Improving health system quality in low- and middle-income countries that are expanding health coverage: a framework for insurance

Worldwide, momentum is growing for health-care reforms that seek to achieve universal health coverage in low- and middle-income countries (LMICs) [1–3]. These initiatives have concentrated on health financing reforms that provide financial protection for their populations and expand access to skilled health services. As access to care expands, health systems risk being over-burdened and failing to deliver safe, effective and patient-focused care required for optimal health outcomes at both individual and population levels. Without simultaneously addressing the quality of health-care services provided, universal coverage schemes focused solely on expanding access will have limited impact on population health [4].

The Joint Learning Network for Universal Health Coverage (JLN) [5] was established in 2010 as a platform for peer-to-peer knowledge exchange (‘joint learning’) among governments and insurance programs in 9 countries pursuing universal coverage— Ghana, India, Indonesia, Kenya, Malaysia, Mali, Nigeria, the Philippines and Vietnam (Fig. 1). Recognizing the twin needs of coverage expansion and strengthening health system quality, participants requested guidance on ensuring that they purchase high-quality care for their patients. Thus, the Quality Track of the JLN was created in 2011, led by the Institute for Healthcare Improvement [6] and the National Institute for Health and Clinical Excellence International [7], to support public sector insurance agencies to learn and test options available to drive improvements in health system quality.

Insurance programs participating in the JLN are affiliated with government health reform efforts, deriving their primary funding from varying combinations of general government revenues (n = 7 organizations), payroll contributions (n = 6), household premiums (n = 5) and/or value-added tax (n = 1) [5, 8]. The benefits design for each organization is varied but most include coverage for some primary health care as well as inpatient care including procedural services. The number of lives covered by the insurance programs in the JLN exceeds 400 million across the 9 member states at various income levels. In several cases, but not all, the universal coverage efforts have focused on low-income populations not already covered by existing insurance programs for private sector workers or civil servants. Details on each plan including the populations served, financing and benefits packages are all available on the JLN website [5].

As the payers for care, insurers in LMICs are uniquely positioned to influence the quality of care they purchase across for their many beneficiaries [4]. Health sector spending increases do not necessarily drive improvements in care or outcomes [9]; insurers looking to expand access to care that is of value to patients need guidance on how to spend their resources wisely to influence quality. The existing literature describes a number of possible approaches—’pay for performance,’ ‘results-based financing,’ selective contracting of providers and data transparency— but offers little guidance on how to use these tools to build a cohesive strategy for quality across a health system. For instance, Leatherman and Sutherland [10] describe an exhaustive taxonomy of ‘quality enhancing interventions’ that fall into six categories: patient-focused interventions, regulatory interventions, incentives, data-driven and IT-based interventions, organizational interventions and health-care delivery models.

A framework that ties these interventions together with purchasers’ levers of control is needed. In this paper, we propose a conceptual framework that situates the insurer at the center of a multi-stakeholder process to improve the quality of a nation’s health system. The framework outlines how insurers’ primary mechanisms to influence quality—namely, paying or not paying for certain activities or achievements—can be used alongside the efforts of other key stakeholders to achieve critical health-system strengthening goals of quality assurance, improvement of services and patient engagement.

Kedar S. Mate, Zoe Sifrim, Kalipso Chalkidou, Francoise Cluzeau, Derek Cutler, Meredith Kimball, Tricia Morente, Helen Smites and Pierre Barker
Publication Date: 
August 2013

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