DESK REVIEWS | 02.01.03. Access

DESK REVIEW | 02.01.03. Access

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

The primary care system is conceptualized for acting as a gatekeeper system. This is one of the aims in the provision of health care in Brazil. The primary care model is in line with the provision of universal access and comprehensive healthcare, it aims to coordinate  the access to specialist and hospital care, and it promotes actions for health promotion and disease prevention (Paim et al., 2011). Investments and organisational strategies, such as the establishment of the Community Health Agents Programme and the Family Health Strategy – FHS, have been carried out and have been helpful to reorganize primary care clinics to focus on the community and to integrate medical care with health promotion and public health actions (Brazilian Ministry of Health, 2019d; Paim et al., 2011).

In addition, more investments in decentralized and computerized regulatory systems have been made by municipalities. These result in the possibility of monitoring of waiting lists for specialized care, increase of service supply, introduction to clinical guidelines, and use of electronic medical records. These strategies end up integrating primary healthcare with the network of specialised services (Paim et al., 2011). According to a study conducted in four Brazilian capitals, referrals to secondary care services that come from family health care teams are usually more effective and have shorter waiting times (Almeida et al., 2010). Although all these advances have been achieved, it is necessary to remember that the primary care system in Brazil may be circumvented by people willing to pay out-of-pocket to access services immediately.

References:

Almeida, P. F. de, Giovanella, L., Mendonça, M. H. M. de, & Escorel, S. (2010). Desafios à coordenação dos cuidados em saúde: Estratégias de integração entre níveis assistenciais em grandes centros urbanos. Cadernos de Saúde Pública, 26(2), 286–298. https://doi.org/10.1590/S0102-311X2010000200008

Brazilian Ministry of Health. (2019d). Estratégia Saúde da Família (ESF).

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797. https://doi.org/10.1016/S0140-6736(11)60054-8

The public health system in India accommodates direct walk-ins and referred patients at facilities across all levels of care (primary, secondary, and tertiary level facilities). Nevertheless, there is a form of gatekeeping in place, in which public primary care facilities provide referrals to secondary/tertiary facilities. However, in rural areas, due to delays in access, poor availability and quality of services, individuals who can afford private care choose to directly seek secondary/tertiary care services privately after their initial primary care consultations. Whereas, in urban areas, the public is likely to directly access secondary/tertiary facilities because of higher demand for care by specialists and the perception that quality of care is better at higher level facilities (Faizi et el., 2016; Mohan and Kumar, 2019; Rural Health Information Hub, 2021).

In the public health care system in India, a referral chain arrangement exists where community-based providers and facilities provide referral advice for care seeking at the next or ever higher level on a case-to-case basis. The referral linkages are bidirectional and rather more evident for maternal health services, where first referral units have been clearly identified. Although health policies and program designs call for referral-based rationing at different tiers of the system, in practice, care can be directly sought at any health kiosk without referral from lower-level health care provider. For example, in urban areas where tertiary care settings are overburdened, the public prefers these facilities as there is a higher demand for care by specialists than by primary care physicians. It is a prevalent perception that quality of care at higher-level facilities is better than the one available at lower levels. On the other hand, in rural communities, it has been noted that care-seekers usually divert to the private providers after an initial consultation with the primary level facilities, as referral care is perceived as costly and inconvenient (Faizi et el., 2016; Mohan and Kumar, 2019; Rural Health Information Hub, 2021).

References:

Faizi, N., Khalique, N., Ahmad, A., & Shah, M. S. (2016). The dire need for primary care specialization in India: Concerns and challenges. Journal of family medicine and primary care5(2), 228–233. https://doi.org/10.4103/2249-4863.192382

Mohan, P., & Kumar, R. (2019). Strengthening primary care in rural India: Lessons from Indian and global evidence and experience. Journal of family medicine and primary care8(7), 2169–2172. https://doi.org/10.4103/jfmpc.jfmpc_426_19

Rural Health Information Hub. (2021). Healthcare access in rural communities. RHI Hub. Available from: https://www.ruralhealthinfo.org/topics/healthcare-access

Yes. The health service delivery system in Kenya is organized across six levels of care, with the first level at the community level and continuing through primary care services, which include dispensaries (level 2) and health centres (level 3), and county referral health services (level 4 & 5) all the way to the national referral health services (level 6). Higher health care facilities act as referral centres for lower-level facilities. For instance, level 1 is the foundation of health care service delivery and referral to a higher level of care is performed to seek additional services such as diagnosis, treatment, admission or to seek expert opinion (Ministry of Health, 2014d). However, sometimes patients bypass the low-level facilities depending on proximity and go directly to higher levels of care resulting to high caseloads. In some circumstances, referral by a health worker from higher to lower levels of care (except level 1) is made, particularly if the higher health facility is far from the client’s home and the client has been prescribed medicines that are available at a nearby lower health facility.

