Background: Achieving universal health coverage (UHC) requires health financing reforms (HFR) in many of the countries. HFR are inherently political. The sustainable development goals (SDG) declaration provides a global political commitment context that can influence HFR for UHC at national level. However, how the declaration has influenced HFR discourse at the national level and how ministries of health and other stakeholders are using the declaration to influence reforms towards UHC have not been explored. This review was conducted to provide information and lessons on how SDG declaration can influence health financing reforms for UHC based on countries experiences. Methods: We conducted a rapid review of literature and followed the preferred reporting items for systematic review and meta-analysis (PRISMA) guideline. We conducted a comprehensive electronic search on Ovid Medline, PubMed, EBSCO, Scopus, Web of Science. In searching the electronic databases, we combined various conceptual terms for “sustainable development goals” and “health financing” using Boolean operators. In addition, we conducted manual searched using google scholar. Results: Twelve articles satisfied our eligibility criteria. The included articles were analyzed thematically, and the results presented narratively. The SDG declaration has provided an enabling environment for putting in place necessary legislations, reforming health financing organization, and revisions of national health polices to align to the country’s commitment on UHC. However, there is limited information on the process; how health ministries and other stakeholders have used SDG declaration to advocate, lobby, and engage various constituencies to support HFR for UHC. Conclusion: The SDG declaration can be a catalyst for health financing reform, providing reference for necessary legislations and policies for financing UHC. However, to facilitate better cross-country learning on how SDG declaration catalyzes HFR for UHC there, is need to examine the processes of how stakeholders have used the declaration as window of opportunity to accelerate reforms.
We registered the protocol a priori in PROSPERO (CRD42020194090) because initially we thought we could conduct a systemic review. However, due to resource constraints, we ended up conducting a scoping review of literature. We thus present here an overview of the methodological approach and highlight minor differences between the protocol and the actual conduct of the review. We conducted a review of findings from studies and reports on how the SDG declaration is influencing or has influenced health financing reforms for UHC. For this review, health financing reforms for UHC is conceptualized to refer to changes in arrangement and management of health financing system sub-functions of revenue collection, pooling, and purchasing, and policy on benefits design and rationing towards efficient and equitable system [30]. The reforms explored are linked or can be attributed to have resulted from global discourses on sustainable development agenda or SDG declaration. In order to improve the transparency and methodological robustness of this scoping review of litertaure, we followed preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines [31], where we defined the review questions; identified, selected and appraised the studies; abstracted the data; and synthesized and interpreted the results. The review questions were: a) How has the SDG declaration influenced the process of health financing reform for UHC? b) What dimensions of health financing have been influenced by the SDG declaration? and c) How have Ministries of Health and other stakeholders used the SDG declaration to influence health financing reforms for universal health coverage? All study designs were considered for the review. This was to account for the complex nature of health financing reforms. Specifically, we included randomized and non-randomized studies, evaluation studies, policy analyses, stakeholder analyses, and peer-reviewed case studies and commentaries. Proposals and studies published in abstracts only were excluded. The inclusion criteria based on population, intervention (exposure) and outcome (PEO) [32], required that the study reviewed: (i) Is on health systems reform, or other government reforms where health financing is a part of the reform process, or is specifically on health financing reforms, and is published between Jan 2012 and June 2020. This date was chosen to include studies conducted after the 2012 Rio de Janeiro United Nations Conference on Sustainable Development, where the process of developing SDG was initiated. (ii) Describes how SDG declaration has influenced reforms in health systems financing for UHC as the intervention. (iii) Reports on changes to at least one of the following health financing dimensions of management or organization i.e., revenue collection, pooling, purchasing, and policy on benefits design and rationing as the outcome. A comprehensive electronic search of six databases was conducted using indexed and free text words in the following databases: Ovid Medline, PubMed, EBSCO, Scopus, Web of Science between March and September 2020 by WDO and FS. In searching the electronic databases, various conceptual terms for “sustainable development goals” and “health financing” were searched. We used the Boolean operators ‘OR’ to combine the terms within each concept and ‘AND’ to combine the two concepts. We did not use search filter for study type, language (we anticipated to use the google translate for non-English articles), country or geographical area in order to find as many studies on the topic as possible. In addition, we screened the reference lists of included studies from the databases for additional eligible studies. We also conducted manual search for relevant articles from publications on websites of WHO, online journals (health systems and reforms, health policy and planning), UHC2030 partnership, and used the search engine google scholar. In order to gauge the viability of the review, we first conducted a pilot electronic search on PubMed using the aforementioned terms. The search yielded 692 potential articles. From initial screening of titles and abstracts, 69 articles were considered potentially eligible. Of the 69 articles, one was in Chinese and one in Spanish, the rest were in English. From the 69 