Aceso Global CEO Maureen Lewis published a response to a recent article by Hutchinson et al., "We need to talk about corruption in health systems," in the International Journal of Health Policy and Management. In her response, she agrees with the authors’ argument regarding the need for greater attention to and work in corruption in health systems globally. She then lays out some of the rationale for how to define the pertinent research questions and how best to address corruption — arguing that governance rather than corruption may offer a preferred starting point. She concludes by highlighting options for measuring, analyzing and stemming corruption in healthcare.
This is the third post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we explore innovative healthcare delivery models emerging from the private sector, and how they might fit into government goals of achieving UHC and comprehensive PHC.
India’s immense socioeconomic, ethnic, epidemiological and demographic diversity creates fertile ground for innovation, and this holds true in the healthcare sector. Much has been written on healthcare innovators and novel technologies emerging from India. While the focus tends to be on affordable medical equipment, therapies and information and communication technologies, outside of the spotlight, some private healthcare organizations are unleashing pioneering delivery models to provide basic care to the poor. For our purposes, a delivery model is merely the ways in which care is provided to a person, population group or patient cohort. Understanding the roll-out process, costs and impacts of these innovative delivery models is important in light of government goals to progressively achieve UHC and to strengthen primary healthcare.
Currently, most healthcare in India is of an on-demand, curative nature, and is primarily provided by hospitals and private practitioners. This is especially the case in the ambulatory market. On one hand, public ambulatory facilities emphasize disease-oriented vertical programs and RMNCH services. On the other, private providers, who deliver over 70 percent of ambulatory care, operate on a fee-for-service basis and have few incentives to move away from the prevailing episodic model of care. Yet the changing burden of disease in India, coupled with rapid aging and urbanization, necessitate a new model in which primary healthcare takes a foundational role and there is close and regular interaction along the continuum of providers, including hospital-based professionals, primary care providers, community health workers and home care providers. Recent government directives are taking first steps toward developing such a model with an emphasis on comprehensive primary healthcare, aligned with global best practice. However, government focus tends to be inward – limited to the public delivery system, which is a relatively small player in the healthcare delivery landscape – rather than looking more broadly at the sector as a whole, and learning from innovative non-profit and for-profit players across India.
The private sector has implemented different types of delivery models that generally aim to provide high-quality, affordable care to those at the bottom of the pyramid. For example, the non-profit CARE Rural Health Mission, which operates in Andhra Pradesh and Maharashtra, is one of many leveraging telemedicine to link trained community health workers with remote physicians at primary care clinics and hospitals. This approach helps to circumvent India’s acute shortage of trained doctors and nurses. In Mumbai, the for-profit Swasth India Medical Center (SIMC) runs a chain of health centers in the city’s slums. Its clinics provide much needed access to drugs, prevention, primary care, dental and diagnostic services, and facilitate referrals to hospitals and specialist as needed. Through smart procurement and efficiency gains from digitized patient records as well as use of standard protocols and referrals, SIMC reportedly offers affordable prices and achieves high patient satisfaction. There are numerous other examples of similar small-scale efforts with potential for scale-up.
These examples embody the novel approaches being tested at the state and district levels as private organizations employ inventive techniques to deliver reliable, lower-cost healthcare. Yet, for all the successes, there have also been failures. E Health Points, a hub and spoke care model leveraging digital technologies and task shifting in rural Punjab, reportedly is no longer in operation Why was it unsustainable, and why have other models with similar features succeeded? Moreover, do these organizations have the performance and capacity to be contracted under the government’s PM-JAY insurance scheme to deliver a primary healthcare package to support expanded access? We don’t know.
With the exception of highly touted models such as the chain of Aravind Eye Hospitals and Narayana Institute of Cardiac Sciences, which provide specialty care for specific conditions, most of what is known about private sector delivery models focusing on the bottom of the pyramid is from landscape mapping exercises (see here and here) and descriptive case studies. Though valuable for raising awareness and introducing policy makers to these innovations, they lack details on performance, implementation processes and potential for scale-up. Without such evidence, it is difficult to replicate successes, inform policies or plug into government efforts to effectively expand coverage. The lack of evidence may be due to resource limitations and lack of capacity of these organizations to measure impact.
These information gaps echo the data and measurement challenges innovators and social entrepreneurs face elsewhere. There needs to be a greater research and policy focus on understanding the “why”, “how” and “so what” behind India’s many innovations in healthcare delivery models, rather than just documenting the “what”. This will put government in a better position to adopt learnings and locally-tested best practices in support of its policies for UHC and comprehensive primary healthcare.
Building on Aceso Global’s recent policy working paper, Driving Value-Based Care: Accountable Care Organizations in Emerging Markets, CEO Maureen Lewis sat down with Andre Medici, Senior Economist for the World Bank, to give her perspective on the potential of ACOs in Brazil as a way to introduce the principles of value-based care. The interview, in Portuguese, was published on his personal blog Monitor de Saúde in May 2019, and can be accessed here: http://monitordesaude.blogspot.com/
The interview is reproduced in English below:
AM: Value-based Health Care (VHBC) is progressively disrupting health markets by creating space for improving quality, reduce costs and paying for performance and outcomes. How are ACOs contributing to this new view of the health market place?
ML: VBHC has stimulated quality in the US in terms of finding ways to incentivize and promote quality, and it has implicitly linked this agenda to a reform of the payment system to incentivize desired outcomes. VBHC is part of a larger movement sparked by the National Institute of Medicine reports: “To Err is Human” and “Crossing the Quality Chasm”. The Accountable Care Organizations (ACOs) are building on those objectives and offer a path to improved integrated and coordinated care that allow paying for value.
ACOs create a partnership between payers and providers, making them accountable to each other within the organization. The structure of the ACO and the embedded incentives that lead to cost containment and higher quality of care include easily accessible primary care services for the defined patient population, prioritization of prevention, and chronic disease management that emphasizes integrated and coordinated care. Together, these initiatives reduce reliance on hospitalizations and emergency care that both improve quality of care for patients and control costs for providers. I have just completed a paper on the subject that provides some insights into ACOs.
AM: What are the basic features of the ACO model and how is this different from traditional secondary-level institutions?
