Financial access to health care and rehabilitation services

This report presents tasks for various types of personnel and the guidelines for their training. It also provides information on issues related to training, as well as the distribution of prosthetics and orthotics personnel and services. This report is a useful tool in the national planning of rehabilitation, and prosthetics and orthotics services

A review is presented of the performance of health-workers In low and middle income countries and of strategies for improving their performances. An overview of issues and evidence about the determinants of performance is given. Health-worker practices are complex behaviours that have many potential influences. Reviews of intervention studies in low and middle income countries suggest that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions. It is reported that few interventions have been evaluated with rigorous cost-effectiveness trials. 

The Lancet, Volume 366, No. 9490, p1026–1035, 17 September 2005

"Although efficient spending on health has always been a desirable goal, it is particularly critical in the face of recent threats, such as HIV/AIDS and drug-resistant bacteria, as well as the problems presented by increasing prevalence of chronic diseases, such as diabetes and cardiovascular disease (CVD), that threaten to roll back the significant health gains achieved in the past two decades. This book is an opportunity to assess anew the costs associated with and the health gains attainable from specific interventions and thereby better inform the allocation of new health funding." 

The implementation of national health insurance reforms designed to move towards universal health coverage by 9 low-income and lower-middle-income countries in Africa and Asia  is reported. Five countries at intermediate stages of reform (Ghana, Indonesia, the Philippines, Rwanda, and Vietnam) and four at earlier stages (India, Kenya, Mali, and Nigeria) are considered. These countries’ approaches to raising prepaid revenues, pooling risk, and purchasing services are described using the functions-of-health-systems framework. Their progress across three dimensions of coverage: who, what services, and what proportion of health costs is assessed using the coverage-box framework. Patterns in the structure of these countries’ reforms including use of tax revenues to subsidise target populations and steps towards broader risk pools are identified. Trends in progress towards universal coverage, including increasing enrolment in government health insurance and a movement towards expanded benefits packages are reported. Common, comparable indicators of progress towards universal coverage are needed.

This report measures health service coverage and financial protection to assess countries’ progress towards universal health coverage (UHC). The report follows the launch of a monitoring framework for UHC, based on broad consultation of experts from around the world. The framework focuses on indicators and targets for service coverage – including promotion, prevention, treatment, rehabilitation and palliation – and financial protection for all. Global access to essential health services including family planning, antenatal care, skilled birth attendance, child immunisation, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation was assessed in 2013, and it was found that at least 400 million people lacked access to at least one of these services. The report also found that, across 37 countries, 6% of the population was tipped or pushed further into extreme poverty ($1.25/day) because they had to pay for health services out of their own pockets. 

Article 26, Habilitation and Rehabilitation, of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) calls for: “… appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life”. The Article further calls on countries to organize, strengthen, and extend comprehensive rehabilitation services and programmes, which should begin as early as possible, based on multidisciplinary assessment of individual needs and strengths, and including the provision of assistive devices and technologies. This chapter examines some typical rehabilitation measures, the need and unmet need for rehabilitation, barriers to accessing rehabilitation, and ways in which these barriers can be addressed.

General principles requiring contextual adaptation regarding optimal policy related governance of health related rehabilitation in less resourced settings were developed from a literature review and realistic synthesis. A systematic review of literature published since 2003 was carried out. Multiple reviewers selected articles for inclusion in the realistic synthesis.  A Delphi survey of expert stakeholders refined and triangulated findings from the realist synthesis. Context mechanism outcome pattern configurations (CMOCs) were identified from the literature and then developed into statements for the Delphi survey, whereby 18 expert stakeholders refined these statements to achieve consensus on recommendations for policy related governance of health related rehabilitation. Several broad principles emerged throughout formulation of recommendations: participation of persons with disabilities in policy processes; collection of disaggregated disability statistics; explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users; robust inter-sectoral coordination; and ‘institutionalising’ programmes.

Health systems’ analysis is not an exact science in the sense that it is not a case of calculating an indicator and comparing that to a target that is set in stone. Instead, the analysis rests on describing elements of the existing system and critically assessing this on the basis of a clear understanding of health financing policy, the objectives associated with UHC, and relevant comparisons with and lessons from other countries. The paper attempts to provide guidance on how this can be done by highlighting the key issues that should be considered and some of the specific questions that should be addressed. It is not intended to provide a strict chapter-bychapter outline for a system assessment, but instead to foster and guide a systematic approach to the analysis of the health financing system. The health financing country diagnostic is written for Ministries of Health, advisors and others actors responsible for developing and implementing health financing policies, and provides step-by-step guidance on how to undertake a situation analysis of a country’s health financing system. Topics considered include: key contextual factors that influence health financing policy and attainment of policy goals; overview of health expenditure patterns; review of health financing arrangements; analysis UHC goals and intermediate objectives; and overall assessment - priorities for health financing reform.

Disparities in access to health services in low- and middle-income countries (LMICs) are reviewed using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Background data on the the numbers of doctors, nurses and beds per populations in various parts of the world is provided. "Different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation, and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor"

Ann N Y Acad Sci. 2008;1136:161-7