Health systems and reform最新文献

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.

In 2014, Indonesia's Ministry of Health established the Indonesian Health Technology Assessment Committee (InaHTAC) to prioritize evidence-based health care technology for inclusion in the national health insurance benefits package. This commentary provides an overview of the current state of the health care technology supply landscape in Indonesia, as well as the impact of HTA studies on priority-setting decisions. Indonesia's decision-making process for health care technology approval and patient access involves multiple stakeholders and follows several evaluation principles. The licensing, inclusion, and evaluation of health care technology is complex and time consuming, however, requiring input from stakeholders with different roles and interests. Although efforts have been made to establish an HTA ecosystem by, for example, engaging in capacity-building activities and issuing guidelines, challenges remain, including a lack of infrastructure, financial resources, and technical capacity and inadequate stakeholder involvement. Additionally, the current position of the HTA unit, which is connected to the Ministry of Health (MOH), and political pressures from the pharmaceutical industry can result in delayed or ignored HTA recommendations. Therefore, the establishment of an independent and robust HTA body that can inform policy makers about health technology development, licensing, dissemination, and use, along with strong regulations to ensure harmonization and coordination among stakeholders, is necessary. This requires a step-by-step approach to address inadequate overall HTA resources.

In recent decades, low- and middle-income countries (LMICs) have turned to health technology assessment (HTA) to prioritize health care interventions in pursuit of universal health coverage. HTA has demonstrated its value through significant cost savings, as shown by Thailand and Brazil, where HTA processes facilitated substantial government savings and drug price reductions. Despite these successes, many LMICs still struggle with insufficient capacity to conduct HTA or incorporate its findings into policy decisions. Only 53 percent of countries surveyed by the World Health Organization (WHO) have a legislative requirement to consider HTA results in coverage decisions. The COVID-19 pandemic highlighted the need for efficient health expenditure, prompting LMICs to seek greater value for money by investing in cost-effective interventions. To achieve this, countries will need to change the way they use HTA in the future, accounting for three important elements: agile leapfrogging past traditional HTA methodologies, aid localization to enhance country ownership and accountability, and regional collaboration to overcome common limitations such as data scarcity and limited local capacity. By addressing these elements, LMICs can optimize health spending, improve health outcomes, and ensure sustainable financing for health care systems, ultimately strengthening global health security and resilience.

Latin America and the Caribbean has made significant progress toward universal health coverage (UHC), but health spending efficiency, equity, and sustainability remain major challenges-and progress is hindered by the difficult macroeconomic context. Health technology assessment (HTA) can make resource allocation more efficient and equitable when systematically used to inform coverage decisions. We highlight five considerations that need to be taken into account to realize the full potential of HTA in the LAC region: i) explicitly link HTA to decision-making and anchor it in legal frameworks, ii) systematically incorporate the opportunity cost as a core principle into HTA activities informing coverage decisions, iii) make the internationally available evidence more fit for purpose for low- and middle-income countries (LMICs), iv) incorporate pragmatism as a key principle of HTA activities in the region, and v) institutionalize the monitoring of HTA processes and results.

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.

Countries pursuing universal health coverage must set priorities to determine which benefits to add to a national health program, but the roles that organizations play are less understood. This article investigates the case of the formation of an organization with a mandate for choice of technology for public health interventions and priorities, the Health Technology Assessment India. First, we narrate a chronology of agenda setting and adoption of national policy for organizational formation drawing on historical documentation, publicly available literature, and lived experiences from coauthors. Next, we conduct a thematic analysis that examines windows of opportunity, enabling factors, barriers and conditions, roles of stakeholders, messaging and framing, and specific administrative and bureaucratic tools that facilitated organization formation. This case study shows that organizational formation relied on the identification of multiple champions with sufficient seniority and political authority across a wide group of organizations, forming a coalition of broad base support, who were keen to advance health technology assessment policy development and organizational placement or formation. The champions in turn could use their roles for policy decisions that used private and public events to raise priority and commitment to the decisions, carefully considered organizational placement and formation, and developed the network of organizations for the generation of technical evidence and capacity building for health technology assessment, strengthened by international networks and organizations with financing, expertise, and policymaker relationships.

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.