ML: The integration of care delivery, financing, information systems, management and marketing set ACOs apart, and so do the incentives of their payment arrangements. Their integration allows joint decision making on how to structure and operate the organization, and it is built on data, efficiency and quality. Importantly, data are used to track clinical care, costs, productivity, patient satisfaction and other indicators of performance. Information technology and data availability at all levels of the ACO are key, as neither quality nor efficiency can be measured without adequate and appropriate data. Data at the point of care is particularly important to support physicians in their disease management and coordination of care functions.
AM: You mentioned that ACOs in US emerged from various angles, such as hospitals expanding outpatient services or health insurance engaging with providers. Could this process be replicated in developing countries such as Brazil? What are the preconditions to do this in Brazil’s SUS or in the health insurance market?
ML: ACOs offer an excellent alternative for fee-for-service dependent systems, but two elements are critical for an ACO: (1) information systems that produce relevant and regular data for monitoring at all levels of the organization, from nurses to physicians to hospital managers to diagnostic providers to clinical managers; and (2) incentives for performance, meaning the providers and managers are accountable for their activities, and receive rewards and/or penalties for meeting or not meeting, respectively, predetermined goals. Without data management, goals and accountabilities are not possible; and, without incentives, change is difficult if not impossible.
Brazil could easily adopt ACOs through various arrangements, for example: as part of a major hospital network; as a new service program built around physician practices; as a major laboratory service company joining with physician practices. Partnerships of players integral to delivering quality care are at the heart of ACOs and can be adapted to the interests of different kinds of investors and actors. Given the strong insurance market in Brazil, partnerships between payers and the above delivery groups could move the cost containment and quality agendas forward. But it implies new ways of doing business.
ACOs are ideal for public-private partnerships (PPPs), adapting the OSS model in São Paulo, for example, where non-profits have full responsibility for service delivery and management. These arrangements are used extensively in the US by Medicaid, the public insurer for the poor that contracts with private companies and non-profits to set up ACOs that serve that population segment. Data and incentives allow government to accompany and oversee progress. Cambridge Health Alliance, an ACO in Boston, is an example where the city has contracted with an ACO to deliver care to a defined population, and they have supported the development of IT, managers and indicators. It entails good management on the part of government, but it helps to shift provision to integrated care providers who have the tools and flexibility to be efficient and raise quality.
AM: In Brazil, the SUS created institutions such as the UPAS, with the objective to increase effectiveness of the health delivery by reducing unnecessary hospitalizations. Do you think that UPAS could be operated similarly to the ACOs in order to improve integrated care in the SUS?
ML: UPAS are a good idea, but they lack the incentives, flexibility, data and accountability that allow ACOs to function effectively. First, the simple lack of electronic health records (EHRs) that allow clinicians to serve patients across time and levels of care undermines the ability to provide integrated care. UPAS physicians and nurses lack the needed data about patients at the point of care. Second, UPAS do not face incentives to avoid the use of higher level care, and are not rewarded for keeping patients healthy and away from unneeded higher levels of care. Third, in places where patients can self-refer to hospitals – as is the case in much of Brazil – providers must make it easy for patients to access primary care. Our work in São Paulo with Consocial suggests that accessing UPAS is time consuming and protracted, leading frustrated patients to public hospitals or the private sector.
AM: Could ACOs work as standalone institutions or do they need to be integrated into health networks to operate efficiently?
ML: ACOs either have an integrated network or access other providers on a contract basis to provide easy access for their patients. For example, an integrated care provider can contract with diagnostic centers, laboratories and hospitals for referral services for their patient population. The primary care providers coordinate care for their patients at all levels, so effectively the primary care providers integrate the services each individual patient needs.
AM: Given that the main incentive to create ACOs lies in changing the payment system, which new healthcare payment systems need to be implemented in Brazil, and what are the challenges and preconditions to implement them?
ML: Payment arrangements within ACOs can take virtually any form and ACOs lend themselves to a combination of payment arrangements. For example, fee-for-service can co-exist with capitation and bundled payments depending on the range of services being offered; alternatively, and most commonly, ACOs simply rely on capitation, but with payment tied to performance, namely cost containment and quality outcomes. Here again, the information system is key to provide data on key indicators. However, the significant payment innovation in ACOs are “shared savings”, where payers, managers and providers share in savings from the lower costs and enhanced quality of care that comes from focusing on primary care and reducing (over) use of hospital and emergency room services. This is a unique payment arrangement that underpins ACO incentives. These are easily adapted in Brazil – the challenge is the partnership that makes it happen and helping providers adapt to change, but these are challenges in the US as well.
AM: Brazil has seen lots of progress in both the SUS and ANS information systems. Are the current systems in Brazil enough to implement a VBHC culture in the Brazilian health systems (SUS and saúde suplementar)?
ML: The situation is mixed. UNIMED BH has such information, as do some of the closed operadores in other major cities in saúde suplementar, but most do not. Those that do can build on that capacity, making the shift to the ACO model less onerous. SUS information systems are lagging behind. It requires investments but more importantly a platform that allows development of EHRs as well as information about the performance of providers and outcomes of care. SUS has neither, and many operadores lack them as well.
Oncology treatment is often costly and occurs over a number of months or years. Restructuring delivery to improve quality and control costs can be achieved through redesigned delivery arrangements and shifts in payment systems. Incentives driven by payment mechanisms allow a shift away from reliance on fee-for-service and case-based payments such as DRGs that reward volume of care, to more mixed arrangements grounded in bundled payments that allow for flexibility but incentivize continuity of care and quality outcomes. This presentation was delivered by Aceso Global CEO, Maureen Lewis, to the Agência Nacional de Saúde Suplementar (ANS), the National Regulatory Agency for Private Health Insurance and Plans in Brazil, in February 2017.
Value-based care (VBC) is increasingly seen as the future in healthcare. VBC shifts the focus in healthcare from paying for volume to paying for quality, linking payment to health outcomes and other indicators of quality and efficiency, rather than to the number of services provided. It targets and measures quality, costs and outcomes across all levels of a healthcare system.
