BACKGROUND Home- and community-based services funded through the Medicaid program account for $125 billion in annual federal and state expenditure (Center for Medicare Services, 2023), serving millions of elderly and disabled individuals who receive care in private residences rather than institutional settings. The decentralized nature of home care delivery creates fundamental accountability challenges: services occur in private homes largely beyond direct supervisory oversight, making home care one of the highest-risk categories for Medicaid fraud. Nationwide investigations by the HHS Office of Inspector General from 2011 through 2015 recovered $975 million in fraudulent home health claims (OIG, 2016). A 2024 New York State Comptroller audit documented $14.5 billion in Medicaid personal care payments made without required electronic visit verification (Office of the New York State Comptroller, 2024). In Massachusetts, a 2024 federal conviction established that a home health agency co-owner defrauded MassHealth of at least $100 million over four years through billing for services never rendered (U.S Department of Justice, 2024). Electronic visit verification was mandated under the 21st Century Cures Act (Pub. L. No. 114-255, § 12006, 2016) to address these vulnerabilities by requiring real-time electronic capture of six data elements at each Medicaid-billable visit: service type, recipient identity, date, location, provider identity, and start and end times. MassHealth selected Sandata Technologies as the Commonwealth's designated EVV aggregator, with hard billing edits scheduled no earlier than July 2026 (MassHealth, 2025). Despite widespread EVV implementation nationally, no published peer-reviewed study has empirically characterized visit-level EVV anomaly patterns from operational agency data or documented the industry-wide pre-submission exception management infrastructure through which GPS verification failures are converted into billing-ready records before aggregator transmission. Direct telephone communication with Axxess customer support on June 16, 2026 confirmed that most agencies use the EVV Exception Center and that through this workflow an agency can achieve 100% compliance (Axxess, personal communication, June 16, 2026). WellSky customer support confirmed on the same date that flagged visits can be changed to verified visits prior to state aggregator transmission (WellSky, personal communication, June 16, 2026). OBJECTIVE This study had two primary objectives. First, to characterize the prevalence, typology, and distribution of EVV anomalies through quantitative analysis of 15,172 de-identified visit records from an operational Massachusetts Medicaid home care agency during the pre-enforcement window preceding MassHealth hard billing edits. Second, to document the industry-wide pre-submission exception management infrastructure across six major documentation platforms through direct vendor communication and systematic platform review, and to characterize the response pattern of Massachusetts home care agencies to voluntary research participation requests. METHODS This study employed a five-agency mixed-methods comparative design. Agency A: cross-sectional observational analysis of 15,172 de-identified Sandata EVV visit records from January 1 through May 20, 2026 (140 days; 120 unique patients; 52 caregivers; 11 procedure codes). Written data use authorization was obtained from Agency A leadership. Six anomaly categories were analyzed: GPS location exceptions (GPS_EXCEPTION field); non-verified visit status (VISIT_STATUS field); systematic minimum-time patterns (ACTUAL_TIME = 8.0 minutes exactly); manual time adjustments (both ADJUSTED_IN_TIME and ADJUSTED_OUT_TIME populated); batch backdating (entry creation timestamps versus visit dates); and geographic impossibility (Haversine formula applied to sequential GPS coordinates). Financial exposure was calculated by applying verified 2026 MassHealth fee schedule rates from 101 CMR 350.00 to actual billing units in non-verified visit records. Agency B: operational observation of Axxess Exception Center pre-submission workflows. Agencies C, D, and E: structured professional interviews and research participation solicitation. Twenty additional Massachusetts Medicaid-enrolled agencies were contacted by telephone for voluntary participation between June 15 and 16, 2026. Direct primary source telephone communication was conducted with Axxess and WellSky customer support on June 16, 2026, including step by step exception center workflow on how to correct a mismatched visit. Systematic review of published technical documentation was conducted for six major documentation platforms: Axxess, WellSky/Kinnser, HHAeXchange, AlayaCare, AxisCare, and Alora Health. All analyses were conducted in Microsoft Excel using raw Sandata export data. RESULTS Agency A: GPS exception flags were present in 12,683 of 15,172 visits (83.6%). The GPS_CALL_IN_DISTANCE field, available for 4,983 records, revealed a mean clock-in distance of 12,922 meters from the patient address, a median of 391 meters, and a maximum of 156,956 meters (97.5 miles). A total of 1,410 visits (9.3%) recorded distances exceeding 10 kilometers and 516 visits (3.4%) exceeded 50 