In terms of private health care, the referral chain is not structured as access to health services is based on proximity and the ability to pay for the services. Some community members access the services of community health providers (residing within their communities) while others visit nearby private clinics where referral to a specialist is made if necessary. However, patients can go directly to a specialist without a referral.

References:

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

 

Yes, within the public system (MoH and social security institutions), gatekeeper systems are in place (primary care, secondary, high specialisation), but not in the private sector.

Yes, universality is one of the principles of SUS. The SUS is based on three doctrinal principles: universality (any Brazilian citizen has the right to access health services in Brazil – this right is well stablished by the Federal Constitution, 1988), equity (aims to diminish health inequalities), and integrated care (regarding person-centred care) (Brazilian Ministry of Health, n.d.-b).

Potential barriers for universal access to health are geographical (related to distance and transportation costs to health care units), financial (the more expensive the services are, the less accessible they become), managerial (quality of personal, waiting lists etc.), and informational (related to education, self-perception of health etc.).

Access to health services is more problematic in some areas, such as riverside communities and in the countryside. Difficult access to these remote areas, in  addition to poor working conditions discourages health professionals to work in such places (Brazilian Society for Medical Clinic, 2019). As an attempt to overcome this barrier, the government developed strategies such as the fluvial family health strategies (where family health teams go to riverside communities by boat) to expand access in places like Amazonia. In addition, the National Policy for Primary Care expands the coverage of health services provision through the creation of UBSs (Basic Care Units) and emergency care units (UPAs) (Brazilian Ministry of Health, 2012). Access to health services is also problematic among indigenous people due to difficulties regarding geographical access, cultural aspects etc. Therefore, the Ministry of Health put together a specific unit responsible for delivering health services for indigenous people (Brazilian Ministry of Health, 2019p).

References:

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

Brazilian Ministry of Health. (2019p, June 20). Secretaria Especial de Saúde Indígena. https://www.gov.br/saude/pt-br/assuntos/sesai_noticias/secretaria-da-sesai-acompanha-mutirao-na-casai-de-goiania

Brazilian Ministry of Health. (n.d.-b). Princípios do SUS. Retrieved December 3, 2019.

Brazilian Society for Medical Clinic. (2019). Médicos para as áreas remotas. Sociedade Brasileira de Clínica Médica. http://www.sbcm.org.br/v2/index.php/artigo/2802-medicos-para-as-areas-remotas-

 

Access to health services remains varied (Baru et al., 2010). Several equity indicators, such as gender, literacy, geographic location (e.g., rural versus urban), and socioeconomic status, influence this (Baru et al., 2010). These operate through complex inter-woven pathways of awareness (e.g., sensitivity to symptoms; services needed), availability (e.g., service provisioning at point-of-care; distance), affordability (e.g., public versus private versus unregulated/informal care providers; generalist versus specialist care), and acceptability (e.g., basket of choices offered, quality of care, provider profile). It has been observed that access is also determined by the profile of the health condition (Kasthuri, 2018). Those with minor ailments, for example, are likely to use care since this is available at the primary level at low cost without the need for specialist opinion and advanced diagnostics (Barik and Thorat, 2015).

Access to care is poor in the empowered action group states (states in central and north-central belt of India that have traditionally had poor health and development indicators) (Kumar and Singh, 2016). Access to care services is also challenging for the urban poor residing in slums and urban settlements (Gupta and Mondal, 2015).

With respect to access to particular health care services, maternal health care service delivery has been strengthened for pregnancy and childbirth related care; however, access to postpartum services and follow up, and care services for sick new-borns (especially institutionalised care) is patchy (Paul et al., 2011). Whereas geriatric care, including home-based care and institutional facilities for adults, is limited across the country, sparing the metropolitan cities (ARDSI, 2010).

