Panama Transition Readiness Assessment Country Report

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.

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Aceso Global Policy Working Paper - Health Policy Challenges in Health Economics and Finance in Latin America

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.

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Mapping CSO Funding Options for HIV & Tuberculosis in the Dominican Republic

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.

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JLN Vertical Integration/Network Diagnostic and Readiness Tool

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 jln.vi@acesoglobal.org if you need more information on the tool.

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LINK TO A WEBINAR PRESENTING THE TOOL

Dominican Republic Transition Readiness Assessment Country Report

This report summarizes the findings of the Transition Readiness Assessment for the Dominican Republic 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 the Dominican Republic to undertake transition planning as the Global Fund winds down its financial support for the national tuberculosis and HIV/AIDS responses.

Specifically, the report: 1) summarizes the Global Fund's financial and non-financial support to the country; 2) describes the epidemiological situation as well as the national response in the Dominican Republic; 3) provides a background on the institutional and enabling environments, human rights and gender situation; 4) overviews the Dominican Republic's health system and analyzes healthcare financing and fiscal space issues; 5) analyzes delivery system enablers and barriers to transition, including supply chain, information systems and the health workforce; and 6) assesses the current and future role of civil society organizations in the national disease responses. The report concludes with recommendations on the pathway forward to facilitate a smooth and sustainable transition.

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Combating Corruption in Global Health

In the past 20 years, the international community has begun to fully recognize the devastating effect of corruption on global health. Poor governance, marked by weak institutions, absence of rule of law, and lax enforcement of health policy, creates conditions for corruption to thrive. This can contribute to health system failure and deprive citizens of access to even basic health services. This paper explores the extent of corruption in health services, as well as  emerging anti-corruption tools and inter-agency frameworks that could prove effective in limiting corruption in global health. While corruption has gained attention in the international sphere, more action is needed in the specific context of global health. This paper was co-written by Maureen Lewis (CEO of Aceso Global), Tim K. Mackey, Jillian Kohler and Taryn Vian.

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Measuring Public Hospital Costs: Empirical Evidence from the Dominican Republic

This paper presents a methodology and analysis to determine the actual costs of inpatient, emergency and outpatient services in a Dominican hospital. By developing and applying a set of survey instruments to a large sample of patients, the authors were able to measure and cost all hospital staff time, in-kind goods, overhead and the depreciated value of plant and equipment related to the treatment of each patient. The study finds that the hospital budget was 50 percent higher than actual costs of services. Further, while spending on personnel comprised the vast majority of the total hospital budget, actual personnel costs for patient treatment were low. Based on these results, the authors suggest that the hospital suffers from gross inefficiency, chaotic medical care organization and poor management.

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Guidance for Analysis of Country Readiness for Global Fund Transition

Aceso Global was tasked by the Global Fund to develop a tool to help countries through the transition process as Global Fund contributions wane and consequently national governments and other in-country stakeholders are expected to shoulder an increasing burden of disease financing and programmatic responsibilities. This Guidance is the culmination of these efforts. It aims to help countries identify financial, programmatic and governance gaps, bottlenecks and risks in the health system that might affect transition.

Specific areas of investigation include service delivery, procurement and supply chain management, human resources, information systems, monitoring and evaluation (M&E), community systems and responses, and health financing, among others. A modular approach allows for flexibility and analysis tailored to country-specific context.

The Guidance was refined following a pilot in Paraguay led by Aceso Global in January 2017, and has since been successfully implemented in Panama and the Dominican Republic.  

 

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Health Investments and Economic Growth: Macroeconomic Evidence and Microeconomic Foundations

Improvements in health status over the last 50 to 100 years have been nothing short of spectacular. Vaccines, antibiotics, and other pharmaceutical developments have drastically reduced the incidence of illness and death. Economic growth has also helped: richer people are better nourished and educated, and richer countries are more able to afford the public goods (such as supply of clean water and sanitation and control of disease vectors such as mosquitoes) that reduce the transmission of disease.

Do improvements in health themselves help to boost economic growth? A resolution of this debate could boost the urgency of the quest for growth, inform that quest, or both. For example, a finding that economic growth reduces infant mortality could hasten the adoption of potentially growth-enhancing policy reforms. To help inform decision making on public policy, this review aims to: i) examine the routes by which improvements in health might indeed increase incomes and growth, and the related evidences; and ii) investigate the determinants of health itself, particularly evidence on the impact of public expenditure policies on health.

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Better Hospitals, Better Health Systems, Better Health

Despite their central role in healthcare delivery and their consumption of the lion’s share of national health budgets, hospitals in many emerging markets remain poorly governed, underfunded, and unevaluated. Hospitals have long been neglected by external stakeholders such as donors and multilateral institutions, and considered “black holes” by government ministries that fund facilities but provide limited governance or accountability. Historically, patients have borne the brunt of this negligence, shouldering high costs for poor quality of care.

This report proposes a Global Hospital Collaborative to transform the emerging market hospital landscape by promoting knowledge sharing, research, and cooperation between global experts and stakeholders in hospital governance, management, financing, and related fields. It was produced by the Hospitals for Health Working Group housed at the Center for Global Development, in collaboration with Aceso Global CEO Maureen Lewis and CTO Gerard La Forgia.

The proposed Collaborative would synthesize and centralize the vast but fragmented knowledge, research, and best practices related to hospital management and financing, as well as integration with the broader health system, and add to this knowledge base through additional research. The Collaborative is imagined as a forum for exchange that can lead to concrete improvements in health on the ground. Potential projects and products could include a web-based knowledge clearinghouse, conferences and webinars, data measurement and analysis, peer-to-peer learning exchanges, and in-country technical assistance. 