kilometers. Non-verified visits totaled 3,333 (22.0%), with estimated potential financial exposure of $246,610 for the five-month period applying verified 2026 MassHealth rates (101 CMR 350.00), annualizing to approximately $642,948 at this single agency. A total of 1,992 visits (13.1%) were documented at exactly eight minutes duration, appearing across four procedure codes including G0299 registered nurse and G0300 licensed practical nurse. Employee E18 recorded 1,304 of 1,441 visits (90.5%) at exactly eight minutes — 6.9 times the agency-wide rate — across four service types, sustained over five months without attenuation. Manual time adjustments affected 601 records (4.0%), with five employees accounting for 299 of 601 adjusted visits (49.8%). Sequential visit records required implied travel speeds of 87 to 230 miles per hour between Massachusetts communities, constituting mathematical proof of fabricated location entries. A weekly batch backdating pattern was identified in which no real-time EVV entries were generated Monday through Thursday, followed by retroactive bulk entry on Friday. Agency B demonstrated systematic use of the Axxess Exception Center to normalize GPS exceptions before Sandata submission, self-reporting 96% compliance — illustrating the EVV Compliance Paradox. Agency C quality assurance professionals identified Drive-By Clock-In Fraud, in which caregivers clock in from within GPS geofence range of a patient's address without entering the premises. Agency D identified a theoretical Complicit Patient vulnerability through dual-device registration. Agency E declined research participation, stating their EVV data was problematic and they did not wish attention called to their records. Of 20 additional agencies approached, zero agreed to participate; responses included -direct refusals, non-responses, and one representative who stated no staff member had any knowledge of EVV. Vendor communication confirmed that most agencies use pre-submission exception management and that flagged visits can be reclassified as verified prior to aggregator transmission (Axxess, personal communication, June 16, 2026; WellSky, personal communication, June 16, 2026). Further documented photographic evidence from Axxess help system showing: The Exception Center workflow step by step, their own template example with a geographically mismatched visit, including a four- day visit error and correction steps: “select a reason code, type clinician signature, click update visit.” Upon completion, the visit is a verified record regardless of the original GPS mismatch or duration anomaly. CONCLUSIONS EVV data contains substantially more actionable fraud intelligence than current practice extracts. Six anomaly categories affecting thousands of visits in a single Massachusetts agency over five months reflect systemic rather than isolated non-compliance. Geographic impossibility requiring 87 to 230 mph implied travel speeds constitutes mathematical proof of GPS location fabrication. Employee E18's sustained eight-minute visit pattern across 1,441 visits and four procedure codes including licensed skilled nursing is statistically impossible as a naturally occurring clinical pattern. The estimated $246,610 in potential financial exposure over five months illustrates the scale of program integrity risk operating within apparently compliant EVV systems. The EVV Compliance Paradox - confirmed by direct vendor communication - demonstrates that compliance rates in GPS-based systems may reflect exception management sophistication rather than care delivery integrity, including the step by step exception center correction workflow that verifies a patient visit with clear original GPS mismatch. The 0% research participation rate across 21 Massachusetts agencies approached, including one that explicitly cited concern about its own EVV data, suggests widespread institutional awareness of compliance vulnerabilities. GPS-based EVV is necessary but structurally insufficient. Hardware-anchored verification requiring physical presence inside the patient's home, supervised biometric enrollment, and cryptographic visit records are the architectural requirements that GPS-based systems cannot meet. Six f
Zahra Niazkhani, Iris Wallenburg, Johanna Hendriks, Rik Wehrens
In the context of increasing healthcare digitalization, hospital-based clinicians are developing and implementing decentralized digital health innovations (DHIs) tailored to their patient and clinical needs. However, achieving financial sustainability remains one of their challenges. We explored clinician innovators' perspectives on these challenges during the implementation and scale-up of their DHIs in a Dutch academic hospital using qualitative methods. Key challenges identified included funding gaps to cover transition costs, misaligned institutional financial incentives and reimbursement structures, short-term logics of funders overshadowing long-term value in DHI financing, and commercialization pressures. Findings provide insights into the financial and operational challenges faced by such context-driven internal innovations, highlighting the need for coordinated project-and institution-level strategies to support sustainable integration into routine care.
