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Evidence for overuse of medical services around the world
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
Journal Article
Levers for addressing medical underuse and overuse: achieving high-value health care
The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
Journal Article
Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia
In Cambodia, diabetes caused nearly 3% of the country’s mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ( $27 per DALY averted) and increases in financial risk protection ($ 2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated$28 and $ 58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.
Journal Article
Implementation of national action plans on noncommunicable diseases, Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam
By 2016, Member States of the World Health Organization (WHO) had developed and implemented national action plans on noncommunicable diseases in line with the
In 2018, we assessed the implementation status of the recommended best-buy noncommunicable diseases interventions in seven Asian countries: Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam. We gathered data from a range of published reports and directly from health ministries. We included interventions that addressed the use of tobacco and alcohol, inadequate physical activity and high salt intake, as well as health-systems responses, and we identified gaps and proposed solutions. In 2018, progress was uneven across countries. Implementation gaps were largely due to inadequate funding; limited institutional capacity (despite designated noncommunicable diseases units); inadequate action across different sectors within and outside the health system; and a lack of standardized monitoring and evaluation mechanisms to inform policies. To address implementation gaps, governments need to invest more in effective interventions such as the WHO-recommended best-buy interventions, improve action across different sectors, and enhance capacity in monitoring and evaluation and in research. Learning from the Framework Convention on Tobacco Control, the WHO and international partners should develop a standardized, comprehensive monitoring tool on alcohol, salt and unhealthy food consumption, physical activity and health-systems response.
Journal Article
Harnessing Country Experiences for Health Benefit Package Design: Evidence-Informed Deliberative Processes and Experiences from the Joint Learning Network; Comment on\ Evidence-Informed Deliberative Processes for Health Benefit Package Design – Part II: A Practical Guide\
Amidst competing priorities for allocating finite health resources, using evidence-informed priority setting is a valuable tool for achieving population-level health goals. The paper by Baltussen, Jansen, and Oortwin (2021) comprehensively reports on the development of practical guidance for evidence-informed deliberative processes (EDPs) which will help with sustainability of programs aimed at universal health coverage (UHC). The authors’ experience with the Joint Learning Network for UHC’s (JLN) peer-to-peer learning platform on evidence-informed priority setting offers insights on the practical challenges faced by countries in HBP design, especially to draw in actors to advocate for the priorities and values across the health system. Lessons harvested from JLN countries that have established such advisory committees can provide practical insights for countries in earlier stages of establishing a systematic process for HBP design. Peer-to-peer learning modalities among countries offer viable and effective approaches to institutionalizing EDPs and systematic priority setting.
Journal Article
Government-sponsored health insurance in india
Since independence, India has struggled to provide its people with universal health coverage. Whether defined in terms of financial protection or access to and effective use of health care, the majority of Indians remain irregularly and incompletely covered. Finally, and most recently, a new generation of Government-Sponsored Health Insurance Schemes (GSHISs) has emerged to provide the poor with financial coverage. Briefly, the main objective of these new GSHISs was to offer financial protection against catastrophic health shocks, defined in terms of an inpatient stay. Between 2007 and 2010, six major schemes have emerged, including one sponsored by the Government of India (GOI) and five state-sponsored schemes. This new wave of schemes provides fully subsidized coverage for a limited package of secondary or tertiary inpatient care, targeting below poverty populations. Similar to the private voluntary insurance products in the country, ambulatory services including drugs are not covered except as part of an episode of illness requiring an inpatient stay. The schemes have organized hospital networks consisting of public and private facilities, and most care funded by these schemes is provided in private hospitals. Ostensibly, the objective of any health insurance scheme is to increase access, utilization, and financial protection, and ultimately improve health status. Due to lack of evaluations and analyses of household data, the authors of this book do not examine the impact of health insurance in terms of these objectives. This book is not meant to highlight problems of the GSHISs, but rather to raise potential challenges and emerging issues that should be addressed to ensure the long-term viability of these schemes and secure their place within the health finance and delivery system.
eBook
Health equity funds as the pathway to universal coverage in Cambodia: care seeking and financial risk protection
Abstract
Cambodia has developed the health equity fund (HEF) system to improve access to health services for the poor, and this strengthens the health system towards the universal health coverage goal. Given rising healthcare costs, Cambodia has introduced several innovations and accomplished considerable progress in improving access to health services and catastrophic health expenditures for the targeted population groups. Though this is improving in recent years, HEF households remain at the higher risk of catastrophic spending as measured by the higher share of HEF households with catastrophic health expenses being at 6.9% compared to the non-HEF households of 5.5% in 2017. Poverty targeting poses another challenge for the health system. Nevertheless, HEF appeared to be more significantly associated with decreased out-of-pocket expenditure per illness among those who sought care from public providers. Increasing population and cost coverages of the HEF and effectively attracting beneficiaries to the public sector will further enhance the financial protection and pave the pathway towards universal coverage. Our recommendations focus on leveraging the HEF experience for expanding coverage and increasing equitable access, as well as strengthening the quality of healthcare services.
Journal Article
Going Universal
This book is about 24 developing countries that have embarked on the journey towards universal health coverage (UHC) following a bottom-up approach, with a special focus on the poor and vulnerable, through a systematic data collection that provides practical insights to policymakers and practitioners. Each of the UHC programs analyzed in this book is seeking to overcome the legacy of inequality by tackling both a \"financing gap\" and a \"provision gap\": the financing gap (or lower per capita spending on the poor) by spending additional resources in a pro-poor way; the provision gap (or underperformance of service delivery for the poor) by expanding supply and changing incentives in a variety of ways. The prevailing view seems to indicate that UHC require not just more money, but also a focus on changing the rules of the game for spending health system resources. The book does not attempt to identify best practices, but rather aims to help policy makers understand the options they face, and help develop a new operational research agenda. The main chapters are focused on providing a granular understanding of policy design, while the appendixes offer a systematic review of the literature attempting to evaluate UHC program impact on access to services, on financial protection, and on health outcomes.
eBook
Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes
Objectives To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality. Design Geographic regression discontinuity study. Setting 572 villages in Karnataka, India. Participants 31 476 households (22 796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28 633 households (21 767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme. Intervention A government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012. Main outcome measure Out-of-pocket expenditures, hospital use, and mortality. Results Among households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, −0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (−5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality. Conclusions Insuring poor households for efficacious but costly and underused health services significantly improves population health in India.
Journal Article