DESK REVIEWS | 02.01.03.01. How are health services accessed?

DESK REVIEW | 02.01.03.01. How are health services accessed?

Every resident in Hong Kong can access primary care services directly by walking-in or making a telephone appointment. Private practitioners are distributed over nearly every community for convenient access. The Government has established the Primary Care Directory which is a web-based electronic database containing contact details, practice information, and professional qualifications of primary care providers in Hong Kong. This facilitates the public to search for suitable family doctors, dentists, and Chinese medicine practitioners in the community (Food and Health Bureau, 2019c). For public healthcare, since the general outpatient clinics are usually overloaded by older adults and persons with chronic illness who need regular follow-up, citizens who cannot afford private doctor consultations or insist in using public primary care have to walk in and queue up for a daily quota early in the morning or they can make a telephone booking for an appointment in the next 24 hours. The Telephone Appointment System of public general outpatient clinics operates 24 hours a day. In 2016, the Government introduced the Electronic Health Record Sharing System (eHRSS), a territory-wide, patient-oriented electronic sharing platform, for both authorised public and private health practitioners to access and share participating patients’ health records to enable more timely diagnosis and treatment, and reduce duplicate diagnostic tests (HKSAR Government, 2019, October). For emergency services, the public ambulance service 999 is free for anyone in Hong Kong. For access to secondary and tertiary care, either public or private, referral from a general practitioner is necessary.

References:

Food and Health Bureau. (2019c, October 1). Primary Care Directory. Retrieved from https://www.pcdirectory.gov.hk/english/welcome/welcome.html

HKSAR Government. (2019, October). Electronic Health Record Sharing System. Retrieved from https://www.gov.hk/en/residents/health/hosp/eHRSS.htm

In rural areas, frontline workers i.e., the ASHAs (Accredited Social Health Activists) facilitate contact with the public health sector. These act as community-based mobilizers that receive performance-linked incentives for service access and utilisation by their catchment population (usually, a village of 1,000 population) (NHSRC, 2019). The Anganwadi Workers from the Women and Child Development Department of the Government of India serve as the other community-based village-level frontline workers that help with maternal child health nutrition and immunization services, and in community mobilization.

The Auxiliary Nurse Midwife (ANM) at the sub-centre serves as the first contact with the formal public health sector (MoHFW, n.d.-b). Even though referral linkage exists between the facilities at the different tiers, care seekers in India most commonly use ‘walk-in’ services. In-patient admissions happen through out-patient and emergency departments. Many health services in rural India are also accessed through the non-formal practitioners, whose services are unregulated, with concerns regarding the quality of care offered (unsafe injection practices, multi-pharmacy, steroid, and antibiotic abuse, etc.) (Gautam et al., 2014). Frequently, these local practitioners serve as the first point of contact for health care seekers and cover up for the unavailability of formal providers. They also refer patients to formal health facilities for care, but often with delay and complications.

In urban areas, for critical cases, people frequently choose to seek care in the private sector. The perception of better care quality, convenience, staff availability, and system responsiveness are some of the reasons for people preferring the private sector over the public health sector (Barik and Thorat, 2015). However, care in the private sector is costlier than the public sector. Drugs and services in the latter are usually subsidised.

Schemes like the Employee State Insurance Corporation, the Central Government of Health Services, Corporate Empanelment Schemes, and Ayushman Bharat serve as the other major routes of health access to public and private health care providers for individuals and families (Table 2.4).

The most recently (2018) launched an insurance scheme under Ayushman Bharat known as the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), which is a government funded health insurance scheme offering socioeconomically disadvantaged families a benefit cover of Rs 5 lakh per year for hospitalizations (National Health Authority, 2022b). With PMJAY, several neurological diseases that require secondary and tertiary care are also covered such as meningitis, epilepsy and stroke, and care can be accessed in both public and private facilities (Paul, 2019). In addition, in September 2021, the Ayushman Bharat Digital Mission (ABDM) was introduced, with the aim of improving digital health infrastructure and bridging current gaps within the country (National Health Authority, 2022a). ABDM will be able to facilitate access of patients to their own health records, allow patients to share their health records with health care providers, provide the ability to access health services via tele-consultations etc. (National Health Authority, 2022a).

Table 2.4 Schemes related to health care

Name of the scheme Details Nature of health issues Coverage Source
Ayushman Bharat

 

 

Two components, which are:

Establishment of Health and Wellness Centres

AB-Pradhan Mantri Jan Arogya Yojana (PM-JAY) –PM-JAY

AB-PMJAY provides financial protection to the socioeconomically disadvantaged. It will offer a benefit cover of Rs. 500,000 per family per year (on a family floater basis).