Auctions play a vital role in modern commerce by offering a transparent, structured, and competitive method for trading goods, services, and data. However, traditional in-person auctions are limited in terms of accessibility, convenience, security, and efficiency. However existing online auction platforms, while addressing some of these limitations, still face challenges such as limited transparency, centralized control, and insufficient security and privacy protections. Moreover these issues become extremely critical in case of sensitive applications like healthcare, defense and finance. To address these challenges, this article proposes a three-phase trading framework. In the first phase, data generation, anonymization, and storage are performed. In the second phase, an ensemble learning-based price forecasting approach is employed to estimate the asking and bidding prices, which depend on the volume and type of data. Finally, in the third phase, a Monte Carlo-inspired auction-based Non-Fungible Token (NFT) trading mechanism (MCiANT) is incorporated to enable efficient trading between buyers and sellers. The efficacy of the proposed MCiANT framework is compared with three distinct auction algorithms: the Vickrey auction, the Markov-Inspired Stationary Distribution Auction (MISD), and the Two-Phase English–Dutch Hybrid Auction (TPEDHA). The results demonstrate that the MCiANT framework significantly outperforms the others, achieving success-rate improvements of 5%, 5%, and 1% over the Vickrey, MISD, and TPEDHA auctions, respectively. Furthermore, the proposed framework is evaluated using health data by measuring anonymization time, encryption time, InterPlanetary File System (IPFS) upload time, and I/O performance.
Do Ethereum's Layer-2 (L2) rollups actually decongest the Layer-1 (L1) mainnet once protocol upgrades and demand are held constant? Using a 1245-day daily panel from August 5, 2021 to December 31, 2024 that spans the London, Merge, and Dencun upgrades, we link Ethereum fee and congestion metrics to L2 user activity, macro-demand proxies, and targeted event indicators. We estimate a regime-aware error-correction model that treats posting-clean L2 user share as a continuous treatment. Over the pre-Dencun (London+Merge) window, a 10 percentage point increase in L2 adoption lowers median base fees by about 13% -- roughly 5 Gwei at pre-Dencun levels -- and deviations from the long-run relation decay with an 11-day half-life. Block utilization and a scarcity index show similar congestion relief. After Dencun, L2 adoption is already high and treatment support narrows, so blob-era estimates are statistically imprecise and we treat them as exploratory. The pre-Dencun window therefore delivers the first cross-regime causal estimate of how aggregate L2 adoption decongests Ethereum, together with a reusable template for monitoring rollup-centric scaling strategies.
This systematic review explores the potential applications of blockchain technology within the financial operations of the UK's National Health Service (NHS), specifically focusing on its impact on general ledgers. The NHS, a complex and vast healthcare system, faces significant financial management challenges, including data fragmentation, inefficiencies in transaction processing, and issues with transparency and auditability. Blockchain, with its inherent characteristics of decentralization, immutability, and cryptographic security, offers a promising paradigm for addressing these issues. This paper systematically reviews the opportunities that blockchain presents for enhancing financial transparency, streamlining payment processes, improving data integrity, and reducing administrative overhead in NHS general ledgers. Concurrently, it critically examines the significant challenges to its adoption, including regulatory hurdles, interoperability concerns, scalability limitations, and the substantial investment required for implementation and training. By synthesizing current literature and identifying key themes, this review aims to provide a comprehensive understanding for policymakers, financial managers, and technology innovators within the NHS regarding the strategic implications of integrating blockchain into healthcare finance.