A particularly promising option for moving towards VBC is the Accountable Care Organization (ACO), an arrangement that integrates all aspects of healthcare delivery and finance, and drives improvement through incentives as well as the initiatives and leadership of clinicians. The ACO model is highly adaptable to local circumstances and can accommodate public and private providers and financing, making it appropriate for countries with mixed healthcare markets, and for those in which payment and provision are divided between public and private sectors.
This Policy Working Paper explains ACOs, their characteristics, benefits and factors driving ACO success in the US; it then outlines the relevance for emerging markets and developing economies, where the ACO model holds considerable promise.
This is the second post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we discuss the state of PPPs in the health sector, and the need for greater evidence on performance and enablers.
Since Government’s endorsement almost 15 years ago as a potential solution to deficient health service delivery, healthcare public-private partnerships (PPPs) have proliferated across India. They represent a rare form of public-private collaboration in a system dominated by private provision, but inhibited by considerable distrust between the two sectors. In effect, public-private engagement for service delivery in India’s health system hardly moves beyond the micro-level realm of PPP transactions. More recently, however, government-sponsored insurance schemes such as PM-JAY are purchasing insurance-related services from private third-party administrators and health services from private hospitals, and represent a bold step forward in public-private engagement. In this post, we focus on PPP models oriented toward expanding service delivery in which state health agencies contract private entities to build and operate facilities or manage services heretofore delivered through the public delivery system. Despite the proliferation of these transactions, little is known about their scope and impacts.
We began analyzing the state of healthcare PPPs in India about a year ago, and quickly found that the evidence-base is thin. In India, states are constitutionally responsible for publicly-financed health service delivery. Our analysis of multiple tender documents, newspaper articles, reports and websites of state PPP cells reveals that over the past decade, state governments across India have primarily focused on infrastructure PPPs. A growing number of states are experimenting with service delivery PPPs . Many of these involve the contracting out of select clinical and non-clinical services, such as diagnostic services (ex: Bihar, Himachal Pradesh) and dialysis services (ex: Delhi, Andhra Pradesh). Some states, such as Karnataka, Meghalaya and Arunachal Pradesh, have outsourced management of some primary care clinics to NGOs. To a lesser extent, states have or are experimenting with contracting out hospital management and service delivery (see examples here and here). Data on the actual number of ongoing PPPs is difficult to obtain or validate.
The impact of these PPPs in terms of quality of care, costs and alignment with public priorities is largely unknown. Some diagnostic and dialysis PPPs have reported positive performance (see here and here), possibly because their narrow scope makes them relatively easier to design, tender, manage and monitor. One model that has widely been panned as a failure is the “land for beds model”, in which land is leased to a private partner to build and operate a hospital at little or no cost, in exchange for meeting specific conditions, usually including designating a share of beds to the poor. A troubled joint venture between the Delhi Government and Apollo Group exemplifies the challenges of this approach. Amazingly, this form of PPP remains under consideration in other states.
Anecdotal evidence suggests that some private operators faced insolvency in part due to late payments from government agencies. Further, while PPPs are often employed to fill gaps in access and quality that the public sector cannot address through its own resources, contracts often lack critical details: performance indicators, accountability frameworks and standard operating procedures are generally missing. As elsewhere, the public sector’s low capacity for contract management in India may be the Achilles heel of PPPs.
The lack of good quality information and data on specific healthcare PPPs in India is concerning. States across India are moving forward with this agenda (see here and here), and many interesting engagements are underway; yet there is little to no rigorous evaluation or even monitoring of these initiatives. Much of the evidence to date is drawn from “light touch” case studies that often appear promotional in nature. Little is known about impacts, lessons learned, and how starting conditions and government and contractor capacities contributed to performance.
As a result, states are left largely to operate in the dark, with limited knowledge of what has worked elsewhere in India, and why. The often ad hoc nature of PPP transactions leaves them vulnerable to repeat past failures, and unable to systematically learn from successes. More and better information and analysis are needed to inform state and national PPP policies so that governments can move this agenda forward in a more informed way. Until then, we can’t be sure why some PPPs succeed while others fail.
Check out other posts in this series below:
This is the first post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we discuss considerations for raising public hospital performance through greater autonomy.
The recent rollout of PM-JAY – a government-subsidized health insurance scheme that aims to provide inpatient coverage up to 500,000 INR per year for India’s poorest families – signals the trajectory of India’s healthcare system. Building on the experiences of earlier state and centrally-sponsored insurance schemes, it solidifies the government’s expanded role as a purchaser of healthcare services. For India’s public sector hospitals, which are accustomed to mainly supply-side financing through line item budgets, this expansion of insurance revenue, together with the separation of healthcare financing from provision, will bring new opportunities, as well as challenges. Specifically, public hospitals will need greater financial and managerial autonomy if they are to respond to the incentives embedded in payment systems set by purchasers to control costs and provide high-quality services (see Chapter 12 of this useful resource for more information). The government’s 2018 New Strategy for India @75 calls for granting some autonomy to public facilities to enable effective use of claims money generated under PM-JAY to improve the care they provide. How India will guide and implement greater autonomy in public hospitals remains an open question.
Indian public hospitals have much to gain from new forms of governance and management. Most are directly operated by state health departments, and as a result, hospital managers have little decision-making authority over inputs or day-to-day operations, and political interference in human resource management is rife. Emerging evidence suggests that Indian hospitals are poorly managed, especially publicly-run facilities. Under these conditions, it is difficult to implement changes in support of quality and efficiency improvements. For both purchasers and patients, the result is often low-value care.
Most successful autonomy-oriented efforts in India to date appear to have occurred in other sectors (e.g., Delhi Metro Rail Corporation, DMRC). Yet, recent evaluations have shed light on some highly successful healthcare examples such as GVK Emergency Management Research Institute (EMRI), which operates emergency transport services, and the Tamil Nadu Medical Services Corporation (TNMSC), which manages the ordering, testing and distribution of drugs and medical supplies throughout the state of Tamil Nadu. India also has a long history of experimenting with autonomous hospitals. These have taken different legal forms, including legislated “autonomous” facilities at the central and state levels (e.g., All India Institute of Medical Sciences (AIIMS), Indira Gandhi Institute of Medical Sciences in Patna), and more recently, public-private partnerships (e.g., Mumbai Municipal Hospital).