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Parallel Systems and Human Resource Management in India's Public Health Services

Increasingly, evidence in India suggests that the delivery of health services suffers from not only a shortfall in trained health professionals, but also from unsatisfactory performance of existing service providers working in the public and private sectors. This study focuses on the public sector and examines de facto institutional and governance arrangements that may give rise to well-documented provider behaviors such as absenteeism, which can adversely affect service delivery processes and outcomes.

The paper considers four human resource management subsystems: postings, transfers, promotions, and disciplinary practices. The four subsystems are analyzed from the perspective of frontline workers, that is, physicians working in rural healthcare facilities operated by two state governments. Physicians were sampled in one state that has instituted human resource management reforms and one state that has not.

The findings are based on quantitative and qualitative measurements. The results show that formal rules are undermined by a parallel modus operandi in which desirable posts are often obtained through political connections and side payments rather than merit. The evidence suggests an institutional environment in which formal rules of accountability are trumped by a parallel set of accountabilities. These systems appear so entrenched that reforms have borne no significant effect.

 

This working paper was co-authored by Gerard La Forgia, Shomikho Raha, Shabbeer Shaik, Sunil Kumar Maheshwari, and Rabia Ali. 

 

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Case Studies: White Paper on Hospital Autonomy Potential in India

These case studies supplement Aceso Global’s White Paper on Hospital Autonomy Potential in India and assess hospital autonomy reforms in Brazil (Sao Paulo), Hong Kong, Vietnam, Portugal, Spain, the UK, and the US (NYC). Each case study introduces the country- or city-specific context leading to reforms, then details how the governance model functions in terms of operational and organizational autonomy, financial management, and accountability. Finally, each case study concludes with an analysis of the model’s strengths and weaknesses, and lessons learned. 

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White Paper: Hospital Autonomy Potential in India

Public hospital autonomy reforms emerged out of frustration over poor hospital performance, citizen distrust of public care and evidence from other sectors of the benefits of delivery models that incorporate or build on private sector incentives. Hierarchical bureaucracy, limited managerial decision-making authority and nonexistent accountability have resulted in poorly performing hospitals, and driven the search for alternative models of health care delivery.

This paper takes up three major organizational forms of hospital autonomy reforms – autonomization, corporatization, and public-private partnerships – and the underlying components necessary for their successful implementation. International examples of hospital autonomy reforms in both OECD and emerging market countries serve as a foundation for analyzing potential opportunities, as well as pitfalls, of autonomy reforms in different contexts.

The paper concludes with an evaluation of the possible application of public hospital autonomy reforms in India. A brief overview of existing autonomy reforms in non-hospital settings is followed by recommendations for the Indian government on the applicability of specific models to the Indian public health sector.

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Who is Paying for Health Care in Eastern Europe and Central Asia?

This paper analyzes informal payments in Eastern European and Central Asian (ECA) public healthcare systems. Informal payments comprise any purchase of health services outside of formal payment channels and therefore escape reporting and regulation measures. These payments, which are highly prevalent across the region, impede access, decrease equity and ferment systemic corruption. As a result, patients either consume less health care or sell personal assets to pay for treatment. This paper highlights the policy implications of informal payments and explores potential solutions to this problem.

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Governance and Corruption in Public Health Care Systems

This paper examines the relationship between governance and health care delivery, defines indicators for governance and corruption, and summarizes country and cross-country evidence using these indicators. The components of governance and corruption examined include perceptions of corruption and performance, management challenges in public health systems, staff absenteeism, informal payments, and misuse of public funds. Concluding that governance plays an important role in the performance of health services, this paper provides policy options for promoting better governance. 

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Governance in Health Care Delivery: Raising Performance

This 2009 paper argues that good governance is central to raising performance in health care delivery. It provides a definition for good governance in health and a framework for thinking about governance issues as a way of improving performance in the health sector. The paper was co-authored by Maureen Lewis and Gunilla Pettersson and published as: Governance in Health Care Delivery: Raising Performance, World Bank Policy Research Working Paper Number 5074. 

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Better Hospitals, Better Health Systems: Urgency of the Hospital Agenda

As the global community shifts to meet the challenge of universal healthcare (UHC), the new priorities and imperatives facing emerging economies will require attention and investment. Climbing costs, rapid escalation of chronic diseases, emergence of complex morbidities and poly-morbidities, relentless urbanization, and expanding expectations of citizens are simultaneously confronting countries as they move towards UHC. Responding effectively to the UHC challenges will entail strengthening health systems to generate better patient services and improved population outcomes. Investing in hospitals and their performance will be key to this success.

Reaching the expectations of universal health coverage requires renewed efforts to upgrade and strengthen hospital investments, and to promote the integration of patient care across levels of care. Whether addressing Ebola outbreaks, promoting maternal and infant survival, managing the burgeoning chronic disease epidemic, or simply meeting the ICU and surgery commitments of healthcare, hospitals remain central. The lack of investment and modernization of hospitals over the past few decades—whether in physical plant infrastructure or management systems—has rendered many expensive inpatient institutions shells of their potential.

This paper outlines the nature of the issues surrounding hospitals in emerging markets, making the case for early action to bridge the abyss of neglected hospital investments and the path needed to address the shortcomings and gaps in current policies and investments.

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Patient Flow Measurement: Definitions, Application and Relevance for LMICs

This briefing note summarizes the concepts, approaches, and benefits of patient flow in the US as a backdrop to exploring the use and relevance of patient flow analysis (PFA) in health care delivery across low- and middle-income countries (LMICs). It is meant to provide some basic understanding of PFA, its potential relevance in LMICs and the possible need for alternative metrics for measuring management in those settings.

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