Browsing by Subject "Health policy"

Background. Since the late 2000s, universal health coverage (UHC) has been identified as an important goal, which is to ensure people’s access to needed health services without suffering from financial hardships. Many countries have adopted health insurance reform as an important approach to meet the goal of UHC. China and Vietnam are two countries that have made great progress through this approach. China covered more than 97% of entire population in 2011, while Vietnam just reached 80% in 2017. Compared with the universal service package in Vietnam, the health insurance in China has been criticized for its limited benefit package and failure to protect patients from financial risks. To compare the development of health insurance and its influence on the attainment of UHC, a mix-method study was conducted in China and Vietnam.

Methods. A policy review was included to compare the important health insurance policies in these two countries. Guided by the WHO UHC model, national-level data on health financing, population coverage, health service use and financial protection were quantitatively analyzed. The quantitative result was present with qualitative data extracted from 16 interviews with UHC scholars, policymakers, and local government agency officers to provide a comprehensive comparison of the health insurance development in China and Vietnam.

Result. Along with the great political efforts to develop the health insurance, a large amount of financial resource for health and health insurance has also been devoted to health insurance. A trend toward health financing through social security fund has been observed in both countries. Regarding the health insurance policy development, China has prioritized the population coverage rate at an early stage. Through extensive subsidies for enrollees of the New Rural Medical Insurance Scheme (NCMS) and Urban Resident Medical Insurance Scheme (URBMI), 97% of China’s total population has been covered since 2011. However, the insurance benefit design is very shallow and has a clear focus on inpatient services. As a result, although an increased use of inpatient services was observed, the real financial burden actually rose. The government has started to increase the benefits package since 2009. A greatly increased government budget and improved benefit package have been observed with a decrease of the financial burden. Meanwhile, there are still gaps between the policy and real implementation, the disparities between benefit packages, health services use and, financial risks still exist among different schemes.

The development of health insurance in Vietnam depends on the expansion of the compulsory scheme. Since 2003, the Vietnamese government has started to increase the number of compulsory groups and gradually introduce a government subsidy for the vulnerable people, including the poor, children, the old and the near poor. A high population coverage rate has been achieved among all the subsidized groups. The service coverage is wide in scope and the reimbursement rate has a pro-poor design. Compared with China, there is no obvious trend on service use. The health insurance in Vietnam also provides better financial protection and has achieved a better equity with protecting the vulnerable groups than in China.

Several important lessons were learned from this comparison between China and Vietnam. The government political and financial input are essential drivers for health insurance development. Government subsidy for premium is a common approach to financing the health insurance and encourage enrollment, which is also proved to be effective in both two countries. The service package design has a strong influence on the health service use pattern and the financial burden. The design of the insurance needs to focus more on equity. The vulnerable groups, especially the poor are still disproportionately suffering from the financial risk caused by using health services and this is still a common challenge facing both China and Vietnam.

