gains in HIV services A systematic review of the evidence from low-and middle-income countries. Bull World Health Organ. 2014;92(7):499-511AD. CrossRef. Medline
Hatt LE, Johns B, Connor C, Meline M, Kukla M, Moat K. Impact of Health Systems Strengthening on Health. Bethesda, MD: Health Finance & Governance Project, Abt Associates Inc.; 2015. https:// www. hfgproject. org/wp-content/uploads/2016/03/Impact-of-Health-Systems-Strengthening-on-Health-7-24-1. pdf. Accessed November 14, 2017.
Stigler FL, Macinko J, Pettigrew LM, Kumar R, van Weel C. No universal health coverage without primary health care. Lancet. 2016;387(10030):1811. CrossRef
Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. CrossRef
Kringos DS, BoermaWGW, Hutchinson A, van der Zee J, Groenewegen PP. The breadth of primary care: A systematic literature review of its core dimensions. BMC Health Serv Res. 2010;10(1):65. CrossRef
Lewin S, Lavis JN, Oxman AD, et al. Supporting the delivery of costeffective interventions in primary health-care systems in low-income and middle-income countries: An overview of systematic reviews. Lancet. 2008;372(9642):928-939. CrossRef
Kruk ME, Porignon D, Rockers PC, Van LerbergheW. The contribution of primary care to health and health systems in low-and middleincome countries: A critical review of major primary care initiatives. Soc Sci Med. 2010;70(6):904-911. CrossRef. Medline
Haas PM. Introduction: epistemic communities and international policy coordination. Int Organ. 1992;46(1):1-35. CrossRef
Independent Evaluation Group. World Bank Group Support to Health Financing. Washington, DC: World Bank; 2014. https:// openknowledge. worldbank. org/handle/10986/21310. Accessed November 13, 2017.
Coarasa J, Das J, Gummerson E, Bitton A. A systematic tale of two differing reviews: evaluating the evidence on public and private sector quality of primary care in low and middle income countries. Glob Health. 2017;13(1):24. CrossRef. Medline
Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science. 1974;185(4157):1124-1131. CrossRef
Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux; 2011.
Cairney P, Oliver K. Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy Health Res Policy Syst. 2017;15(1):35. CrossRef
WaneW. The Quality of Foreign Aid: Country Selectivity or Donors Incentives World Bank Policy Research Working Paper Series No. WPS 3325. Washington, DC:World Bank; 2004. http:// documents. worldbank. org/curated/en/171951468765313837/ The-quality-of-foreign-aid-country-selectivity-or-donors-incentives. Accessed November 13, 2017.
Stuckler D, Feigl AB, Basu S, McKee M. The Political Economy of Universal Health Coverage. Background paper for the Global Symposium on Health Systems Research, 16-19 November 2010, Montreux, Switzerland. Geneva: World Health Organization; 2010. https://pdfs. semanticscholar. org/3261/ 5063a79a268af0aeea7fbab993fb609a78b1. pdf. Accessed November 13, 2017.
Savedoff WD, de Ferranti D, Smith AL, Fan V. Political and economic aspects of the transition to universal health coverage. Lancet. 2012;380(9845):924-932. CrossRef
O'Connell T, Rasanathan K, Chopra M. What does universal health coverage mean Lancet. 2014;383(9913):277-279. CrossRef
Baltussen R, Jansen MP, Mikkelsen E, et al. Priority setting for universal health coverage: we need evidence-informed deliberative processes, not just more evidence on cost-effectiveness. Int J Health Policy Manag. 2016;5(11):615-618. CrossRef
Gopinathan U, Ottersen T. Evidence-informed deliberative processes for universal health coverage: broadening the scope. Comment on "Priority setting for universal health coverage: we need evidenceinformed deliberative processes, not just more evidence on costeffectiveness. " Int J Health Policy Manag. 2016;6(8):473-475. CrossRef
Baltussen R, Jansen MP, Bijlmakers L, Tromp N, Yamin AE, Norheim OF. Progressive realisation of universal health coverage: what are the required processes and evidence BMJ Glob Health. 2017;2(3): e000342. CrossRef. Medline