This blog post is part of a wider HSG blog series in the lead up to the Universal Health Coverage Forum 2017, which takes place in Tokyo, Japan from 12 – 15 December. In this series, HSG members provide their perspectives on how Health Policy and Systems Research is fundamental to acheiving Universal Health Coverage by 2030.
By Arin Dutta, Senior Health Economist, and Shreeshant Prabhakaran, Technical Advisor for Health Financing, and Suneeta Sharma, Vice President for the Americas Health Practice at Palladium
Health policy and systems research (HPSR) has tended to shy away from exploring how improved legal-regulatory conditions might accelerate progress toward universal health coverage (UHC). Isolating and quantifying the effects of these types of governance-related changes is inherently complex, and progress on UHC outcomes are often difficult to link to a specific policy.
Health Policy Plus (HP+), a project funded by USAID and PEPFAR, acted as the co-chair of the Policy and Regulation thematic working group (TWG) in the recent Marshalling the Evidence for Health Governance Initiative, led by USAID and the World Health Organization. Our TWG aimed to address the lack of evidence on what constitutes a supportive legal-regulatory environment to act as a strong base for UHC-oriented reforms. In the related report, we explored how laws, regulations, and policies implemented in different countries had an impact on their achievement of UHC goals.
Countries on the cusp of undertaking major health system reforms should prioritize their governance interventions based on the risks specific to their health system contexts. Nevertheless, certain areas of research should be emphasized now to assist countries in drafting and implementing relevant laws and regulations. Our review found that emphasis should be placed in the following three areas:
1. Avoid or mitigate unintended responses to policy change
Countries should attempt to reduce the negative or unintentional aspects of inadequate legal and regulatory structure design. For example, several UHC reforms of health financing focused on the legal structures that implemented a separation between purchaser and provider, along with new provider payment mechanisms, as a way to increase efficiency, promote quality, and ultimately improve health outcomes. However, in many instances, such as in Indonesia, Colombia, and Thailand, the purchasing models adopted ended up incentivizing an inefficient level of curative and hospital-based care. Further, insufficient attention was paid to developing and implementing policies that would incentivize providers, and the system as a whole, to deliver more and higher-quality primary, preventive, and promotive care.
2. Capture synergies in governance-related effects
We found that many governance-related effects can be mutually reinforcing in the way policy changes impact health systems. For example, UHC-related reforms that improve transparency of health-related rules (e.g. for user fees and exemptions/waivers) also help to increase the accountability of providers to patients. Reforms that were intended to increase accountability (e.g. opening consumer redressal mechanisms for health services or seeking survey-based opinions on quality of care) also managed to reduce corruption and increase responsiveness across the system. If there was better understanding of the effects policy changes — whether legal, regulatory, or operational — can have on governance areas that are less tangible, then these effects can be proactively designed and even amplified. Areas where we found the greatest potential for synergies are in increased responsiveness, accountability, and transparency. Future research should build on the suggestion in our review that these governance results are often linked in health sector reform and, together, can lead to step-change improvements in the functioning of the health system.
3. Prioritize and sequence policy change actions
Governments may have political and process constraints on the number of legal and regulatory changes they can design and implement in a period leading up to, and during, health sector reform. However, it is important to consider when a number of changes that target different health system stakeholders may be necessary to make any one, overarching reform effective. For example, our review found that task-shifting policies, aimed at increased efficiency in the use of clinical health staff, were often ineffective if they were not implemented as part of a suite of policy reforms related to pre-service and in-service training, and accreditation and regulation by medical and nursing bodies. Similarly, legal changes separating purchaser from provider that were not accompanied with improvements in the autonomy of facilities or in the stewardship and oversight of a new payer organization led to avoidable inefficiencies and distortions in the health system.
Governance in the context of UHC: an emerging area of HPSR
Governance-related effects and changes in laws, regulations, and policies can play a critical role in making progress towards UHC. While we found a large body of qualitative literature in this area, integrative studies, meta-analyses, and systematic reviews focusing on specific areas of this field are sorely lacking. There is still a dearth of literature that adopts a governance lens in assessing the success of health system reforms. More research is also needed to understand how country context drives policy effectiveness — in particular, how changes to laws and regulations generated intended and positive effects — and to quantify and use quasi-experimental and experimental methods to explore the effects of governance-related reforms on UHC outcomes.