Given these experiences, reforms that increase the autonomy of public hospitals have considerable potential in India – assuming accountability mechanisms are ratcheted up simultaneously to keep autonomous hospitals aligned with public priorities. Recognizing this, government has initiated steps in this direction. For example, under PM-JAY and some state-sponsored insurance schemes, public hospitals are allowed to retain payments received through insurance claims according to formulas set by the schemes.
Yet, there is a need for caution. Our extensive review of hospital autonomy experiences in India and globally revealed numerous possible pitfalls, as well as factors for success. What came through most clearly, however, was the need to ground any autonomy-oriented reform in the local (e.g., state) context, with strong understanding of enabling (and disabling) factors in the broader financial, institutional and political environment. This is a challenge in India, as past and ongoing hospital autonomy initiatives have not been assessed. Even for existing legally “autonomous” hospitals, little is known about effective decision-making authority, managerial capacity, performance or lessons learned.
With limited data or information, it will be difficult for government to develop truly evidence-based policies or programs. There is a need to focus efforts on gathering critical evidence on existing autonomy initiatives before launching new ones, to support learning and continual improvement over time.
This report summarizes the findings of the Transition Readiness Assessment for Panama carried out by Aceso Global and APMG Health, with financial and technical support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. It aims to support Panama’s transition planning as the Global Fund scales down its financial support for the national tuberculosis and HIV/AIDS responses. To produce a complete report, the Aceso Global team used the Guidance for Global Fund Transition to inform the analysis and consulted with numerous local stakeholders, including government officials at the Ministries of Health and Finance, Global Fund staff members and local civil society organizations.
The report summarizes the Global Fund's financial and non-financial support to the country, analyzes the epidemiological situation as well as the national response in Panama and provides a background on the institutional and enabling environments, human rights and gender situation.
Based on a thorough analysis of the Panamanian health system, the Aceso Global team identified the most pressing opportunities and threats to be considered during the transition process. Recommendations included the following: increasing the outreach to high risk communities to improve the identification of TB patients, particularly among indigenous groups and communities with weak links to primary care clinics; merging the HIV and TB programs of the Ministry of Health and the Social Security Fund to avoid duplication of effort and reduce inefficiencies; and committing to anti-discriminations actions. In addition, the report underlined civil society organizations’ urgent need for assistance in sustainability planning.
Aceso Global has been working with the Inter-American Development Bank (IDB) on the Salud Mesoamérica Initiative (SMI). SMI is a pioneering public-private partnership between the Bill & Melinda Gates Foundation, the Carlos Slim Foundation, the Government of Spain, the IDB, the countries of Central America, and the state of Chiapas, Mexico. It is one of the most successful and thoughtfully designed results-based aid (RBA) models and we are excited to join and contribute to their effort, while also learning from their work.
SMI aims to reduce maternal and child health inequalities through an RBA model that is in alignment with the priorities established by the governments of the region. The SMI model is based on four basic concepts:
1. Countries have to work within the poorest 20% of their populations, selected based on Poverty Incidence Data;
2. SMI funds can only finance evidence-based, cost-effective and promissory interventions for maternal and child health;
3. All projects are co-financed by SMI and countries (50% average cost-sharing) and must be executed using the SMI results based aid model; and
4. All results are externally verified by an independent third party through both household and health facility surveys. If countries meet 80% of their goals, they receive 50% of their original investment to use freely within the health sector.
Specifically, Aceso Global is tasked with designing an innovative learning program for middle managers to support Quality Improvement (QI) efforts in the eight SMI countries. The program breaks from more traditional training styles that use didactic lecturing and aims to reach behavior change and competency development with interactive and experiential learning techniques. The curriculum focuses not only on the “hard skills” of measuring and improving quality of care, but also on “soft skills” like leadership, team building, communication, coaching and continuous learning that are essential ingredients for any change process. It is firmly grounded in the local realities of the SMI countries and uses case studies, experiential learning and peer-to-peer exchanges to convey contents over the course of the ten-month training.
The competency development program equips middle managers with the necessary skills to coach frontline primary healthcare providers on QI. It also contributes to the larger transformation agenda that SMI and country leaders are pursuing to fundamentally shift the way that care is delivered, to put quality at the center of organizational culture, and to move towards a true learning system that accepts failure and is relentless in the pursuit of innovation and improved performance.
Aceso Global is also developing a unique evaluation strategy for the learning program that examines changes in leadership, organizational culture and skill development, deploying customized evaluation instruments that will gauge the extent to which hard and soft skills have been mastered. The purpose is to yield standardized, comparable data on leadership behaviors and organizational contexts that influence the successful implementation of QI initiatives and ultimately lead to improvements in maternal and child health.
This project falls under Aceso Global’s quality portfolio, which addresses quality of care across the health system by: (1) collaborating with country leaders to put quality of care culture, measurement, improvement and innovation at the center of national healthcare agendas; (2) working closely with providers and stakeholders on the frontlines to shift the culture around quality of care and improve the use of quality data; and (3) integrating quality data with national health information systems, including supporting or developing quality dashboards. Our portfolio approach echoes some of the key takeaways from last year’s wave of reporting on global quality of care, including the Lancet Commission’s High-quality health systems in the Sustainable Development Goals era: time for a revolution, the OECD, World Bank and WHO report, Delivering Quality Health Services: A Global Imperative for Universal Health Coverage, and finally the Institute of Medicine’s Crossing the Global Quality Chasm, for which Aceso Global CEO and Founding Director Maureen Lewis was an expert reviewer.
For more information, please contact: Sarah Mintz, firstname.lastname@example.org
 Salud Mesoamerica Initiative Program Description, Progress and Results, May 2016
Aceso Global published its Annual Report 2018, which showcases the organization’s considerable growth over the last year, and its continued commitment to addressing fundamental structural issues in healthcare globally.
Aceso Global’s Annual Report 2018 highlights the many activities, projects and engagements the organization undertook in its third year. These ranged from designing a Network Model for Brazil’s public healthcare system, to supporting UNAIDS in their sustainability efforts in Mozambique, to participating in conferences around the world as distinguished panelists and keynote speakers. The Report also provides a financial overview, illustrating the organization’s growth.
