The imperative for systems thinking to promote access to medicines, efficient delivery, and cost-effectiveness when implementing health financing reforms: a qualitative study

Background: Health systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. Expansion of health insurance coverage offers promise in the quest for sustainable healthcare financing for many of the health systems in the region. However, the broader policy implications of expanding health insurance coverage have not been fully investigated and contextualized to many African health systems. Methods: We interviewed 37 key informants drawn from public, private and civil society organizations involved in health service delivery in Botswana. The objective was to determine the potential health system impacts that would result from expanding the health insurance scheme covering public sector employees. Study participants were selected through purposeful sampling, stakeholder mapping, and snowballing. We thematically synthesized their views, focusing on the key health system areas of access to medicines, efficiency and cost-effectiveness, as intermediate milestones towards universal health coverage. Results: Participants suggested that expansion of health insurance would be characterized by increased financial resources for health and catalyze an upsurge in utilization of health services particularly among those with health insurance cover. As a result, the health system, particularly within the private sector, would be expected to see higher demand for medicines and other health technologies. However, majority of the respondents cautioned that, realizing the full benefits of improved population health, equitable distribution and financial risk protection, would be wholly dependent on having sound policies, regulations and functional accountability systems in place. It was recommended that, health system stewards should embrace efficient and cost-effective delivery, in order to make progress towards universal health coverage. Conclusion: Despite the prospects of increasing financial resources available for health service delivery, expansion of health insurance also comes with many challenges. Decision-makers keen to achieve universal health coverage, must view health financing reform through the holistic lens of the health system and its interactions with the population, in order to anticipate its potential benefits and risks. Failure to embrace this comprehensive approach, would potentially lead to counterproductive results.

