Identifying Health System Priorities for Equitable Access to Health Services in Low- and Middle-Income Countries
Feldhaus, Isabelle Maxine
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CitationFeldhaus, Isabelle Maxine. 2020. Identifying Health System Priorities for Equitable Access to Health Services in Low- and Middle-Income Countries. Doctoral dissertation, Harvard University, Graduate School of Arts & Sciences.
AbstractIn 2019, the World Health Organization announced that up to 5 billion people will be unable to access health care in 2030 if governments fail to sufficiently increase investments in health care. The three papers that comprise this dissertation explore themes of access to health care and priority setting to improve access via outreach and financial risk protection for the most vulnerable populations. They employ methods of economic evaluation and decision sciences to support decision-making towards these aims in resource-constrained settings.
Immunization remains one of the most effective interventions to reduce child morbidity and mortality, but is an essential health service that still fails to reach every child in low- and middle-income countries. Using a structural equation model informed by the literature on 'decision space' in health systems, Paper 1 examines whether the decentralized management structure of India’s intensified immunization program and its capacity to reached previously unimmunized children were related. Study results highlighted that a greater capacity to make decisions at local operational levels was associated with fewer planned vaccination sessions being implemented under the program at the subdistrict level, but was not related to the number of children vaccinated per session. Greater reductions in morbidity and mortality due to vaccine-preventable diseases may be derived from greater attention to programmatic management and organization to improve immunization coverage and access to other essential health services.
Achieving high levels of financial risk protection is another indication of adequate access to health care and continues to be an objective of health systems. Despite comprehensive social health protection schemes, some countries experience low claims of the entitlements provided through these schemes. Paper 2 investigates this phenomenon, examining the relationships between patients’ awareness of their benefits and their utilization of them in Cambodia. Study findings reveal that the majority of beneficiaries under the country's public health protection scheme were aware of their entitlements, but chose to seek care from private rather than public providers, where services would be free of user fees. Microsimulations of interventions aimed at increasing patients' awareness suggest that initiatives intervening on the decision of where to seek care (i.e., public vs. private facilities) may prove more fruitful towards increasing financial risk protection compared to interventions implemented within public facilities alone. Overall, interventions aimed at increasing awareness of entitlements were only associated with very small increases in user claims and suggest that beneficiary awareness may not be a major barrier to access in this context as initially hypothesized.
With the increasing burden of expensive non-communicable diseases, health policies will need to establish efficient and equitable policies that reduce financial barriers to accessing routine health services for the poor. Paper 3 explores the potential economic costs, health gains, and financial risk protection benefits associated with provision of diabetes-related care in the context of Cambodia’s social health protection scheme, the Health Equity Funds. Using Markov modeling and cost-effectiveness analysis, the study points to how providing effective service and financial coverage for screening and treatment services for diabetes would lead to the substantial health and financial risk protection benefits for the Cambodian population. Examining the impact of health and financial benefits showed that such a policy would particularly benefit women and the poorest.
These three papers tackle burgeoning challenges in access to health care for children, the poorest, and women in lower-middle income settings, pointing to potentially effective and cost-effective solutions to improve access to address communicable and non-communicable diseases. Paper 1 highlights how the design of organizational structures for decision making may relate to improved outreach to increase access to immunization for hard-to-reach children. Paper 2 evaluates hypotheses on how to improve access to health services through appropriate use of health coverage, and Paper 3 determines the cost-effectiveness of reducing barriers to accessing non-communicable disease services among the poor. Together, these studies contribute to decision making regarding health systems strengthening interventions aimed at reducing access barriers and addressing population health needs in the unique contexts of low- and middle-income country settings.
Citable link to this pagehttps://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37365965
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