Health systems and reform最新文献

All health systems must set priorities. Evidence-informed priority-setting (EIPS) is a specific form of systematic priority-setting which involves explicit consideration of evidence to determine the healthcare interventions to be provided. The international Decision Support Initiative (iDSI) was established in 2013 as a collaborative platform to catalyze faster progress on EIPS, particularly in low- and middle-income countries. This article summarizes the successes, challenges, and lessons learned from ten years of iDSI partnering with countries to develop EIPS institutions and processes. This is a thematic documentary analysis, structured by iDSI's theory of change, extracting successes, challenges, and lessons from three external evaluations and 19 internal reports to funders. We identified three phases of iDSI's work-inception (2013-15), scale-up (2016-2019), and focus on Africa (2019-2023). iDSI has established a global platform for coordinating EIPS, advanced the field, and supported regional networks in Asia and Africa. It has facilitated progress in securing high-level commitment to EIPS, strengthened EIPS institutions, and developed capacity for health technology assessments. This has resulted in improved decisions on service provision, procurement, and clinical care. Major lessons learned include the importance of sustained political will to develop EIPS; a clear EIPS mandate; inclusive governance structures appropriate to health financing context; politically sensitive and country-led support to EIPS, taking advantage of policy windows for EIPS reforms; regional networks for peer support and long-term sustainability; utilization of context appropriate methods such as adaptive HTA; and crucially, donor-funded global health initiatives supporting and integrating with national EIPS systems, not undermining them.

Producing a Health Technology Assessment (HTA) is resource intensive, therefore, an explicit process for Topic Identification, Selection, and Prioritization (TISP) can optimize the use of limited resources to those HTA topics of national importance. TISP does not have to be complicated, however, a formalized process facilitates HTA recommendations that better align with local priorities. The comprehensiveness of TISP processes varies according to countries' needs and to the types of decisions HTA supports. There may be many relevant considerations for TISP, such as the resources available for allocation within the health system, the number of dedicated personnel to complete HTA, and the number of stakeholders and institutions involved in the decision-making process. In countries where HTA-supported decision-making is well-established, the process for TISP is usually formalized. In settings where HTA is emerging, relatively new, or where there may not be the necessary supporting institutional mechanisms, there is limited normative guidance on how to implement TISP. We argue that developing a clear process for TISP is key when institutionalizing HTA. Moreover, insights and experiences from more formalized HTA systems can provide valuable lessons. In this commentary we discuss three institutional aspects that we believe are vital to TISP: 1) Begin topic selection with a clear link to health system feasibility, 2) Ensure legitimacy and impact through transparent TISP processes, and 3) Include the public from the start to embed patient and public engagement throughout HTA.

Efforts to advance health technology assessment (HTA) in Taiwan have aimed to optimize the allocation of National Health Insurance (NHI) resources. This study documents and analyzes the historical timeline of Taiwan's efforts in HTA, identifying areas to advance the HTA system, such as gaining broad stakeholder acceptance. We document ambitious plans to establish a larger, independent HTA center and how these plans did not materialize. The historical timeline also describes the primary focus of HTA shifting to serve the needs of decision-making authorities and committees. We argue that these changes resulted in growth of the HTA system, but also led to significant external criticism and potential compromise of its foundational principles. The inability to create a national HTA center can be attributed to several factors, including an immature ecosystem of HTA-Policy-Patient-Provider-Academic collaboration, a lack of a supportive culture, and challenging political and economic conditions. Nevertheless, if effectively managed, Taiwan's current HTA system could play a crucial role in rational decision-making, informed choices, and efficient NHI resource management. We argue that greater autonomy is crucial for enhancing financial sustainability and protecting against external influences to ensure objective and credible assessments. Additionally, we emphasize the importance of fostering a conducive learning environment to improve methodological expertise.

The COVID-19 pandemic has highlighted the need for priority setting in health financing and resource allocation, spotlighting the limitations of traditional health financing strategies. This commentary explores the relevance of mathematical modeling in enhancing allocative efficiency within the health sector, especially in the aftermath of the pandemic. We draw from the World Bank's experiences in supporting over 20 countries to employ mathematical optimization models for priority setting, aiming to achieve optimal health outcomes within constrained budgets. The pandemic's impact on economic growth, revenue collection, debt stress, and the overall fiscal space available for health financing has necessitated a paradigm shift toward prioritizing efficiency improvements in health service delivery. We outline lessons learned from such modeling and chart future directions to enhance efficiency gains, including for integrated, patient-centered approaches to health service delivery. We advocate for flexible and effective localized priority-setting, leveraging data-driven insights to navigate the complexities of health financing in a post-COVID era.