The Government of India (GOI) is committed towards addressing these challenges and achieving the goal of Universal Health Coverage (UHC) for its population, especially for the poorest, through Ayushman Bharat (Ayushman Bharat-HWCs and Ayushman Bharat-PMJAY). The Government has also made efforts to cap the cost of items (such as essential scheduled drugs, certain medical devices, consumables etc.) and regulate establishments (the Clinical Establishment Act of 2010) to secure affordability and quality in the private health sector (Ministry of Law and Justice, 2010; National Pharmaceutical Pricing Authority, 2013). However, these have coincided with failure of the private health sector and single-doctor facilities to thrive and sustain. Since most of the urban care provision is delivered by the private sector and the per capita annual public budget commitment to health (and as proportion of the national GDP) (NHSRC, 2021) by India continues to be amongst the lowest in the world, the health sector is headed for complex evolution.

References:

Alzheimer’s and Related Disorders Society of India (ARDSI). (2010). THE DEMENTIA INDIA REPORT  2010: Prevalence, impact, cost and services for dementia. New Delhi. Available from https://ardsi.org/pdf/annual%20report.pdf

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

Baru, R., Acharya, A., Acharya, S., Kumar, A. S., & Nagaraj, K. (2010). Inequities in access to health services in India: caste, class, and region. Economic and political Weekly, 49-58.

Gupta, I., and Mondal, S. (2015). Urban health in India: who is responsible? The International Journal of Health Planning and Management, 30(3), 192–203. https://doi.org/10.1002/hpm.2236

Kasthuri, A. (2018). Challenges to Healthcare in India – The Five A’s. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine, 43(3), 141–143. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166510/

Kumar, V., & Singh, P. (2016). Access to healthcare among the Empowered Action Group (EAG) states of India: Current status and impeding factors. The National medical journal of India29(5), 267.

Ministry of Law and Justice. (2010). The Clinical Establishments (Registration and Regulation) Act. Government of India. Available from: http://clinicalestablishments.gov.in/WriteReadData/969.pdf

National Health System Resource Centre (NHSRC). (2021). National Health Accounts-Estimates for India: 2017-2018. Ministry of Health and Family Welfare, Government of India. Available from: https://nhsrcindia.org/sites/default/files/2021-11/National%20Health%20Accounts-%202017-18.pdf

National Pharmaceutical Pricing Authority. (2013). List of Notified Prices. Department of Pharmaceuticals, Ministry of Chemical and Fertilizers. Government of India. Available from: https://www.nppaindia.nic.in/en/utilities/list-of-notified-prices/dpco-2013/

Paul, V. K., Sachdev, H. S., Mavalankar, D., Ramachandran, P., Sankar, M. J., Bhandari, N., … & Kirkwood, B. (2011). Reproductive health, and child health and nutrition in India: meeting the challenge. The Lancet, 377(9762), 332–349. https://doi.org/10.1016/S0140-6736(10)61492-4

Despite its recent introduction (2014), the NHIS is reported to have reached almost 70 per cent of the population (Agustina et al., 2019, p.76).

However, there appear to be substantial gaps in terms of coverage of the so-called ‘missing middle’, even though considerable subsidies and improved access to health care for those living in poverty have been established. This ‘missing middle’  represents approximately 34.4 million people who are working in informal employment but not living in poverty. While some argue that this group does not seek insurance cover due to the required premiums, others suggest that ‘availability of services and poor understanding of health insurance’ stops people from signing up (Agustina et al., 2019, p.94)

Agustina and colleagues (2019, p.76) further report that the availability and quality of primary care services, drugs, and medical supplies as well as the poor and disassociated health information systems pose challenges to the provision of universal health care in Indonesia.

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

The introduction of UHC, named “Afya Care” described above supports only 5% of the population (4 counties) during its pilot phase. In 2022, the World Bank funded programme will be rolled-out across all counties (Kariuki, 2019). In addition to the four counties covered by ‘Afya Care’, one county that is not among the trial counties has implemented‘Makueni care’ which covers access to public health services. This leaves 42 counties to rely on NHIF.  In those counties, members (formal and informal workers) have to either make monthly contributions in order to access either public or private health care or pay at the hospital similar to other community members. NHIF has contracted hospitals under three categories (A, B and C) for contributors. Under category A (government hospitals), members enjoy full and comprehensive cover (maternity and medical diseases including surgery). Category B (some private and mission hospitals), members receive a comprehensive cover but in case of a surgery, the member would co-pay.  Category C (private), members pay specified daily benefits (NHIF, 2020). If the fee in a particular hospital exceeds the insurance limit, patients are required to pay the balance. Patients are therefore encouraged to visit hospitals that are within the NHIF cover.