“Across our diverse activities and projects, our focus has been on systematically working with our clients to respond to their most pressing needs, ensure quality and assist in devising creative solutions,” says CEO Maureen Lewis.
Latin American and Caribbean (LAC) countries have achieved a great deal in healthcare over the past few decades, reflecting early investment as well as creativity and experimentation at a level and scope beyond much of what has occurred in other regions. The mixed public-private system serving much of the region, the experience with social health insurance (SHI) and private insurance, and experiments with health service delivery and financing provide lessons that deserve further attention and implementation. Importantly, the rallying cry regarding insufficient spending captures only part of the challenge. Better organization, financing and delivery grounded in targeted incentives and accountabilities could have a major impact on raising access, quality and efficiency.
Regionally the health financing mix entails high reliance on out of pocket payments (OOP) and private insurance. Only 12 countries benefit from over 50 percent of public financing. Waiting time, and time-intensive requirements to access care within publicly financed systems pose high costs to patients. Even the poor turn to private alternatives.
Shortcomings in the quality and efficiency of services to date have received little attention or investment. Quality measures are scarce and no consensus exists on standards; facility management is weak; few studies that touch on relative productivity to measure efficiency; and, costs are largely unknown.
Over the coming decades, the rapidly shifting demographic, social and epidemiological patterns in the region will affect both public revenues and the demand for healthcare. The aging population and the rise of NCDs both have serious implications for healthcare costs in both the public and private sectors, and for the type of care required, e.g. more preventive services, long-term management of chronic conditions, integrated care and palliative care.
Health policy reforms in LAC deserve to be driven by sustainability. Integrated healthcare offers a solution to fragmentation in delivery and financing, and involves reliance on effective information technology that tracks performance and patients, and provider payment reforms that incentivize efficiency and quality, among other initiatives. Maintaining the coexistence of different health systems (SHI, public financing and delivery, private health insurance by employers or individuals) can be supported by the integration of medical records, adherence to protocols and clinical pathways, establishment of health networks built around primary care, along with harmonized incentives and payment systems affecting both hospitals and primary care. These restructuring initiatives can reinvigorate healthcare systems and prepare them for success and sustainability in the 21st Century. They offer a direction for reform that allows adapting to existing circumstances and institutions, but with updated objectives, infrastructure and processes.
The WHO recently released a brief on “The Transformative Role of Hospitals in the Future of Primary Health Care” as part of its Technical Series on Primary Healthcare. It builds on two documents, “People-Centred Hospitals towards Universal Health Coverage: a WHO Position Paper” and “A Global Vision for Person- and Community Centered Hospitals in a PHC-based Health System,” both of which are in press. Aceso Global CTO Gerard La Forgia participated as a technical expert to and contributing author of these foundational documents.
The release of this brief is timely, reflecting a growing consensus in the global health community about the fundamental role of primary care in achieving person-centered universal health coverage (UHC), and the need to rethink traditional functions of hospitals to support this agenda.
Historically, hospital and primary care systems have operated in siloes, with hospitals isolated and primarily focused on what happens within their walls, and largely absent from preventive and promotive care. The resulting care model has been fragmented, inefficient, and curative in focus, often with an outsized share of services delivered by hospitals, due in part to the lack of integration across the health system. In low- and middle-income countries (LMICs), this has contributed to distorted costs and poor quality; these systems do not serve NCDs adequately, and recent health gains and longer lifespans are being jeopardized by their failures.
The WHO Expert Group brief envisions a future of primary healthcare in which hospitals break out of their walls and actively contribute to the development of comprehensive primary care, in partnership with primary care providers and communities. New roles for hospitals will be coupled with improved hospital organization and management to raise performance, supported by an enabling institutional and policy environment that facilitates needed change. The brief outlines this vision, and touches upon pathways to transformation. The forthcoming WHO position paper provides more specifics and will serve as a resource for policymakers and planners in LMICs.
Since its founding, Aceso Global has been at the forefront of this global movement calling for renewed thinking on the roles of hospitals in people-centered healthcare systems. CEO Maureen Lewis and CTO Gerard La Forgia were founding members of and led the Center for Global Development Hospitals for Health Working Group, and have been consistent voices highlighting the key role of hospitals in reaching UHC. Aceso Global has worked in numerous countries to strengthen hospital management, raise performance, and integrate inpatient and primary care. Most notably, we provided options for a hospital PPP in St. Lucia, led the production of a Vertical Integration/Network Diagnostic and Readiness Tool for the Joint Learning Network and advised a number of countries on hospital reform, among other efforts.
This WHO brief highlights the nexus in the hospital, primary care and UHC agendas, and represents an important step forward in the global movement toward better integrated, more responsive healthcare systems.
Aceso Global CEO Maureen Lewis shares her take on the Brazilian healthcare system. See here for a link to the original article, which is reproduced below.
What Makes Brazil’s Healthcare system so different? Prof. Maureen Lewis of FGV-EAESP shares her take on the unique mixed public and private health system in the country.
At a glance
Brazil, a country adored all over the world for its coffee, samba, football and Jiu-jitsu, is certainly not just another ‘BRIC’ in the wall. With a population of roughly 200 Million, the country is unique not only through its inclusion into the OECD club and economic tug-of-war between boom and recession, but also by its distinct Healthcare sector. Composed of around 6,800 public and private hospitals, 195,000 service units and almost 500,000 hospital beds (Industry Report, Healthcare: Brazil, The Economist Intelligence Unit, September 2014), the health sector counts for ~9% of Brazil’s GDP (2015), with a health expenditure per capita of almost USD 705 (OECD). Divided into private and public components, the healthcare system consists of everything ranging from small, low quality hospitals to world-class research hospitals.
To cover the costs incurred by the citizens at these units, the Federal, State and Municipal governments have put into place the Single Unified Health System (SUS), the funding for healthcare facilities is provided via the federal prospective reimbursement system, the AIH (Authorization for Hospital Admission). Moreover, there are 6 private high-complexity Centres of Excellence all over the country which provide free health care to the citizens in return for tax breaks from government.