Background: Peru had more COVID-related deaths per capita than any other country. Given its relative wealth as an Upper Middle Income Country, Peru did not receive many COVID vaccine donations through COVAX, and challenges directly negotiating for vaccines with pharmaceutical companies delayed Peru’s initial response. However, once vaccines were procured, Peru successfully initiated wide-spread vaccination campaigns. This study was done to understand Peru’s unique COVID challenges and successes and aims to explore barriers and enablers of Peru’s pandemic response to offer lessons for the scale-up of vaccinations, health innovations, and pandemic response capacity in Peru, Latin America, and globally. Methods: 31 semi-structured in- depth interviews were conducted in Lima, Peru with 35 individuals from public, private, academia, healthcare, and civil society sectors that worked in diverse geographies across Peru. Participants were recruited through purposeful and snowball sampling via WhatsApp, based on the inclusion criteria of being involved in Peru’s COVID-19 pandemic response and preparedness (i.e., with vaccine procurement and distribution, emergency health innovations, and community responses). Ethics approval was received from the Duke University Campus Institutional Review Board. Written and verbal consent was obtained from participants before each interview. A qualitative content analysis is currently being done on the interview transcripts. Afterwards a force field analysis will be applied to understand which factors most negatively and positively impacted Peru’s pandemic response capacity. Results: Preliminary findings from the 31 interviews indicate political instability, cross-sector competition, a fragmented health system, and limited medical resource manufacturing and regulations limited Peru’s pandemic response. However, previous experience with vaccination campaigns, community-based support, and cross-sector collaboration influenced effective COVID vaccine distribution and vaccination levels. Conclusion: Peru experienced some small-scale effective COVID response measures, but these were overshadowed by large-scale systemic and political issues, hindering Peru’s pandemic response. This study explores economic, cultural, political, and social factors that impacted Peru’s COVID response, and includes diverse perspectives from various sectors and geographies, increasing the validity and generalizability of findings. However, future studies should include equal representation of sectors and geographies, as most participants represent the public sector and worked in Lima.

Background: Outbreaks of infectious diseases such as Ebola have dramatic economic impacts on affected nations due to significant direct costs and indirect costs, as well as increased expenditure by the government to meet the health and security crisis. Despite its dense population, Nigeria was able to contain the outbreak swiftly and was declared Ebola free on 13th October 2014. Although Nigeria’s Ebola containment success was multifaceted, the private sector played a key role in Nigeria’s fight against Ebola. An epidemic of a disease like Ebola, not only consumes health resources but also detrimentally disrupts trade and travel to impact both public and private sector resulting in the ‘fearonomic’ effect of the contagion. In this thesis, I have defined ‘fearonomics’ or the ‘fearonomic effects’ of a disease as the intangible and intangible economic effects of both informed and misinformed aversion behavior exhibited by individuals, organizations, or countries during an outbreak. During an infectious disease outbreak, there is a significant potential for public-private sector collaborations that can help offset some of the government’s cost of controlling the epidemic.

Objective: The main objective of this study is to understand the ‘fearonomics’ of Ebola in Nigeria and to evaluate the role of the key private sector stakeholders in Nigeria’s Ebola response.

Methods: This retrospective qualitative study was conducted in Nigeria and utilizes grounded theory to look across different economic sectors in Nigeria to understand the impact of Ebola on Nigeria’s private sector and how it dealt with the various challenges posed by the disease and its ‘fearonomic effects'.

Results: Due to swift containment of Ebola in Nigeria, the economic impact of the disease was limited especially in comparison to the other Ebola-infected countries such as Liberia, Sierra Leone, and Guinea. However, the 2014 Ebola outbreak had more than a just direct impact on the country’s economy and despite the swift containment, no economic sector was immune to the disease’s fearonomic impact. The potential scale of the fearonomic impact of a disease like Ebola was one of the key motivators for the private sector engagement in the Ebola response.

The private sector in Nigeria played an essential role in facilitating the country’s response to Ebola. The private sector not only provided in-cash donations but significant in-kind support to both the Federal and State governments during the outbreak. Swift establishment of an Ebola Emergency Operation Centre (EEOC) was essential to the country’s response and was greatly facilitated by the private sector, showcasing the crucial role of private sector in the initial phase of an outbreak. The private sector contributed to Nigeria’s fight against Ebola not only by donating material assets but by continuing operations and partaking in knowledge sharing and advocacy. Some sector such as the private health sector, telecom sector, financial sector, oil and gas sector played a unique role in orchestrating the Nigerian Ebola response and were among the first movers during the outbreak.

This paper utilizes the lessons from Nigeria’s containment of Ebola to highlight the potential of public-private partnerships in preparedness, response, and recovery during an outbreak.