Decentralization has emerged as a prominent strategy for health sector reform in low- and middle-income countries (LMICs), aiming to enhance service quality, efficiency, equity, and responsiveness. This study systematically reviews literature published between 2021 and 2025 to explore the role of decentralized health systems in shaping healthcare service quality across LMICs. Using PRISMA 2020 guidelines, 20 eligible studies were identified and analyzed from databases including PubMed, Scopus, Web of Science, and Google Scholar. Thematic synthesis of findings reveals mixed outcomes: while decentralization improves local responsiveness, enhances community engagement, and strengthens health system performance in some settings, it also exacerbates disparities in others due to uneven institutional capacity, limited fiscal resources, and fragmented coordination. Key performance areas identified include human resource deployment, financing, access to services, and equity in service delivery. The study emphasizes the significance of local capacity-building, efficient resource allocation, and integrated planning in attaining sustainable and equitable healthcare improvements within decentralized systems. This review provides practical insights for policymakers aiming to align decentralization strategies with health equity and service quality objectives.
The problem of surprise medical billing has become quite ubiquitous in the American healthcare system, impacting the wallets of insured citizens adversely as they unknowingly seek the services of providers who are out of network. Although the No Surprises Act has created federal safeguards to prevent surprise bills, there are portions in the regulatory system that have not been addressed sufficiently, and a system-wide approach is needed for technical solutions. The approach is transformative as the Integrated Financial Systems (IFS) are increasingly offered on the basis of advanced interoperability standards like Fast Healthcare Interoperability Resources (FHIR) and promising emerging technologies such as blockchain and distributed ledger systems. These technologies bring more transparent, efficient, and secure healthcare billing ecosystems, which are beneficial to all stakeholders because patients achieve greater financial clarity and simplified billing procedures, providers realize a streamlined approach to revenue cycle management and fewer administrative tasks, and insurers achieve faster claims processing and fraud detection. The rise of IFS brings with it critical, ethically-driven concerns surrounding algorithmic decision-making and data privacy that would require the implementation of explainable AI, routine bias evaluation, and human judgment via Human-in-the-Loop frameworks to warrant fair results among various patient groups.
I am writing in response to “The Urgent Need for Developing a Common Health Insurance Policy in Bangladesh: A Perspective” [1]. The article effectively highlights the pressing need for a universal health insurance system in Bangladesh. However, it largely advocates for conventional solutions that have faced challenges in implementation across low- and middle-income countries. A paradigm shift is necessary—one that moves beyond traditional state-led models to explore decentralized, technology-driven, and behaviorally informed strategies tailored to Bangladesh's economic and social realities. Habib and Molla reports that out-of-pocket healthcare spending amounts to 68.5% of total healthcare costs in Bangladesh which causes financial difficulties for numerous citizens [2]. They suggest raising government funding while improving coverage through existing health programs. Using only state-funded initiatives fails to address the constraints that stem from both fiscal capacity and administrative efficiency issues. A better solution combines mandatory insurance with voluntary options through digital financial access while employing behavioral economics to boost participation rates. The scarcity of health insurance payments stems from people's distrust of financial institutions and their inability to see immediate advantages from coverage. Behavioral economics provides solutions through default enrollment models which require people to actively decline insurance coverage. Mobile banking platforms bKash and Nagad should integrate health insurance services through automatic micro-premium withdrawals which maintain user involvement while avoiding yearly payment requirements. Insurance communication becomes more effective through behavioral alignment when risk protection