Caught between private and public funding
Lately, a trend has been observed in the spending of the SUS – an increase in funds for public-owned facilities and a sharp decline in funds in privately owned hospitals. The SUS under-reimburses for care for non-public providers, leading to the closure of several philanthropic facilities. This has generated increased demand for private insurance for people to benefit from care at public hospitals.
Such divergence runs a risk of reducing engagement and support for improved healthcare performance by the growing middle and upper-class population who are increasingly relying on private insurers and providers.
As such, middle and upper-class citizens are benefiting from private insurance through their own pockets or those of their employers and at the same time paying for the SUS through taxation.
The economics of healthcare
What makes things even more interesting is that a rise in chronic conditions and diseases across Brazil has influenced a shift in the demand for hospitals towards more specialty care than general hospitalization. This is costing the average Brazilian more than the traditional remedies at hand. As suggested by a private sector report, a decline in the mortality rate can be seen for several diseases and illnesses credited to improved living conditions, rising levels of education and improved preventive measures. The same cannot be said for illnesses such as cancer, cardiovascular disease and perinatal disorders which seem to have replaced the more easily treated illnesses. This has, in a way, led to a sharp increase in the average costs to state for diagnosis and treatment.
But not all of this cost expense can be attributed to the change in disease complexity. An argument can be made towards the heavy investments that Brazil is making in technology in healthcare. Interestingly, Brazil has more MRIs and CT Scanners than several of the developed countries such as the UK and almost three times more than Mexico.
Another factor that can be attributed is the demographic of the private insurance enrolees. It is seen that that over 45% of the age groups that use this type of insurance hail from either the under 18 or the over 59 categories, both of which are generally non-performing categories that are highly susceptible to illnesses. The increase in life expectancy rates of the country is ironically, only adding to its woes.
In the face of these high costs and expenditure, it has been imperative for the Brazilian healthcare industry to keep its revenues high. But the recent trends discussed above have led to a reduction in hospitalisations, pushing the healthcare industry towards a risk of loss. Loss ratios have been increasing substantially over the past few years. To gain control over spending and to improve the overall efficiency of the healthcare industry, financing seems to pose a challenge for the Brazilian administration for the years to come.
Complex problems – simpler fixes
The picture is clear. Despite having made efforts to establish a single healthcare system, Brazil’s can at best be described as mixed and fragmented. The government funded SUS finances less than half of all healthcare, with the balance being covered by private insurers and through self payment.
Despite financial malpractices and several other irregularities associated with it, the AIH remains the preferred method of hospital payment, which suggests the need for drastically improving and optimizing its application. In the same vein, amends need to be made towards the cross disparity between public and private sectors of insurance and healthcare providers to ensure that the services are rightly paid for.
The imbalance between inflation rates will eventually become an issue for insurers and the insured, the implications of which could inflict damage to the image and economic health of private hospitals.
A part of the solution could be to close low-volume, high-cost small hospitals. Brazil should further focus on improving management, efficiency and added value, and also adhere to protocols in order to boost productivity and enhance quality. Stricter accreditation norms and keen oversight could help identify waste and promote improved performance, which in turn could lower costs.
Finally, the consumers and patients should be given bigger roles to play in order to facilitate improved hospital function and network performance as part of the country’s agenda for the future. It cannot be denied that the healthcare system is going through a rough patch, but it is certainly worth saving. As the saying goes – it’s always darkest before dawn.
Basándose en un previo Análisis de la Preparación para la Transición en el proceso de salida del Fondo Mundial, Aceso Global trabajó con asociaciones sin fines de lucros (ASFL) en la República Dominicana para comprender los mecanismos de financiación pública y desarrollar las capacidades de las organizaciones para competir por subvenciones públicas y recursos de otra procedencia, Anna Bonfert, economista de la salud, resume nuestros principales hallazgos y sugerencias para continuar un trabajo que se muestra muy promisorio.
La República Dominicana ha logrado importantes avances hacia una generación sin VIH. Mientras que la prevalencia del VIH en la República Dominicana sigue siendo el doble de la media en América Latina y el Caribe; en los últimos 15 años, los casos nuevos de infección por año han disminuido rápidamente desde su punto máximo en el principio de los años 2000.
Uno de los factores de éxito ha sido el compromiso activo de las ASFL. Dado que muchas de estas organizaciones fueran creadas en las mismas comunidades afectadas por el VIH, pasaron a ser el centro de la respuesta nacional. La República Dominicana ha visto un surgimiento de ASFL especializadas, que trabajan con grupos vulnerables y marginados, los mismos grupos que son desproporcionadamente afectados por el VIH y el estigma. Debido a que pueden establecer y mantener una relación de apertura y confianza mutua que les permite trabajar en el terreno, las ASFL tienen acceso a comunidades que no serían alcanzadas por programas oficiales a nivel nacional, provincial o local. Entre esas comunidades y colectivos se encuentran los de trabajadores sexuales, personas trans, gay y otros hombres que tienen sexo con hombres, usuarios de drogas inyectables e inmigrantes haitianos. Las ASFL sirven como una interfase entre los servicios públicos y estos grupos, y utilizan enfoques diferenciados que reflejan la diversidad de las comunidades.
En los últimos 15 años, la sociedad civil ha florecido gracias al apoyo recibido con los fondos de donantes para actividades relacionadas con la prevención y control del VIH y la protección de los derechos y la dignidad de las poblaciones y grupos clave. Las subvenciones externas a menudo han sido entregadas con la condición de que los fondos se ejecuten con la participación de las ASFL, para así garantizar que se escuchen las voces de las comunidades afectadas por el VIH y se atiendan sus necesidades de manera efectiva, defendiéndose sus derechos y bienestar. La lucha contra el estigma y la defensa de los derechos humanos han sido quehaceres fundamentales de las ASFL, pero muchas de ellas también participan en actividades de divulgación, prevención y acceso al tratamiento.
Al mismo tiempo, el gobierno de la República Dominicana ha reconocido el importante trabajo realizado por las más de 200 ASFL que participan actualmente en la respuesta al VIH. El reconocimiento se ha expresado (y materializado) a través de actualizaciones de instrumentos legales y códigos, así como mediante compromisos financieros para subvencionar internamente las operaciones de las ASFL. De hecho, ahora hay más de una docena de fuentes de financiamiento público disponibles para las ASFL que trabajan en el área del VIH. Estas incluyen: el Centro Nacional de Fomento y Promoción de las ASFL, una institución gubernamental dedicada a la concesión de subvenciones a las ASFL, acuerdos con los gobiernos provinciales y acuerdos de gestión conjunta con el Ministerio de Salud.