This was a qualitative study that sought to determine the potential health systems impacts that would result from the proposed expansion of the public sector employees’ health insurance scheme as a pathway towards UHC in Botswana. It was part of a larger study that sought to understand the demand and uptake of health insurance among the public sector employees in the country. In Botswana, the health system follows a decentralized structure with varying levels of autonomy at the district level. The national Ministry of Health (MOH) is the central planning and policy formulation unit, with the overall responsibility of coordinating and supervising district level implementers to achieve the national health policy objectives [15, 16]. The district health system is comprised of many actors, drawn from the public, private and civil society, all working together to deliver health services. The district is the core implementation unit providing health services based on the principles of the primary health care (PHC) [15, 16]. Within the district, there are different levels of health facilities that form the service delivery chain. These range from clinics and health posts, to primary and district hospitals. The latter form the first referral point within the district health system, offering a range of basic specialist support to the clinics and health posts (that mainly provide preventive health services) [16, 17]. There are also private providers at the district level, some of which have entered into collaborative arrangements with the public sector to provide health services. At the pinnacle of the referral system, are two national referral hospitals and two large private hospitals that offer a range of specialist health care. Figure 1, is a schematic presentation of the MOH organizational service delivery structure [15]. Ministry of Health Organizational Structure. The key Ministry of Health, organizational structures charged with policy setting and implementation Private sector providers are mainly concentrated in urban areas, where they cater for the population with the capacity to pay, while those in the rural areas are chiefly served by public sector providers [18]. Within the public sector, particularly in the peripheral areas, some of the key challenges that are often cited include, lack of adequate infrastructure, limited access to essential medicines and other health technologies, among others. Within the public sector, access to essential medicines is guaranteed by the government whereas in the private sector, clients pay for medicines through medical insurance or out-of-pocket [15, 18]. However, for a number of chronic medications, the government has entered into partnership with the private outlets (starting with major urban centers) to dispense medicines to patients from the public sector. Financial resources for health are mainly drawn from government, donors and private sector (including household) sources [15, 18]. For government as a source, a portion of tax revenues is allocated for health service provision in accordance with the national health policy guidelines. Government contributes the bulk of resources, with the private sector playing an increasingly important role in contributing approximately 25% of the total health expenditure. Donor funding on the other hand is mainly focused on specific health program areas such as HIV/AIDS and tuberculosis [18, 19]. Both the government and the private sector also play a significant role in pooling financial resources for health. Through its general taxes, the government raises revenues which it earmarks a proportion to finance health service delivery. At the same time, government as an employer has a medical scheme for its employees, which covers approximately 55% of the public sector employees which translates to approximately 70,000 principal beneficiaries. The scheme is voluntary with the government contributing 50% of the premium amount that employees have to pay to become members [18]. In addition to the public sector employee’s health insurance scheme, there are more than 10 private medical insurance companies of various sizes which in total also cover approximately 70,000 beneficiaries. Therefore, in total there are approximately 140,000 principal beneficiaries with health insurance coverage for a population of about 2.2 million people [18, 20]. With this arrangement, Botswana has made great strides in critical areas such as HIV/AIDS and maternal and child health. For example, the country has recorded universal coverage with key interventions such as antiretroviral treatment (ART) and prevention of mother to child transmission (PMTCT) of HIV. Priority services such antenatal healthcare, skilled birth attendance and childhood vaccination have also consistently recorded high coverage across the country over time [15, 21]. However, as Kutzin points out, UHC should be viewed as a direction rather than a destination [7]. This is particularly true for Botswana when considering the other priority areas such as non-communicable diseases that have not been comprehensively addressed, despite concerted efforts [2, 5, 21]. Our analysis was anchored on the framework described by WHO, where the health system is viewed as comprising six discrete pillars [22–25]. This definition was essential in promoting a common understanding among the stakeholders. As shown in Fig. 2, the framework is underpinned by the core functions of the health system, namely; service delivery; health workforce; health information; medical products, vaccines and technologies; financing; and leadership and governance. The framework espouses a logical pathway from inputs into a health system to produce the desired impacts in the form of population health gain [23, 25]. The Health System Framework. An illustration of the health system framework, adapted from the WHO. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, Switzerland: World Health Organization; 2007 Effective health systems are expected to increase population access to quality medicines and other health interventions in order to improve health [26]. Apart from improving health, the health system is also expected to enhance the responsiveness to the legitimate non-health expectations of those seeking health, and ensure fairness in financial contribution [22, 23, 25]. Responsiveness captures the aspect of the individual’s interactions with the health system, with the considerations of dignity, respect and freedom of choice for those seeking healthcare. Financial and risk protection, on the other hand, covers the fact that contributions to the health system should be based on household ability to pay, and therefore that poor households should not be impoverished in their quest for quality health care. Finally, service provision should be done efficiently and cost effectively while adhering to the principle of equity [23–25]. The study period was from June to September 2015. Study participants were selected through non-probability sampling procedures termed purposive sampling. In summary, purposive sampling techniques involve selecting certain units or cases based on a specific purpose rather than randomly. In our case, this was a judgement selection based on the participant’s knowledge and involvement in the financing and health service delivery with the Botswana healthcare system. Our sample was then supplemented using snowball sampling methods (also referred to as chain sampling), whereby the initial respondents referred us to the other potential respondents until no new information was forthcoming, or achieved saturation. In order to guide our initial judgement in the selection of initial respondents, we first undertook a desk review mapping out the different stakeholders involved in health financing and service delivery in Botswana. These comprised of the public and private sectors; non-governmental and civil society organizations (NGO), including the faith based actors; and bilateral and multilateral development organizations, among others. A representative list of 31 organizations was drawn to ensure that views of all key stakeholders were represented in our study. Of the 31 organizations, 8 were identified as public sector; 11 were from the private sector; 6 were classified as NGOs; and 6 fell into the bilateral and multilateral development organizations. The public sector consisted of employers; health service providers such as hospitals and clinics; and academic and research institutions. Meanwhile, the private sector had an array of providers (mainly private hospitals and private practitioners), health financiers, as well as small-to-large employers. From the 31 organizations, 1-2 key informants were identified based on their organizational functions and knowledge of health financing and service delivery in the country. In total, we identified a sample of 42 participants, of which 15 were not able to participate due to work commitments. However, from the initial 27 participants, we were able to get 10 additional referrals that enriched our data collection to achieve saturation. Table 1, shows the breakdown of the 37 key informants, ranging from policy-makers to frontline health workers, that were interviewed. The interview process used a semi-structured interview guide developed to solicit perceptions on the impact of health financing reforms on universal health coverage aspirations. Its development was primarily based on prior research on the health system framework and the interaction of its various components as it pertains to progress towards universal health coverage. Categories of Participants The key informant interview (KII) approach was used to collect data from the selected participants. Simply, KIIs are qualitative, in-depth interviews of respondents selected for their first-hand knowledge about a topic of interest. In our case, arrangements were made to secure a 45-min appointment and a suitable venue to conduct the face-to –face interview. This ensured that participants were not unduly distracted during the interview. Before the KII started, researchers introduced themselves, explaining the objectives of the study and securing verbal informed consent to proceed with the interview. Participants were made aware that they could cease participating in the interview at any stage without prejudice. The interview proceeded with the participant introducing himself or herself and giving an overview of his/her work experience as it relates to the objectives of the study. Leading questions, prepared by the authors, ensured that the participants responded to the key topical issues of interest. The specific focus was on access to medicines, efficiency, and cost-effectiveness of health service delivery. Table 2, shows the summary of some of the open ended questions that participants were asked during the interview. All the interviews were conducted in English. Summary of the Interview Questions aFurther clarification was provided to include comparisons between the urban –rural populations; those using private-public sector facilities; those employed and unemployed Interviews were transcribed verbatim and in their entirety. In order to achieve uniformity, the same researcher (AL) transcribed all the interviews. The transcripts were then analyzed applying thematic content analysis. This approach is appropriate for semi-structured expert interviews as it is used for coding text with a predefined coding system which can then be refined and completed with new themes emerging. Our initial coding system identified, “access to medicines”, category which was defined following priori literature on health systems efforts towards universal healthcare coverage. It is generally accepted that access and utilization of medicines and other health technologies is an essential link between health resources and improvements in population health [4, 6]. From the interview transcripts, data were both deductively and inductively coded, whereby a series of codes were developed and then grouped into similar concepts. These concepts were then combined to form categories (efficiency and cost effectiveness) or were assigned to the category of “access to medicines”, defined earlier. Table 3, shows the successive steps of data reduction employed from simple codes to global themes. Thematic Analysis Framework

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• achoki, tom
• lesego, abaleng