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Specialist groups have often advised health ministers and other decision makers in developing countries on the use of social health insurance (SHI) as a way of mobilizing revenue for health, reforming health sector performance, and providing universal coverage. This book reviews the specific design and implementation challenges facing SHI in low- and middle-income countries and presents case studies on Ghana, Kenya, Philippines, Colombia, and Thailand.

Background Privatization is widely perceived as a tool to improve healthcare access; however, its impact on the access of surgical care has not been quantified. We used cholecystectomy as a model to assess the variation in access between coexisting public (PB) and private providers (PVs). Methods We performed cross-sectional analysis of patients who underwent cholecystectomy at two major PB and PV groups serving Riyadh, Saudi Arabia. Representative sample sizes were estimated based on 95 % confidence level and ±5 confidence interval (CI). Exclusion criteria were major comorbidities, emergency cholecystectomies, age ≥60 and concurrent non-minor procedures. Data collected were patients’ demographics, payer status, and durations of symptoms, diagnosis and hospitalization. Results Between 2012 and 2104, samples of 330 and 297 were randomly selected from the total of 2164 and 1315 cases performed at PV and PB, respectively. Seventy-eight PV and 73 PB cases were excluded. The distribution of publically funded/insured/self-paid was (3/179/70 PV) and (209/0/4 PB), respectively. Median durations between symptoms and surgery for PV and PB cases were 90 and 365 days ( P  < 0.001), respectively, while the wait times after ultrasound-based diagnosis were 125 and 11 days ( P  < 0.001), respectively. Median hospitalization time was significantly shorter in PV compared to PB (1 vs. 2 days, P  = 0.001), and same-day admissions were more frequent in PV 94 % than PB 41 % (RR 2.3, CI 1.9–2.7). Conclusions When coexist in a competitive environment, PV offers a remarkably better access to cholecystectomies compared to PB. Facilitating access to PV can be an effective strategy to improve patient’s access to surgical care.

It has been more than 20 years since Brazil's 1988 Constitution formally established the Unified Health System (Sistema Unico de Saude, SUS). Building on reforms that started in the 1980s, the SUS represented a significant break with the past, establishing health care as a fundamental right and duty of the state and initiating a process of fundamentally transforming Brazil's health system to achieve this goal. This report aims to answer two main questions. First is have the SUS reforms transformed the health system as envisaged 20 years ago? Second, have the reforms led to improvements with regard to access to services, financial protection, and health outcomes? In addressing these questions, the report revisits ground covered in previous assessments, but also brings to bear additional or more recent data and places Brazil's health system in an international context. The report shows that the health system reforms can be credited with significant achievements. The report points to some promising directions for health system reforms that will allow Brazil to continue building on the achievements made to date. Although it is possible to reach some broad conclusions, there are many gaps and caveats in the story. A secondary aim of the report is to consider how some of these gaps can be filled through improved monitoring of health system performance and future research. The introduction presents a short review of the history of the SUS, describes the core principles that underpinned the reform, and offers a brief description of the evaluation framework used in the report. Chapter two presents findings on the extent to which the SUS reforms have transformed the health system, focusing on delivery, financing, and governance. Chapter three asks whether the reforms have resulted in improved outcomes with regard to access to services, financial protection, quality, health outcomes, and efficiency. The concluding chapter presents the main findings of the study, discusses some policy directions for addressing the current shortcomings, and identifies areas for further research.

Ghana has committed politically, legislatively, and fiscally to providing universal health insurance coverage for its population with the intent of reducing financial barriers to utilization of health care.. However, under current cost and enrollment projections the system will not be financially sustainable in the long term, so there is more work to do. This book provides an important evidence-based review of the current performance of Ghana's health system and options for reform. As such, it provides an overall picture of the Ghana health sector, how things were and how things have changed, as well as a situational analysis of the performance of the health delivery and health financing systems using the latest available data. Finally, it discusses key reform issues and options in the context of the country's likely fiscal space. An important and valuable contribution of this book is its examination of how Ghana is performing compared to its neighboring countries and compared to other countries with similar incomes and health spending, providing global benchmarks for Ghana's health system performance.