A pesar de estos avances positivos, el país todavía aún está en vías de identificar mecanismos asegurar que el trabajo de las ASFL se encuentra en un derrotero sostenible para avanzar sin contratiempos ni interrupciones. Esta inquietud es cada vez más apremiante porque varios donantes internacionales que actualmente apoyan el programa nacional de VIH y tuberculosis han anunciado su retiro gradual, lo que podría provocar interrupciones en el programa contra el VIH y los servicios proporcionados por las ASFL, que hasta el momento se han apoyado en recursos externos y, en algunos casos, han dependido exclusivamente de estos. Al mismo tiempo, a pesar de las numerosas fuentes de financiamiento público que han surgido, el acceso a estas puede ser difícil.
A medida que las ASFL exploran formas de mantener su trabajo y sus actividades de gestión, se encuentran peguntándose: si todas estas fuentes de financiamiento público están disponibles, ¿por qué es tan difícil recibir financiamiento del gobierno? ¿Y por qué no hay una guía sobre cómo competir para obtener fondos públicos? Para enfrentar estos desafíos, Aceso Global, en asociación con El Fondo Mundial para la lucha contra el SIDA/VIH, la tuberculosis y la malaria, trabajó con las ASFL en la República Dominicana para comprender el panorama de financiamiento público y desarrollar la capacidad de asociaciones para competir por subvenciones públicas y otros fondos.
Primero, examinamos cómo funcionan en la República Dominicana los procesos de calificación y solicitud de financiamiento público. ¿Qué documentos deben presentar las ASFL, cuándo y dónde? ¿Cuáles son los diferentes pasos involucrados, y cuáles son las fechas límite para cumplir con esos pasos? ¿Dónde pueden ir las ASFL para obtener información adicional? Si se pregunta a diferentes funcionarios del gobierno es probable que obtengan diferentes respuestas. Como pronto se pudo constatar existe toda la información necesaria, pero está dispersa en diferentes sitios web, departamentos dentro del Ministerio de Salud e incluso personas a cargo de procesos específicos. A menudo, la información relevante no está disponible en un formato fácil de usar. También se constató que hay muchos pasos repetitivos necesarios para solicitar financiamiento, y que algunas pautas son contradictorias.
Nuestro documento de Mapeo y las hojas informativas que lo acompañan (en español) organizaron la información dispersa en una ubicación de acceso fácil y simplificaron las pautas existentes en un formato fácilmente comprensible. Los documentos proporcionan a las ASFL una imagen clara de los pasos administrativos necesarios para calificar para la financiación pública.
Durante el proceso, también se pudo observar que las ASFL varían considerablemente en su experiencia y capacidad. Mientras que algunas ya compiten con éxito para obtener financiamiento público, otros apenas están comenzando a establecer los sistemas y las estructuras requeridas para cumplir con los requisitos para competir por este y conseguir obtenerlo. Un mayor desarrollo de la capacidad podría mejorar la competitividad de las ASFL para los fondos públicos. ¿Cómo se escribe una propuesta persuasiva? ¿Qué es lo que se debe y no se debe hacer en la planificación y ejecución de proyectos? ¿Cómo configurar los sistemas de monitoreo y la evaluación para mostrar lo que ha logrado a través del financiamiento gubernamental? ¿Existe una manera más efectiva de promover servicios ofrecidos por las ASFL, tanto a entidades gubernamentales como a otros financiadores nacionales? Estas son algunas de las preguntas que enfrentan las ASFL, y la capacitación en estas áreas basada en nuestro material educativo, que permitirá a las ASFL pasar de ser receptores pasivos de fondos de donantes a promotores activos que pueden ofrecer y vender sus servicios al gobierno y otras fuentes de subvención.
Estas organizaciones brindan servicios valiosos en salud y derechos humanos, más allá de lo que el gobierno puede proporcionar por sí solo. Son fundamentales para la sostenibilidad a largo plazo de la respuesta nacional al VIH / SIDA y merecen un impulso en la forma de capacitación y el apoyo para fortalecer su papel de liderazgo en la República Dominicana.
This report maps out and provides detailed analysis of the domestic financing mechanisms available to civil society organizations (CSOs) in the Dominican Republic that are involved in the national responses to HIV and tuberculosis (TB). It identifies the barriers CSOs face when attempting to access and execute public and private domestic funds, and also highlights areas of opportunity, providing specific recommendations for government and international donors to support expanded grant-giving to CSOs. The report’s annexes contain step-by-step training materials to guide CSOs through the at times complex and confusing processes required to access public funding.
Aceso Global completed this report for The Global Fund to Fight AIDS, Tuberculosis and Malaria as part of the organization’s ongoing efforts to ensure the sustainability of the Dominican Republic’s national disease programs. CSOs play a critical role in ensuring access to prevention and treatment services for HIV and TB, especially for vulnerable and marginalized groups, but are largely reliant on international support. In the context of reduced external funding, this report positions CSOs to better compete for domestic resources.
Aquí para la versión en español de esta publicación.
Building on a previous transition readiness assessment, Aceso Global recently worked with civil society organizations (CSOs) in the Dominican Republic on understanding the public funding landscape, and building their capacity to compete for public grants and other funding. Anna Bonfert, Health Economist, summarizes our main findings and suggestions for moving forward.
The Dominican Republic has made important strides towards an AIDS-free generation . While HIV prevalence in the Dominican Republic continues to be almost double the average for the Latin America and Caribbean countries, it has fallen rapidly over the last 15 years from the peak in the early 2000s.