Many factors affect responsiveness of elected policy makers to public opinion. While a full understanding of this topic is not possible without decades of careful research, this dissertation examines a few important areas. In particular, I look at the effects of party competition on legislator responsiveness, the dynamics of interest group politics and the ability of some voters to obtain disproportionate representation, and the nuances of how to interpret public opinion itself for a specific policy.

The first two chapters, on party competition and interest groups, make use of secondary data generated by the government, other scholars, and various relevant organizations. The chapters employ data on the behaviors and characteristics of members of Congress, election results, campaign finance data, and population and demographic information. Using appropriate econometric models, I find in chapter 1 that significant competition between the two major parties does serve to increase responsiveness to the public at the level of the individual legislator, with effects at the aggregate level being somewhat weaker. In recent years, it is difficult to estimate these effects because of the generally high levels of party competition and low variance across district.

Using similar data and methods, the exploratory analysis in chapter 2 suggests a relationship between unorganized groups of voters and the positions their elected officials take, independent of party, district average public opinion, and organized interest group contributions. The results also suggest that context matters a great deal in determining which groups will be influential.

Chapter 3 examines the nature of public opinion itself, using the Affordable Care Act as a case study. I conducted a survey experiment to assess how the distribution of opinions on the Affordable Care Act might change in response to priming different design features of the law. My findings indicate that opinion on the ACA is malleable and depends on what pieces of the law people think about at the time of response. In the real world, this implies that which parts of the ACA are highlighted and how it is discussed publicly will affect its future. Policy pork, as defined in the chapter, can build up support, but wedge provisions in the law can serve to entrench the opposition further. These implications can also be applied to other complex, highly visible reform bills.

A final concluding chapter attempts to apply these findings, as well as other political science research, to the case of the Medicare Access and CHIP Reauthorization Act (MACRA). Based on my assessment of the political context of this act, which was hailed as a permanent resolution to a longstanding debate over Medicare provider payments, I argue that the debate is not actually over, and that group interests, the design of the law, and broader contextual factors will ensure the debate continues.

Electroencephalography (EEG), a neuroscience method which requires sustained access to the scalp and hair, has many clinical and research applications. It is an essential feature of the rapidly growing consumer neurotechnology market. Neuroethicists have criticized EEG for being unaccommodating to phenotypic differences in hair type - a flaw which contributes to the systematic exclusion of minority groups from research. This exclusion legitimizes concerns about the generalizability of EEG research and effectiveness of EEG-based technologies. The following report employs a review of the most current literature across neuroscience, ethics, and technology publication sources to demonstrate how exclusion EEG research creates gaps in theoretical knowledge that disproportionately impact minorities and have profound implications for medical and consumer products. This paper summarizes the many applications of EEG and examines the impact of exclusion on EEG-based research and technology development. It outlines the risks of maintaining exclusion and provides policy recommendations for how to mitigate those risks by prioritizing inclusion in research methods.