 

Launched in 2018. Over 2,89,23,388, hospital admissions have been covered as of 28th February 2022 (National Health Authority, 2022b). National Health Portal of India (2019)
Employees’ State Insurance Scheme Employees of factories and other establishment’s where 10 or more persons are employed. Cover incidences of sickness, employment injury related death and provides medical care to insured persons and their families. Benefits about 2.13 crore insured persons/ family units. National Portal of India (2020)
Central Government Health Scheme For Central Government employees. The medical facilities are provided through Wellness Centres (previously referred to as CGHS Dispensaries) / polyclinics. Approximately 35 lakh beneficiaries are covered by CGHS in 71 cities all over India. MoHFW (2020a)

 

References:

Barik, D., & Thorat, A. (2015). Issues of unequal access to public health in India. Frontiers in public health3, 245.

Gautham, M., Shyamprasad, K. M., Singh, R., Zachariah, A., Singh, R., & Bloom, G. (2014). Informal rural healthcare providers in North and South India. Health policy and planning29(suppl_1), i20-i29. https://doi.org/10.1093/heapol/czt050

Ministry of Health and Family Welfare. (n.d.-b). Rural Health Statistics 2019-2020. Statistics Division, Ministry of Health and Family Welfare. Government of India.

Ministry of Health and Family Welfare. (2020a). Central Government Health Scheme.

National Health Authority (2022a). Ayushman Bharat-Digital Mission. Government of India. Available from: https://abdm.gov.in/

National Health Authority (2022b). Ayushman Bharat-Pradhan Mantri Jan Arogya. Government of India.

National Health Portal (2019). Ayushman Bharat Yojana. Government of India. Available from: https://www.nhp.gov.in/ayushman-bharat-yojana_pg

National Health Systems Resource Centre (2019). Update on ASHA Programme: July 2019. Ministry of Health and Family Welfare. Available from: https://nhsrcindia.org/sites/default/files/2021-06/ASHA%20Update%20July%202019.pdf

National Portal of India (2020). Employee State Insurance Scheme. Government of India. Available from: https://www.india.gov.in/spotlight/employees-state-insurance-scheme#tab=tab-1

Paul, V. (2019). Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY): Hope for Millions and Exciting New Prospects for Neuro-Healthcare. Neurology India67(5), 1186. https://doi.org/10.4103/0028-3886.271284

Patients access primary care practitioners through the Puskesmas. There is a maximum ratio of 5,000 patients per primary care practitioner to encourage quality of care. Furthermore, primary care practitioners have been trained on ‘standard care competencies for the most common 144 diagnoses and 11 medical conditions’ by the Indonesian Medical Council. Where patients present with other conditions, they receive a referral to a specialist based in a lower-class hospital. Only from there, patients can be referred to higher class hospitals (Agustina et al., 2019, p.89).

Lack of knowledge on how to access services has been reported among subsidised members of the National Health Insurance System (NHIS) (Agustina et al., 2019, p.94).

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Approximately 63% of Kenyans access public health facilities. The facilities are unequally distributed across the 47 counties, with a national average facility density of 22 health facilities per 100,000 populations. The average distance between places of residence and nearest low level health facilities is about 3 kilometers (an average time of one hour by foot), which becomes a hindrance to uptake of health services (Mugo et al., 2018). Considerable distance to the nearest formal health provider acts as an important barrier to access for Kenyans from rural communities, who are therefore more likely to rely on traditional healers rather than seek care services in health facilities.

Nearly a third of the population in Kenya access levels 1-3 levels of care (further described in table 2) which form 80% of public health facilities as they are focused on primary health care services, while the hospitals (rest of the facilities) provide specialized services (Mugo et al., 2018). The national health sector referral strategy aims to improve client access to services and provides clear guidelines on referral processes through (Ministry of Health, 2014d):

  • Realization of the capacity of health care providers to make appropriate referrals
  • Development of protocols that will lead to referral system efficiency and effectiveness
  • Promotion of information use and communication technology (ICT) to manage referral processes
  • Promotion of research and innovation for referrals

Another initiative by the national government to increase access to health care services includes implementation of the Universal Health coverage (UHC), called “Afya Care” which is part of the Big Four Agenda. The Big Four Agenda has been implemented by the Kenyan government to ensure (i) the Expansion of the Manufacturing Sector, (ii) Affordable Housing, (iii) Affordable Healthcare and (iv) Food Security.