A key success factor has been the active engagement of CSOs. Since many of these organizations are born out of the very communities that are affected by HIV, they have evolved to be at the heart of the national response. The Dominican Republic has seen the rise of specialized CSOs working with vulnerable and marginalized groups, those that are often disproportionally burdened by the HIV epidemic and face stigma. Because they can build trust and work on the ground with their peers, CSOs have access to communities that would otherwise not be reached by the national HIV program, such as sex workers, trans people, gay and other men who have sex with men, injecting drug users and Haitian migrants. CSOs serve as an interface between public services and these groups, and use differentiated approaches that reflect their diversity.
Over the last 15 years, the civil society space has flourished as donor funds for HIV-related activities abounded. These funds have often been contingent on CSO engagement and advocacy to ensure that the voices of affected communities are being heard, and their needs effectively addressed. Combating stigma and defending human rights are core competencies of CSOs, but many of them also engage in outreach, prevention and access to treatment.
At the same time, the government of the Dominican Republic has started to recognize the important work performed by the more than 200 CSOs currently involved in the HIV response. This recognition came in the form of updates to the legal code as well as financial commitments to fund CSO operations. In fact, there are now more than a dozen sources of public funding available to CSOs working on HIV. These range from the Center for CSO Promotion, a government institution dedicated to grant-making to CSOs, to agreements with Provincial Governments, to co-management arrangements with the Ministry of Health
Despite these positive strides, the country is still grappling with how to put the work of CSOs on a sustainable path moving forward. This question is increasingly pressing as several international donors currently supporting the national disease program have announced their gradual withdrawal, potentially leading to disruptions in HIV programming and services provided by the CSOs, who thus far have benefitted from, and in some cases relied on, external monies. At the same time, despite the numerous public funding sources that have emerged, access can be difficult.
As CSOs explore ways to stay afloat, they find themselves scratching their heads: if all of these public funding sources are available, then why is it so hard to actually receive funding from the government? And why is there no guidance on how to compete for public funding? To address these challenges, Aceso Global in partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria worked with CSOs in the Dominican Republic on understanding the public funding landscape, and building their capacity to compete for public grants and other funding.
First, we examined how the qualification and application processes for public funding actually work in the Dominican Republic. Which documents do CSOs need to submit, when and where? What are the different steps involved, and their timelines? Where can CSOs go for additional information? Ask government officials, and you will likely get different answers. As we soon discovered, the necessary information exists, but is scattered across different websites, departments within the Ministry of Health and even individuals in charge of specific processes. Often, relevant information is not available in a user-friendly format at all. We also noticed that there are many repetitive steps required to apply for funding, and that some guidelines are contradictory.
Our Mapping document and its accompanying factsheets (in Spanish) organized the scattered information in one readily accessible location, and streamlined existing guidelines into an easily digestible format. It provides the CSOs with a clear picture of the administrative steps required to qualify for public funding.
During the process, we also became keenly aware that CSOs range considerably in their experience and capacity. While some already compete successfully for public funding, others are just beginning to set up the systems and structures required to comply with public funding requirements. Further capacity building can improve CSOs’ competitiveness for public funds. How do you write a compelling proposal? What are do’s and don’ts in project planning and execution? How do you set up the M&E systems to show what you have accomplished through government funding? Is there a more effective way to promote your services, both to government entities and other domestic funders? These are some of the questions CSOs are facing, and training in these areas based on our material will allow CSOs to move from being passive recipients of donor funding to active promoters who can effectively sell their services to the government and other sources of support.
These organizations provide valuable services in healthcare and human rights, beyond what government is able to provide on its own. They are critical to the long-term sustainability of the national response to HIV/AIDS and deserve a boost from training and support to strengthen their leadership role in the Dominican Republic.
There is often confusion surrounding discussions on innovative financing in the context of global health. This summary of a past CUGH conference session on the subject clarifies what is meant by global health specialists when they debate “innovative payment mechanisms” and challenges associated to it. Aceso Global’s CEO Maureen Lewis opened the session with a presentation on the emergence of new actors in global health financing and the shifts in donor priorities away from disease specific programs towards more integrated programs, which could be financed by innovative financing mechanisms. Click here for the full post.
This webinar, organized by the JLN’s Vertical Integration and New Roles for Hospitals learning exchange team, presents the Vertical Integration Diagnostic and Readiness Tool, a survey instrument that helps countries assess and implement vertical integration policies, programs, and pilots.
The Vertical Integration/Network Diagnostic and Readiness Tool is designed to help stakeholders in low and middle-income countries to successfully assess readiness and review current policies and initiatives relating to vertical integration. The tool is also designed to collect data and information on existing vertical integration pilots.
The Vertical Integration/Networks Diagnostic and Readiness Tool is divided into three instruments, each targeted at different stakeholders:
Instrument 1 is addressed to policymakers, payers and regulators and it covers system-wide policies, regulations and leadership supporting (or inhibiting) vertical integration at the national or federal level. It focuses on broad policy and institutional attributes of vertical integration at the national level.
Instrument 2 is addressed to healthcare facilities and front-line practitioners. It seeks to understand the degree to which vertical integration has been introduced and incorporated into the delivery system as well as the supporting institutional and financial environment. In addition to assessing capacities and nuts-and bolts features of vertical integration (or the lack thereof), it also assesses organizational environments in terms of policies, leadership and support for the same. It also gathers information on four types of patient transitions from the perspective of the respondents: PHC-hospital, specialist-PHC, hospital-home, and community-PHC-hospital for MNCH.
Instrument 3 is addressed to practitioners and implementers of vertical integration pilots and initiatives. It covers the major enablers or disablers in the broader institutional and financial environment as well as vertically integrated care practices implemented by these initiatives. Each initiative will probably cover a single type of patient transition.
To facilitate implementation, an online version of the tool is also available using through the Survey Solutions software. Find instructions on how to access the Survey Solutions version by downloading the tool below.
The tool builds upon findings from a March 2018 Join Learning Network coproduction workshop in Manila facilitated by Aceso Global.
Please email email@example.com if you need more information on the tool.
This presentation explores the challenges facing the Brazilian healthcare sector in terms of quality, efficiency and outcomes. It draws from the US experience with value-based care to highlight possible directions for innovation in Brazil, with a focus on integrated care, alternative payment mechanisms and new roles for information technology. Aceso Global CEO Maureen Lewis delivered this presentation at the seminary Dasa/Valor Econômico in São Paulo, Brazil, in November 2018.