Background Refugees, asylum seekers, and migrants without status experience precarious living and working conditions that disproportionately expose them to coronavirus disease 2019 (COVID-19). In the two most populous Canadian provinces (Quebec and Ontario), to reduce the vulnerability factors experienced by the most marginalized migrants, the public and community sectors engage in joint coordination efforts called intersectoral collaboration. This collaboration ensures holistic care provisioning, inclusive of psychosocial support, assistance to address food security, and educational and employment assistance. This research project explores how community and public sectors collaborated on intersectoral initiatives during the COVID-19 pandemic to support refugees, asylum seekers, and migrants without status in the cities of Montreal, Sherbrooke, and Toronto, and generates lessons for a sustainable response to the heterogeneous needs of these migrants. Methods This theory-informed participatory research is co-created with socioculturally diverse research partners (refugees, asylum seekers and migrants without status, employees of community organizations, and employees of public organizations). We will utilize Mirzoev and Kane’s framework on health systems’ responsiveness to guide the four phases of a qualitative multiple case study (a case being an intersectoral initiative). These phases will include (1) building an inventory of intersectoral initiatives developed during the pandemic, (2) organizing a deliberative workshop with representatives of the study population, community, and public sector respondents to select and validate the intersectoral initiatives, (3) interviews ( n  = 80) with community and public sector frontline workers and managers, municipal/regional/provincial policymakers, and employees of philanthropic foundations, and (4) focus groups ( n  = 80) with refugees, asylum seekers, and migrants without status. Qualitative data will be analyzed using thematic analysis. The findings will be used to develop discussion forums to spur cross-learning among service providers. Discussion This research will highlight the experiences of community and public organizations in their ability to offer responsive services for refugees, asylum seekers, and migrants without status in the context of a pandemic. We will draw lessons learnt from the promising practices developed in the context of COVID-19, to improve services beyond times of crisis. Lastly, we will reflect upon our participatory approach—particularly in relation to the engagement of refugees and asylum seekers in the governance of our research.

Background: Private health care services were officially recognized in Vietnam in 1989, and for the last 15 years have competed with the public health system in providing primary curative care and pharmaceutical sales to rural populations. However, the quality of these private and public health care services has not been evaluated and compared. Methods: A community-based survey was conducted in 30 of the 160 communes in Hung Yen, which were selected by probability proportional to population size (PPS) sampling. All commune health centres (CHCs) and private health care providers in the selected communes were surveyed on human resources, services provided, availability of medical equipment and pharmaceuticals, knowledge and clinical performance for acute and chronic problems. Patient satisfaction and cost of care associated with recent illness were measured using a random household survey covering 30 households from each of the selected communes. Results: There were 11.5 private providers per 10 000 population, compared with 6.7 public providers per 10 000. A quarter of private providers were employees of the public health sector. Less than 20% of the private providers had registered their practice with the government system. Eleven per cent (26/234) had no professional qualifications. Fifty-eight per cent (135/234) provided treatment as well as selling medications. Public sector infrastructure was superior to that of the private providers. The quality of services provided by public providers was poor but significantly better than that of private providers. Patient satisfaction and costs of care were similar between the two groups. Conclusions: Private providers are successfully competing with the public health centre system in rural areas but not because they provide cheaper or better services. The quality of private health care services is not controlled and is significantly poorer than public services. Current practice in both systems falls below the national standard, especially for the management of chronic health problems. The low quality of health care services at a community level may help explain the previously observed phenomena of high levels of self-medicating, low utilization of commune health centres and over-utilization of tertiary health care facilities.

Background Health workers are at high risk of job burnout. Primary care in China has recently expanded its scope of services to a broader range of public health services in addition to clinical care. This study aims to measure the prevalence of burnout and identify its associated factors among clinical care and public health service providers at primary care facilities. Methods A cross-sectional survey (2018) was conducted among 17,816 clinical care and public health service providers at 701 primary care facilities from six provinces. Burnout was measured by the Chinese version of the Maslach Burnout Inventory-General Scale, and multilevel linear regression analysis was conducted to identify burnout’s association with demographics, as well as occupational and organisational factors. Results Overall, half of the providers (50.09%) suffered from burnout. Both the presence of burnout and the proportion of severe burnout among public health service providers (58.06% and 5.25%) were higher than among clinical care providers (47.55% and 2.26%, respectively). Similar factors were associated with burnout between clinical care and public health service providers. Younger, male, lower-educated providers and providers with intermediate professional title, permanent contract or higher working hours were related to a higher level of burnout. Organisational environment, such as the presence of a performance-based salary system, affected job burnout. Conclusions Job burnout is prevalent among different types of primary care providers in China, indicating the need for actions that encompass the entirety of primary care. We recommend strengthening the synergy between clinical care and public health services and transforming the performance-based salary system into a more quality-based system that includes teamwork incentives.