messages replace long-term health investment messaging. A new approach would be the implementation of health insurance models supported by diaspora communities. The annual remittance amount of over $22 billion in Bangladesh lacks an organized system to direct this money toward healthcare funding. Insurance plans that allow expatriates to pay insurance premiums for family members and support community-based risk funds would enhance healthcare coverage among vulnerable populations. The Philippines and Mexico together with other countries have established successful diaspora-backed healthcare insurance systems which reduced healthcare expenses paid directly by patients to millions of people [3, 4]. Technological integration is also crucial. The article correctly identifies healthcare financing problems yet fails to investigate blockchain-based claims automation and AI-based adaptive pricing solutions. Blockchain technology brings transparency to operations while reducing fraud and streamlines claim settlements through automation to establish system-wide trust [5]. AI-driven underwriting systems allow for risk-based premium adjustments which enables insurance affordability for different income groups according to Rix [6]. Proof-of-concept deployments in Rwanda and Kenya show that these innovations can scale up for emerging markets [7, 8]. Bangladesh needs to prevent implementing models from high-income countries because their economic and institutional structures differ too much from its own. The country needs to prioritize a combined method that includes public-private collaborations with technological enhancements and behavioral economic practices. The implementation of mobile-based microinsurance and remittance-backed financing and blockchain claims processing requires initial testing through pilot programs for framework scalability purposes. The absence of forward-thinking strategies makes universal health coverage efforts stay theoretical instead of becoming practical initiatives. MD. Faisal Ahmed: writing – review and editing, writing – original draft, conceptualization, methodology, investigation, validation, resources, data curation. The author declares no conflicts of interest. Data sharing not applicable to this article as no data sets were generated or analyzed during the current study. No new data were generated or analyzed in this study. All supporting information and references are publicly available as cited in the article.
Costase Ndayishimiye, Richard Nduwayezu, Christoph Sowada, Katarzyna Dubas‐Jakóbczyk
Results-based healthcare financing policies have been adopted in countries worldwide, including those with limited resources. We conducted a retrospective, semistructured interview study to evaluate healthcare providers' experiences with Rwanda's performance-based financing (PBF) policy and the factors influencing its implementation. Guided by the health policy evaluation model-context, content, process, and actors-as a deductive framework supplemented by inductive coding, we analysed data from 21 participants (doctors, n = 13; nurses, n = 5; midwives, n = 3). Providers described PBF as a key motivator, supplementing incomes, increasing accountability, and fostering teamwork to meet performance targets. PBF was credited with improving patient outcomes, particularly in incentivized services; however, concerns arose regarding disparities in service prioritization. Key facilitators of and barriers to the implementation of PBF were identified, providing insights into its operational dynamics. Strong political commitment and integration into national strategies, such as Imihigo, along with decentralization through district steering committees, were key contextual enablers, enhancing the program's flexibility and alignment with local priorities. The content factors centred on a two-tiered contracting system, combining national accreditation processes with individual performance incentives. Process factors supporting PBF were characterized by decentralized evaluations, audits, and multilevel communication, which collectively bolstered accountability mechanisms. The engagement and capacity of stakeholders were highlighted as crucial to the success of PBF. Nonetheless, significant barriers, such as payment delays, manual documentation, untimely evaluations, insufficient training, limited provider participation in decision-making, and the exclusion of patients as stakeholders, were identified. These findings offer practical recommendations for policymakers aiming to improve or adapt provider payment mechanisms in similar contexts.