articles, we were able to retrieve 68 full length articles, the exception being the one published in Chinese. The article in Spanish was translated using google scholar. After review of full length articles of the 68 studies, two studies were found to meet our eligibility criteria; Agustina et al. [33] and Wang and Zhou [34]. In addition to gauging viability of the review, the pilot search enabled improvement of our screening and eligibility, data abstraction and quality assessment tools in terms of appropriateness and uniform application of criteria across reviewers (WDO and FS), thus enhancing the validity of the process and minimizing bias in the study identification and selection. All retrieved articles from the databases were exported to EndNote X9 [35], where duplicates were removed. The titles and abstracts of identified articles were screened for potential eligibility. Full text of studies judged as potentially eligible were retrieved. The text retrieved were screened in detail for eligibility, using a standardized screening form (Additional file 1: Appendix 1) in duplicate. The number of studies included and excluded are documented and illustrated in the PRISMA flow diagram (Fig. 1). The full texts of all relevant studies found to meet the inclusion criteria were retained for the final synthesis [36]. The studies that failed to meet the inclusion criteria at the full-text screening phase were documented with reasons for the exclusion from the analysis. PRISMA flow chart Data was abstracted using standardized data abstraction form adapted from the Joanna Briggs Institute (JBI) data abstraction format (Additional file 1: Appendix 2) [37]. Summary of data extraction (Table 1) has been provided so that readers can assess the critical review process for this study. The study characteristics extracted included the bibliographic details of study (study title, author, year of publication), objectives (purpose of the study), study design, setting (country); influence of SDGs declaration on health financing reforms; the dimension or aspect of health financing system reformed; and how ministries of health and other stakeholders have used SDGs declaration to drive health financing reform for UHC (Table (Table11). Characteristics of the included study and findings Agustina et al [33], 2019, Indonesia, Study design: Qualitative, documentary review – SDGs led to discussions on health financing sustainability for UHC – Establishment of a scheme that was adaptable, accommodate diverse needs, assures financial risk protection – In 3 years (by 2019), the NHIS became the largest single-payer health insurance scheme in the world Revenue Collection – Intense solicitation of payments from self-enrolled members – Categorization of contributors/sources of revenue for pooled fund Pooling of funds – Reduced fragmentation in risks pools – Establishment of Social Security Agency for Health (SSAH) – Law of mandatory % allocation of government budget to health Purchasing – A Single payer for UHC established – Payment-capitation and diagnostic-related group based on Indonesia tariff. Policy on benefit entitlements – Scope of services covered by capitation payment is determined by Indonesian Medical Council – Decrease in fee-for-service payment Fahim et al [38], 2018, Bangladesh, Study design: Mixed method, documentary review – The national health policy 2011–2032 updated to address contemporary issues of SDG and UHC – Health financing policy emphasizing solidarity in financing, equity of access and provision of quality care Pooling of funds – Policy emphasis on allocating a significant percent of government spending to health – Exploring ways of reducing OOP Chilufya and Kamanga [39], 2018, Zambia, Study design: Commentary Study aim: – Zambia’s transformational health agenda is in tandem with SDGs target 3.8 – Health sector strategic plan 2017–2021 was informed by the SDG agenda – Country building on the progress past health reforms during SDG era. Revenue Collection – Exploring ways of implementing sustainable health care financing – Mandatory pre-payment contribution being established Pooling of funds – Commitment to allocating sufficient government funding for health – Establishment of NHIF fund as a pooling agency Purchasing – Exploring reforming payment mechanism from inactive to active purchasing Ahmadnezhad et al. [40], 2019, Iran, Study Design: Quantitative, document review Purchasing – Ministry of Health and Medical Education (MOHME) reduced co-payment Policy on benefit entitlements – Basic health insurance coverage extended from 83.2% of population to 93.2% – Aim to decrease prevalence of catastrophic expenditure to less than 1% by end of 2021 Lee et al. [41], 2019, Republic of Korea, Study design: Qualitative, documentary review – In 2017, government announced NHI reform ‘Moon Jae-in care’ to increase coverage rate to 70% by 2022 and its considered a government’s commitment to health-related SDG – Reinforcing the benefits and financial coverage of national health insurance (NHI) is a core aspect of the reform – The advent of SDGs and inclusion of the President’s name in the health financing reform indicates how seriously the government has taken health financing reforms for UHC Policy on benefit entitlements – The population already covered, reform focuses on increasing the scope/depth of coverage and reducing cost-sharing – Reducing out-of-pocket (OOP) from the cost sharing component to minimize the catastrophic and impoverishing expenditure Nagpal et al. [42], 2019, LPDR, Study design: Quantitative, review of surveys data – Approved national health insurance (NHI) Law in 2017 – To achieve the health targets in the SDG and meet new and emerging challenges, the Government of LPDR accelerated its efforts towards universal health coverage, e.g. the nationwide scale-up of free at point of care MCH services – The NHI was quickly rolled out in 15 provinces by the end of 2017, and covered the entire country except Vientiane capital by the end of 2018 Pooling of funds – In 2016/17, free MCH program was consolidated with 3 other social protection schemes into a single national health insurance scheme (reducing number of risk pools), Purchasing – User fee payment by pregnant women and children under 5 replaced by case-based payment under the MCH initiative Capuno et al. [43], 2018, Philippines, Study design: Mixed method, depth interviews