Background: Since December 2015, the World Health Organization (WHO) Research and Development (R&D) Blueprint for Action to Prevent Epidemics1 has maintained a list of 10 priority pathogens that have a high epidemic and pandemic potential and no or few medical countermeasures (MCMs, i.e., vaccines, diagnostics, and therapeutics). Barriers to facilitating R&D for these MCMs include lack of information on what candidate MCMs are currently in the pipeline, the estimated costs to advance this portfolio of candidates through the pipeline and the anticipated product launches. This study aimed to help close these information gaps, focusing specifically on the pipeline of therapeutics for the 10 “Blueprint diseases”. Methods: We conducted a pipeline portfolio review to summarize which candidate therapeutics against the 10 priority diseases are currently in the pipeline, and at what development phase. Based on this pipeline, we then estimated the costs of moving these candidates through the pipeline, using a modified version of a financial modeling tool called the Portfolio to Impact (P2I) model. The model also estimates likely product launches. Based on the current pipeline, there would be no launches of therapeutics for several of the 10 diseases; we used the model to estimate the additional costs to launch these “missing” products. Results: The pipeline portfolio review identified 78 candidate therapeutics for the 10 Blueprint diseases as of December 3rd, 2018. The pipeline is dominated by Zika and Ebola, whereas the other Blueprint pathogens have very few candidates. The P2I model estimates that it would cost $1.76 billion to move these current candidates through the pipeline from 2019 to 2030, which would lead to an estimated 8.78 cumulative product launches. These launches would be dominated by simple biologics (n=2.30) and simple repurposed drugs (n=4.92). The three diseases that are likely to have the most product launches are Ebola (n=3.21), Zika (n=2.91), and Rift Valley Fever [RVF] (n=1.42). For the other seven Blueprint diseases, the model suggested there would be no launches of therapeutics. We estimated that it would cost an additional $0.64 billion to $1.46 billion dollars to launch these “missing“ therapeutics (i.e., one therapeutic for each of these seven diseases), depending on the complexity of the product type. Conclusions: Our study found that while the current pipeline is likely to lead to launches of therapeutics for three of the Blueprint diseases—Ebola, Zika, and RVF—it is unlikely that there would be launches for the other diseases. We hope our results will help to mobilize additional financing and to inform new funding mechanisms, which are urgently needed for emergency response and preparedness against the highest threat diseases. We also hope that the study results will help identify where the pipeline has gaps, so that funding can be better directed to areas of greatest need.

After the 2012 London Summit on Family Planning, there have been major strides in advancing the family planning agenda for low and middle-income countries worldwide. Much of the existing infrastructure and funding for family planning access is in the form of supplying free contraceptives to countries. While the average yearly value of donations since 2000 was over 170 million dollars for contraceptives procured for developing countries, an ongoing debate in the empirical literature is whether increases in contraceptive access and supply drive declines in fertility (UNFPA 2014).

This dissertation explores the fertility and behavioral effects of an increase in contraceptive supply donated to Zambia. Zambia, a high-fertility developing country, receives over 80 percent of its contraceptives from multilateral donors and aid agencies. Most contraceptives are donated and provided to women for free at government clinics (DELIVER 2015). I chose Zambia as a case study to measure the relationship between contraceptive supply and fertility because of two donor-driven events that led to an increase in both the quantity and frequency of contraceptives starting in 2008 (UNFPA 2014). Donations increased because donors and the Zambian government started a systematic method of forecasting contraceptive need on December 2007, and the Mexico City Policy was lifted in January 2009.

In Chapter 1, I investigate whether a large change in quantity and frequency of donated contraceptives affected fertility, using available data on contraceptive donations to Zambia, and birth records from the 2007 and 2013 Demographic and Health Surveys. I use a difference-in-difference framework to estimate the fertility effects of a supply chain improvement program that started in 2011, and was designed to ensure more regularity of contraceptive supply. The increase in total contraceptive supply after the Mexico City Policy was rescinded is associated with a 12 percent reduction in fertility relative to the before period, after controlling for demographic characteristics and time controls. There is evidence that a supply chain improvement program led to significant fertility declines for regions that received the program after the Mexico City Policy was rescinded.

In Chapter 2, I explore the effects of the large increase in donated contraceptives on modern contraceptive uptake. According to the 2007 and 2013 Demographic and Health Surveys, there was a dramatic increase in current use of injectables, implants, and IUDs. Simultaneously, declines occurred in usage of condoms, lactational amenorrhea method (LAM), and traditional methods. In this chapter, I estimate the effect of the increase in donations on uptake, composition of contraceptive usage, and usage of methods based on distance to contraceptive access points. The results show the post-2007 period is associated with an increase in usage of injectables and the pill among women living further away from access points.

