International Journal of Health Policy and Management
Volume:8 Issue: 10, Oct 2019

To assess whether early health economic modeling helps to distinguish those healthcare innovations that are potentially cost-effective from those that are not potentially cost-effective. We will also study what information is retrieved from the health economic models to inform further development, research and implementation decisions. 

We performed secondary analyses on an existing database of 32 health economic modeling assessments of 30 innovations, performed by our group. First, we explored whether the assessments could distinguish innovations with potential cost-effectiveness from innovations without potential cost-effectiveness. Second, we explored which recommendations were made regarding development, implementation and further research of the innovation.  

Of the 30 innovations, 1 (3%) was an idea that was not yet being developed and 14 (47%) were under development. Eight (27%) innovations had finished development, and another 7 (23%) innovations were on the market. Although all assessments showed that the innovation had the potential to become cost-effective, due to improved patient outcomes, cost savings or both, differences were found in the magnitude of the potential benefits, and the likelihood of reaching this potential. The assessments informed how the innovation could be further developed or positioned to maximize its cost-effectiveness, and informed further research.  

The early health economic assessments provided insight in the potential cost-effectiveness of an innovation in its intended context, and the associated uncertainty. None of the assessments resulted in a firm ‘no-go’ recommendation, but recommendations could be provided on further research and development in order to maximize value for money.

To improve the performance of the healthcare system, Mali’s government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa.  

This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle’s members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR).  

Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership.  

The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention.

The desire for universal health coverage in developing countries has brought attention to community-based health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households’ decisions to enrol and renew membership in these schemes.  

We collected household data from 464 households in 14 villages served by a large CBHI scheme in south-western Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively.  

Results revealed that household’s socioeconomic status, husband’s employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI.  

While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.

Timely warnings and examples of industry interference in relation to tobacco, alcohol, food and breast milk substitutes are given in the editorial by Tangcharoensathien et al. Such interference is rife at national levels and also at the global level. In an era of ‘private public partnerships’ the alcohol and food industries have succeeded in insinuating themselves into the global health environment and their influence is seen in key recommendations regarding non-communicable disease (NCD) risk factors in United Nations (UN) reports. The absence of legally binding health treaties in these areas facilitates this industry engagement and the Framework Convention on Tobacco Control provides a valuable model to apply to control of other hazardous products.

Numerous investigations demonstrate that the problem of corruption in the health sector is enormous and has grave negative consequences for patients. Nevertheless, the problem of corruption in health systems is far from eminent in the international health policy debate. Hutchinson, Balabanova, and McKee have identifed in their Editorial five reasons why the health policy community has been reluctant to talk about it: (1) Problem of defining corruption; (2) Some corrupt practices are actually ways of making dysfunctional systems work; (3) The serious challenges to researching corruption; (4) Concerns that focus on corruption is a form of victim blaming that ignores larger issues; and (5) Lack of evidence about what works to tackle it. In this commentary, we pay a closer and critical look at these five excuses for doing nothing. We conclude that the vast majority of the world population, being the poor in low and middle-income countries (LMICs) who disproportionately suffer from the problem of corruption in health systems, need good people with high moral and ethical principles who have the courage to disregard these five reasons. The poor need good people who understand that it is crucial to first acknowledge this problem, despite the obvious uncertainties involved, before you can change it. The poor therefore need good editors, good policy-makers, good managers, and good clinicians. We agree with the authors that we first need to talk about corruption. But above all, we need good people who are subsequently willing to walk the talk.

Aligning innovation processes in healthcare with health system demands is a societal objective, not always achieved. In line with earlier contributions, Lehoux et al outline priorities for research, public communication, and policy action to achieve this objective. We endorse setting these priorities, while also highlighting a ‘commitment gap’ in collectively addressing system-level challenges. To acknowledge that stakeholders engaged in dialogue with one another are addressing the commitment gap is not a small step but a giant leap towards realising a socially responsible innovation agenda. Translating system-level demand signals into innovation opportunities is, therefore, the task-cum-art of all stakeholders, one that often prompts them to innovate how they deal with innovations.

Hutchinson et al offer a compelling argument for greater attention to and work in corruption in healthcare. We indeed need to talk about corruption, to understand and to grasp how to prevent and address it. This paper lays out some of the rationale for how to define the research questions, how best to address corruption – arguing that governance rather than corruption may offer a preferred starting point, and highlighting some options for measuring, analyzing and stemming corruption.

The call of the editorial of the International Journal of Health Policy and Management regarding the “Need to talk about corruption in health systems” is spot on. However, the perceived difficulties of why this is so should be explored from an actor’s perspective, as they differ for government actors, donors and the research community. In particular, false dilemmas around definition problems should be demystified, including by building systematic bridges between the anti-corruption/integrity and health policy communities of practice. In addition, the focus on corruption in frontline health service delivery generating mainly problems of access to health, needs to be complemented with addressing sophisticated kickback schemes, nepotism, and state capture of legislative and regulatory agencies and processes draining the health systems of large amounts of resources leading to another false dilemma of assumed sector underfunding. In terms of what can be done, comprehensive corruption experience and risk assessments conducted by independent actors, eg, universities, aimed at generating some basic consensus among the different actors of priority areas to be addressed on the basis of a co-responsibility approach could provide the basis for reform. Finally, governments and private sector actors in countries characterized by systemic corruption and clientelistic political systems will not reform themselves without strong and sustained demand from civil society and the media.

As the Canadian Institutes of Health Research (CIHR) leads in designing and implementing the new Health System Impact (HSI) Fellowship program, we congratulate Sim et al for their thoughtful contribution to the nascent literature on embedded research, and for advancing our own learning about the HSI Fellowship experience. In our commentary, we describe the HSI Fellowship and its key components, discuss the factors that motivated and inspired the creation of the program, and highlight successes thus far.