To become members, those working in the informal sector can opt to pay a monthly premium of 500 Kenya Shillings (about $5.00 US dollars) per household to access both outpatient and inpatient services or directly pay for the services at the point of care. The formal sector contributions are based on salary scales (representing 2.4% of the gross salary) (Okungu, Chuma, & McIntyre, 2017). In addition to issues around health care inaccessibility due to distance to health care providers (geographical characteristics)  and inability to pay for the health services (individual characteristics), quality of care is also impaired in many counties as several facilities cannot supply sufficient amounts of drugs for non-communicable diseases and also experience inadequate staffing levels (Barker, Mulaki, Mwai, & Dutta, 2014; Turin, 2010). Data collected in 2010 from a nationally representative sample of public health centers and dispensaries across all 8 provinces (before devolution) in Kenya revealed evidence of pro-rich inequalities for electricity and laboratory services, and for availability of drugs and qualified staff. Less than 20% facilities had all drugs on the tracer list in stock. These resources provide salient inputs into the quality of care provided at health facilities (Toda et al., 2012). Societal (social and cultural) factors can also influence health seeking behavior, for instance, past interactions with a favorable view of services may result in continuing visit to the same provider. Similarly, stigma around certain conditions is a contributor to where and how people seek or avoid seeking care (Turin, 2010). Provider characteristics also provide a range of actions that a person can take when in need of care (Awiti, 2014).

References:

Awiti, J. O. (2014). Poverty and health care demand in Kenya. BMC Health Services Research, 14(1), Pp. 560. https://doi.org/10.1186/s12913-014-0560-y

Barker, C., Mulaki, A., Mwai, D., & Dutta, A. (2014). Devolution of healthcare in Kenya assessing county health system readiness in Kenya: a review of selected health inputs. Washington, D.C. https://doi.org/10.13140/RG.2.2.36622.87363

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

NHIF. (2020). Inpatient services.

Okungu, V., Chuma, J., & McIntyre, D. (2017). The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms. International Journal for Equity in Health, 16(1), 39. JOUR. https://doi.org/10.1186/s12939-017-0535-9

Toda, M., Opwora, A., Waweru, E., Noor, A., Edwards, T., Fegan, G., … Goodman, C. (2012). Analyzing the equity of public primary care provision in Kenya: variation in facility characteristics by local poverty level. International Journal for Equity in Health, 11(1), 75. https://doi.org/10.1186/1475-9276-11-75

Turin, D. R. (2010). Health Care Utilization in the Kenyan Health System: Challenges and opporunities. Inquiries Journal, 2(9), 2–3. http://www.inquiriesjournal.com/articles/284/health-care-utilization-in-the-kenyan-health-system-challenges-and-opportunities

Social protection in health is granted to all Mexicans as a right by the fourth article of the Constitution. However, different issues make access unequal and undermine the achievement of universal coverage that the Mexican government strives for. Among these issues is the absence of a universal national health system, access to health service (and social security) based on employment and insurance status, as well as unequal social and economic development throughout the states that results in differences in the development of the infrastructure and human resources available. Thus, unequal access and quality of care between urban and rural areas, northern and southern states, and between those covered by social security, public and private sector insurance schemes are observed (OECD, 2017a).

Program-based health care also has meant that health care provision focuses on some illnesses, age groups or conditions (pregnancy and birth, diabetes, hypertension, reproductive health), leaving some age groups, such as older adults, and conditions such as AD and other dementias, underserved. As such, those who access the private sector could get a consultation with a geriatrician or dementia specialist any time, while referrals to these specialists in the public sector are practically inexistent given the low number of public posts of these within the public sector.

References:

OECD. (2017a). Estudios Económicos de la OCDE México (OCDE Publishing, Ed.). OCDE Publishing. https://www.oecd.org/eco/surveys/mexico-2017-OECD-Estudios-economicos-de-la-ocde-vision-general.pdf