and documentary review – Duterte government’s aims to attain the health-related SDG targets through extending health insurance coverage to all, thus ensuring each Filipino “financial freedom when accessing services”, – The Philippines Health Agenda 2016–2022 was informed by and has taken into consideration Philippines commitment to SDG agenda – Main health goals and strategic policies including on health financing are reflected in the Mid-term Philippine Development Plan developed based on ambition to achieve SDG targets Revenue Collection – Continued preservation of Sin Tax for health – Earmarking has helped to sustain progress towards achieving of SDG target on UHC Purchasing – PhilHealth as single purchasing agency Policy on benefit entitlements – Poor, marginalized and vulnerable protected from cost of health care through Sin Tax – There is stronger link between DOH’s national objective for health and the national development plan following the SDG declaration – DOH was successful in generating political and financial support to pursue universal health access and in legislating various proposal e.g. Sin Tax Law Dayrit et al. [44], 2018, Philippines, Study design: Health system review, mix method – SDGs has informed Philippine Health Agenda [Administrative Order No. 2016–0038] which is about reforming PhilHealth into main national purchaser of health services – SDGs is seen as facilitator of natural progression towards universal health access Pooling of funds – Changes in pooling arrangement with mandatory PhilHealth cover Purchasing – Reformed capitation and no-balance billing arrangement for members – Fee-for-service phased out and case-rate payment applied by PhilHealth Policy on benefit entitlements – Increased benefit ratio -expanding enrollment of the poor in the NHIP & promoting quality of services Ranabhat et al. [45], 2019, Nepal, Study design: Systematic review Policy on benefit entitlements – Free maternal and child health (MCH) services at point of care – Development of MCH service package – Nationwide scale-up of the scheme following limited geographic scope – Lobby by visionary health care professionals, international organization and interest groups that consistently made reference to government commitment to SDGs led to establishment of national health insurance program. – In 2016 the government through Ministry of Health and Population started social health insurance scheme in some district and extended to 22 other districts by 2018. Gera et al. [46], 2018, India, Study design: Commentary – Government has taken important policy level initiatives in the recent years, especially after the launch of SDGs that include establishment of National Institution for Transforming India (NITI Aayog) and roll out of national health policy 2017. – The Integration of SDG agenda in NHP-2017 and NITI Aayog’s Vision for Health (2032) has provided an unprecedented opportunity for health financing reforms for UHC Pooling of funds – Establishment of new flagship National Health Protection Scheme recently launched by the union government Policy on benefit entitlements – Exploration on how to incrementally expand coverage to cover larger population proportion and the range of services covered – Leadership of federal Ministry of Health (MOH) has fostered a collaborative effort with other Government ministries and agencies, and state governments in the SDG era leading to the formation of national health protection scheme. – Effective stewardship from the federal MOH, reorganization of health care service delivery and strengtehing community participation and accountability. Wang et al. [34], 2020, China, Study design: Qualitative, documentary review – As part of Healthy China 2030, health is considered crucial entry-point to achieving SDGs because of its ability to lift people out of poverty – “Healthy China 2030” will improve access to essential health services covered by health insurance and financial assistance scheme Policy on benefit entitlements – 95% of the population covered by health insurance schemes – Improved medical care insurance for targeted poverty-stricken population Tan et al [47], 2018, China, Study design: Commentary – Healthy China 2030 was a response to the 2030 United Nations SDGs – A momentous endeavor to enhance public health Revenue Collection – Encourage development of commercial health insurance schemes to supplement National Health Insurance Schemes Policy on benefit entitlements – Improved health insurance system targeting economically backward region – Healthy China 2030 has led to financial protection for the poor We had planned to assess the quality of included articles for analysis using the Joanna Briggs Institute’s critical appraisal checklists for qualitative, quantitative and mixed-methods studies, however after reflections of the eligible articles, this was not conducted. This is because we included some articles that do not typically fall under conventional studies approaches such as commentaries and health system reviews, yet they met our eligibility criteria. Quality assessment was meant to support judgement on the relative contribution of each study to the development of explanations and relationships between SDG declaration and health financing reforms. However, given our review questions, quality assessment of articles would not have swayed these explanations of the relationship between SDG declaration and health financing reforms for UHC. We used NVIVo and a thematic framework (Additional file 1: Appendix 3) to facilitate analysis. Thematic framework synthesis is a qualitative approach that involves selecting, recording and categorizing key issues and themes [48]. For each article, the process involved familiarization with information, identification, recording, categorization and interpretation of the influence of SDG declaration on health financing reforms, and how Ministries of Health and other stakeholders have used the SDG declaration to advance health financing reforms towards UHC. We used Kutzin’s framework for analyzing health financing systems [8], to examine the changes in the organization and/or management of health financing functions. We then examined whether or not these changes were as result of the SDG declaration. Findings on the three review questions are presented narratively in the following section.
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