This Commentary explores the relationship between Health Technology Assessment (HTA) and Health Benefits Package (HBP) design to achieve Universal Health Coverage (UHC) in low- and middle-income countries. It emphasizes that while HTA evaluates individual healthcare interventions, HBP reform aims to create comprehensive service sets considering overall population health needs and available resources. Challenges in LMICs include limited local data and technical capacity, leading to reliance on cost-effectiveness estimates from other settings. We suggest a practical approach by combining HTA and HBP elements through a hybrid or compartmentalized method. This approach sets differentiated cost-effectiveness thresholds for specific healthcare platforms or programs (e.g., primary care or essential surgery), aligning priority-setting with organizational considerations, ethics, and implementation strategies. Strong institutions and academic support are vital for evidence-informed priority-setting processes. In summary, HTA can play a pivotal role in designing HBPs for UHC in LMICs, and a compartmentalized approach can enhance priority-setting while considering budget constraints and equity.

Health benefits packages in Colombia-what is covered, by whom, and at what cost-have evolved over the past thirty years. Coverage changed from two explicit health benefits packages (with benefits linked to ability to contribute) to an implicit approach that covers, in theory, everything for everyone, excluding a narrow negative list of services and health technologies. This article explores the evolution of priority setting in Colombia during two periods of major reform. Each period had its own advantages and disadvantages associated with different institutional arrangements, processes, and methodologies. Colombia's evolution provides several lessons for other low- and middle-income countries interested in institutionalizing evidence-based priority-setting.

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.

This study aimed to assess the effects of a two-stage funding reform, involving DRGs-based (Diagnostic Related Groups) payments for inpatient care and capitation funding for outpatient care, respectively, on services volume and care expenditure of county hospitals in Zhejiang province, China. A quasi-experimental design was adopted, involving 6 hospitals from 2 counties in the intervention group and 12 hospitals from 5 counties in the control group. The DRGs-based payments for inpatient care and capitation funding for outpatient care were introduced in January 2018 and January 2019, respectively. Controlled interrupted time-series analyses were performed to determine the effects of the funding reforms using monthly data over the period from January 2017 to December 2019. The volume of inpatient care decreased after the introduction of the first-stage DRGs-based payments, which was accompanied by an increase in the volume of outpatient visits. The DRGs-based payments led to a reduction of on average 1390 Yuan total expenditure per episode of inpatient care and 1116 Yuan out-of-pocket (OOP) payment per episode of inpatient care. However, the average outpatient expenditure per visit increased. So did the corresponding OOP payment per outpatient visit. The introduction of the second-stage capitation funding for outpatient care reversed the increasing trend of outpatient care. The average expenditure and OOP payment per outpatient visit decreased. The funding reforms create a significant effect on service volumes and expenditures in county hospitals. A coordinated approach to both inpatient and outpatient funding mechanisms is needed to minimize cost-shifting between inpatient and outpatient care and to achieve the intended policy outcomes.

Through greater understanding of past social, cultural, economic, political, scientific and technological forces which shaped our current health systems to separate mothers and newborn infants, we can begin to devise effective approaches to reshape these systems to meet the needs of mothers and newborn infants today. Medical science and technology have evolved vastly in the last century; however, effects of historical factors persist in our current health care systems, reflected in separate maternal and neonatal care in different departments with distinct guidelines, providers, and treatment locations. This separation prevents maternal-infant skin-to-skin contact and bonding, which significantly affects infant development, well-being, and that of their caregivers. We explore historical precedents for the separation of maternal-newborn care, including the transition from midwifery home care to hospital obstetric care, reasons for the increase in hospital births and hospital nursery development, and the effects of world wars, federal acts, health insurance, rooming-in practices, and the development of medical advances such as antibiotics, on hospital infrastructure. This information is evaluated in the context of modern scientific advancements to show that the conditions which shaped health systems to separate mothers and newborns in the past no longer hold. The insights gained will help to identify strategic actions to reshape health care systems to enable more integrated maternal-newborn care and the practice of Kangaroo Mother Care, and to improve survival outcomes and well-being for mothers, families, and their newborn infants.

From 2005 to 2019, the Mexican government financed cervical cancer treatment for individuals without social security insurance through Seguro Popular's Fund for Protection against Catastrophic Health Expenses. To better understand the impact of this program on access to treatment, we estimated the cervical cancer treatment gap (the proportion of patients with cervical cancer in this population who did not receive treatment). To calculate the expected number of incident cervical cancer cases we used national surveys with information on insurance affiliation and incidence estimates from the Global Burden of Disease study. We used a national claims database to determine the number of cases whose treatment was financed by Seguro Popular. From 2006 to 2016, the national cervical cancer treatment gap changed from 0.61 (95% CI 0.59 to 0.62) to 0.45 (95% CI 0.43 to 0.48), with an average yearly reduction of -0.012 (95% CI -0.024 to -0.001). The gap was greater in states with higher levels of marginalization and in the youngest and oldest age groups. Although the cervical cancer treatment gap among individuals eligible for Seguro Popular decreased after the introduction of public financing for treatment, it remained high. Seguro Popular was eliminated in 2019; however, individuals without social security have continued to receive cancer care financed by the government in the same healthcare facilities. These results suggest that barriers to care persisted after the introduction of public financing for treatment. These barriers must be reduced to improve cervical cancer care in Mexico, particularly in states with high levels of marginalization.