The pilot phase of the UHC (launched in 2018 with a national roll-out out expected in 2022) is covering 4 out of 47 counties with a high disease burden, (Kisumu, Machakos, Nyeri and Isiolo – which represent about 5% of the Kenyan population) and involves the removal of user fees at all public health facilities (including levels 4 and 5). It also ensures ‘commodity security’ that is, uninterrupted supply of quality and affordable medicines through KEMSA. This pilot phase encourages uptake and utilization of community Health Volunteer (CHVs) services and strengthening health systems in the other 43 counties by ensuring efficient and appropriate use of health funds in preparation for scale-up (Kariuki, 2019). Provision of health services will cover emergency, community, outpatient, and inpatient services for both communicable and no-communicable illnesses including mental health and maternity care. Furthermore, there is a focus on improving access to quality primary health care services by supporting operation and maintenance costs. There is only one out of the 43 non-pilot UHC counties (Makueni County), that has introduced some component of universal health care (Makueni Care), where a family (household) pays an annual fee of Kshs. 500 ($5 US dollars) to cover both preventive and curative services as well as free access to health care services (without payment) for individuals above 70 years. However, most hospitals are located far from people’s homes and only a small percentage of the population is able to access extensive services at higher levels of care (table 2). For instance, the risk of developing multiple illnesses and requiring long-term support is higher among older people, yet some of these services and medications can only be accessed at higher levels of care (levels 4-5) and are therefore inaccessible to a large population. In other non-pilot UHC counties, access to health care is limited. Out-of-pocket costs for registration upon first visit to the health facility and limited supply of medication at the public facilities create barriers to access and quality of care.

References:

Kariuki, S. (2019). World Health Day: Universal Health Coverage – Everyone, Everywhere – Celebrating Kenya’s journey towards universal health coverage. https://www.health.go.ke/wp-content/uploads/2019/04/WORLD-HEALTH-DAY-SUPPORT-07-04-2019.pdf

Ministry of Health. (2014d). Kenya Health Sector Referral Strategy. Ministry of Health Division of Emergency and Disaster Risk Management Afya House. https://www.measureevaluation.org/pima/referral-systems/referral-strategy

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya.https://repository.kippra.or.ke/bitstream/handle/123456789/2095/an-assessment-of-healthcare-delivery-in-kenya-under-the-devolved-system-sp19.pdf?sequence=1&isAllowed=y

Mexico does not have a universal-access National Health System. The health system is highly fragmented among different institutions that provide services depending on affiliation. For those formally employed, social security and health services are provided by two institutions, the Mexican Social Security Institute (IMSS) for those in the private sector, and the Institute for Social Security and Services for State Employees (ISSSTE) for those employed in the national or state-level public sector. In addition, the Ministry of Health provides health services for those who are employed in the informal sector or those who did not accrue enough time in formal employment to be eligible to services at IMSS or ISSSTE.

Within all these sub-systems, services are organised and accessed within a gate-keeping system where people have access to primary care clinics with general or family doctors (equivalent to GPs) as the first point of contact. They conduct first assessments, diagnoses, and treatment and, when necessary, refer patients to specialist physicians, laboratory or diagnostic tests, and major procedures such as hospitalisation or treatments that are provided within a hospital setting.

All private services can be accessed at the point of service, irrespective of service needed such as diagnosis/care of specialist physicians, diagnostic tests, or hospitalisation. These services have to be paid directly to the provider through out-of-pocket payments or insurance policies where insurance companies cover the costs or reimburse the patient, depending on the plan they contracted.

All public (MoH) and social security institutions are based on a reference system (gatekeeping), where primary care units –usually named family medicine clinics—are the main point of access and where care is provided by primary care physicians. When needed, they refer patients to any laboratory or diagnostic tests.

In the private sector, access is mostly through specialist doctors, responding to a specific need –either from previous diagnosis or expected need. Since a change in legislation in the year 2001, a segment of the private sector that has significantly increased is the use of pharmacists who provide “health orientation” by General Practitioners (medico general) and have profited from the parallel sale of medications (Gutierrez et al., 2014).

References:

Gutiérrez, J. P., García-Saisó, S., Dolci, G. F., & Ávila, M. H. (2014). Effective access to health care in Mexico. BMC Health Services Research, 14(1). https://doi.org/10.1186/1472-6963-14-186

Rationed by waiting lists and queuing systems, public healthcare services are accessed via a District Health system, as the preferred government mechanism for primary care service provision for the majority of South Africans (Mahlathi & Dlamini, 2015). Services are accessed through public clinics, public hospitals, community health centres/clinics and ambulance services, and governed by the use of Norms and Standards.

The PHC sector has around 3500 clinics and health centres across the country that is accessible within 5km to more than 90% of people living in South Africa (McKenzie et al., 2017).

Private healthcare services are accessed by those who have medical insurance, or those who pay the private rates and fees attached to these private and specialist services, via private practices and hospitals.

References:

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from: http://www.prographic.com/wp-content/uploads/2016/07/0316-south-africa-case-studies-web.pdf

McKenzie, A., Schneider, H., Schaay, N., Scott, V., & Sanders, D. (2017). Primary Health Care Systems (Primasys). In World Health Organization and Alliance for Health Policy and Systems Research. Available from: https://apps.who.int/iris/bitstream/handle/10665/341145/WHO-HIS-HSR-17.38-eng.pdf?sequence=1