In Chapter 3, I explore attitudes towards the contraceptive supply system, and identify areas for improvement, based on qualitative interviews with 14 experts and 61 Zambian users and non-users of contraceptives. The interviews uncover systemic barriers that prevent women from consistently accessing methods, and individual barriers that exacerbate the deficiencies in supply chain procedures. I find that 39 out of 61 women interviewed, both users and non-users, had personal experiences with stock out. The qualitative results suggest that the increase in contraceptives brought to the country after 2007 may have not contributed to as large of a decline in fertility because of bottlenecks in the supply chain, and problems in maintaining stock levels at clinics. I end the chapter with a series of four recommendations for improvements in the supply chain going forward, in light of recent commitments by the Zambian government during the 2012 London Summit on Family Planning.

Background: Human Resource for Health (HRH) is one of the most important building blocks of the health system. The performance of the health systems is substantially impacted by the performance of health workers. Egypt has a highly fragmented health care system. Health services in Egypt are currently managed, financed, and provided by agencies in both public and private sectors. Egypt's health system has limited government oversight of the private sector and more open-ended healthcare market, which has contributed to a complexity of Public Private Mix (PPM). Since 1996, Egypt has been undergoing the Health Sector Reform Program (HSRP) with the aim of achieving universal healthcare coverage of the country. This study was conducted to contribute to the evidence in understanding the PPM of HRH in Egypt, towards contributing to the national dialogue to address related issue with its governance and development. Methods: This study uses qualitative method and literature review to approach the research topic. We visited 4 public hospitals and 3 private hospitals in Cairo, Benha and Fayoum in May to July, 2014. We conducted 45 in-depth interviews with health workers and 5 key-informant interviews with health policy experts. Document reviews were conducted from December 2013 to February 2015. Documents relevant to the country context and health profile were retrieved through PubMed and Google Scholar. Government activity and statistics were retrieved through openly published government report and reports from international organizations. An interview guide was developed and pretested. Interviews were recorded and transcribed. Data analysis began while data collection was still ongoing. Using a grounded theory approach, we reviewed the transcripts of interviews and coded with a table of key words. Codes and transcripts were double-checked for accuracy, based on which relevant themes were decided. We also compared the codes and transcripts among different stakeholders. Results: Egypt has a highly fragmented health care system. Health services in Egypt are currently financed and provided by a mix of agencies in both public and private sectors. The uncontrolled growth of private sector has impacted the performance of health workers. Dual practice, the practice of a health worker simultaneously engaging in both the public and private sector, is a prevailing phenomenon in the health workforce in Egypt. Dissatisfaction with the public salary is considered as the main reason which drives health workers to private sector. While pursuing private practice, most people still hold their position in public sector for a variety of reasons. Perceived as a mechanism to compensate the low salary in public sector, dual practice is accepted in the current Egyptian health system despite well-recognized negative impacts on the quality of care. Conclusions: A vast majority of doctors in Egypt has been involved in dual practice, while the prevalence of dual practice is much lower in nurses than in doctors. Financial concerns drive Egyptian doctors to conduct private practice. Meanwhile, most of them still hold their public posts, with various reasons including to gain clinical experience, academic titles, professional reputation, etc. Comparing with doctors, smaller proportion of nurses engage in dual practice as nurses tend to have longer shift time, less significant difference between public and private salaries, and more family responsibility. Dual practice helps to compensate the low salary in public sector although it is considered to negatively impact the quality of care in public sector. However, there is lack of rigorous regulations being implemented to govern the dual practice in Egypt. The weakness in health workforce management in public sector, especially in retention and performance evaluation, is interacting with the regulation and impact of dual practice in the country. The international experience indicates that definitive answer to cope with dual practice is not available and there is no uniform recipe to deal with the issue of dual practice. Further research is needed for the design of the approach to break the vicious circle of weak public capacity and unregulated dual practice, and to make use of HRH as a potential component to bridge public and private sector. It is also necessary to quantify and evaluate the impact of dual practice on social welfare from the perspectives of different stakeholders. Additionally, structural interventions are sorely needed in strengthening public sector and integrating private sector into the overall health system reform.