Background Preventive health services play a vital role in population health. However, access to such services is not always equitably distributed. In this article, we examine the barriers affecting utilisation rates of preventive health services, using Chile as a case study. Methods We conducted a cross-sectional study analysing secondary data from 206,132 Chilean adults, taken from the 2015 National Socioeconomic Characterisation Survey of the Government of Chile. We carried out logistic regressions to explore the relationship between the dependent variable use of preventive services and various demographic and socioeconomic variables. Results Categories more likely to use preventive services were women (OR=1.16; 95%CI: 1.11–1.21) and inactive people (OR=1.41; 95%CI: 1.33–1.48). By contrast, single individuals (OR= 0.85 ; 95%CI: 0.80–0.91) and those affiliated with the private healthcare provider (OR= 0.89; 95%CI: 0.81–0.96) had fewer odds of undertaking preventive exams. Conclusions The findings underline the necessity of better information campaigns on the availability and necessity of preventive health services, addressing health inequality in accessing health services, and tackling lifestyle-related health risks. This is particularly important in countries – such as Chile – characterised by high income inequality and low utilisation rates of preventive health services.

Objective. The merits of mixed public and private health systems are debated. Although private providers have become increasingly important in the Indonesian health system, there is no comprehensive assessment of the quality of private facilities. This study examined the quality of physical resources of public and private facilities in Indonesia from 1993 to 2007. Design and Setting. Data from the Indonesian Family life Surveys in 1993, 1997, 2000 and 2007 were used to evaluate trends in the quality of physical resources for public and private facilities, stratified by urban/rural areas and Java-Bali/outer Java-Bali regions. Main Outcome Measures. The quality of six categories of resources was measured using an adapted MEASURE Evaluation framework. Results. Overall quality was moderate, but higher in public than in private health facilities in all years regardless of the region. The higher proportion of nurses and midwives in private practice was a determinant of scope of services and facilities available. There was little improvement in quality of physical resources following decentralization. Conclusions. Despite significant increases in public investment in health between 2000 and 2006 and the potential benefits of decentralization (2001), the quality of both public and private health facilities in Indonesia did not improve significantly between 1993 and 2007. As consumers commonly believe the quality is better in private facilities and are increasingly using them, it is essential to improve quality in both private and public facilities. Implementation of minimum standards and effective partnerships with private practice are considered important.

Background Patient safety in a healthcare setting is now a major global concern. Millions of people suffer disabling injuries or death directly related to medical care errors, particularly in developing countries. Evidence about patient safety culture in Ethiopia is limited. Therefore, this study was designed to assess the level of patient safety culture and associated factors among healthcare providers in government and private healthcare providers. Methods and materials Institution based cross-sectional study was conducted from May to June 30, 2022. Self-administered hospital survey on Patient Safety Culture (HSOPSC) tool was used to select 448 study participants. Epi Data version 4.6 and SPSS version 26 were used for data entry and analysis. Chi-square test, Bi-variable, and multivariable logistic regressions were done to determine the association between the independent and outcome variable. Result A total of 448 healthcare providers with a response rate of 99.6% participated. The prevalence of good patient safety culture was 50.9%( 95%CI: 46.2, 55.6%). Patient safety culture difference was observed between government and private healthcare providers (× 2 = 22.6, df = 1, p  = 0.000). Type of hospitals (AOR = 0.37(95% CI:(0.21, 0.68), profession (AOR = 2.16 (95% CI:(1.02,4.62), job satisfaction (AOR = 0.19,95%CI:(0.12,0.30), participated in patient safety programs(AOR = 2.69:(95%CI:1.53,4.75), providing necessary equipment and materials (AOR = 2.05(95%CI: 1.18,3.55%), and work shift (AOR = 0.47( 95%CI: 0.25,0.93) were found significantly associated with good patient safety culture among healthcare providers. Conclusion The prevalence of good patient safety culture was relatively low. Patient safety culture difference is observed between government and private healthcare providers. Type of hospitals (public or private), profession, job satisfaction, participation in patient safety programs, providing necessary equipment and materials, and work shifts were associated factors for patient safety culture. Therefore, it is better to design patient safety improvement strategies for both government and private healthcare providers.