BACKGROUND: Historically marked by a high infant mortality rate, Sweden's healthcare reforms have successively led to a robust, decentralized universal child health system covering over 97% of the population 0-5 years. However, inequities in health have become an increasing problem and the public health law explicitly states that health inequities should be reduced, resulting in various government initiatives. This study examines the experiences of Central Child Health Services (CCHS) teams during the implementation of the Child Health Services Accessibility Agreement between the State and the regions starting in 2017. The agreement aimed to enhance child health service accessibility, especially in socio-economically disadvantaged areas, but broadly stated guidelines and the short-term nature of funding have raised questions about its effectiveness. The aim of this study was to understand the experiences of CCHC teams in implementing the Child Health Services Accessibility Agreement, focusing on investment decisions, implementation efforts, as well as facilitators and barriers to using the funds effectively. METHODS: CCHC teams were purposefully sampled and invited via email for interviews, with follow-ups for non-respondents. Conducted from January to October 2023, the interviews were held digitally and recorded with individuals familiar with the agreement's implementation within these teams. Both authors analyzed the transcripts thematically, applying Braun and Clarke's framework. Participants represented a cross-section of Sweden's varied healthcare regions. RESULTS: Three main themes emerged from the thematic analysis: "Easy come, easy go," highlighting funding uncertainties; "What are we supposed to do?" expressing dilemmas over project prioritization and partner collaboration; and "Building castles on sand," focusing on the challenges of staff retention and foundational program stability. Respective subthemes addressed issues like fund allocation timing, strategic decision-making, and the practical difficulties of implementing extended home visiting programs, particularly in collaboration with social services. CONCLUSIONS: This study uncovered the challenges faced in implementing the Child Health Services Accessibility Agreement across different regions in Sweden. These obstacles underline the need for precise guidelines regarding the use of funds, stable financing for long-term project sustainability, and strong foundational support to ensure effective interprofessional collaboration and infrastructure development for equitable service delivery in child health services.
María Teresa Jiménez-Buñuales, Pilar León Sanz, Paulino González Diego, María Leonor González Menorca
In Spain, the public National Health Service provides care to Spaniards and other residents and is tailored for a decentralized state of autonomies. Each Autonomous Community has legislative capacity in its organization and management. We study the case of the collaboration between private hospitals and the public health service in La Rioja, an Autonomous Community of Spain located in the North of the Iberian Peninsula, due to the importance that this relationship has in health systems, in general. We applied the case study method as a methodological tool in a long-term local study. The interpretation was carried out within a national context, which allows us to understand its meaning and the historical keys to hospital development in this region. Primary sources have been reviewed (mainly reports, catalogs, and censuses of hospitals from the Ministry of Health and the Government of La Rioja) and other secondary sources, located in archives, libraries, Institute of Rioja Studies, and Department of Health. The hospital system in La Rioja was characterized by a predominance of public beds compared with private ones, although there has been a growing trend in the number of private beds from 2013 onwards due to the incorporation of health and social care convalescent hospitals (two). La Rioja has been promoting public-private collaboration (seen as a strategic alliance) and focusing on agreements in the socio-health space, particularly using the management service agreement and the concession of work formulas. The development of the public health service in La Rioja, from 1986 to 2019, has been determined by a progressive lower dependence on specialized hospitals from other health services of neighboring Autonomous Communities and by a mixed public-private hospital system.
The Covid-19 vaccine market concentration and hoarding that left many Global South countries unable to access vaccines in a timely manner have led to calls to expand and decentralize manufacturing capacity as a critical element towards more equitable access to vaccines globally Multiple initiatives are underway to build manufacturing infrastructure in low-and middle income countries (LMICs). However, without proper attention to who owns and controls the production and underlying technologies, there is a risk that well-meaning donor investments reinforce market dynamics that favour a handful of major international producers over truly local efforts This is particularly relevant for the African Vaccine Manufacturing Accelerator (AVMA), the new US$ 1Bn financing instrument approved by the Board of Gavi, the Vaccine Alliance, in December 2023
Open access
Global Health Care Issues
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Dr Abubakar Yakubu Anadavi, Adah Patrick Eneojo, Dr Emmanuel Bola Jonah K
The epidemiologic approach was used to conduct the cross-sectional survey to observe and identify supply-side risks qualitatively and quantitatively linked to the determinants of the outcomes for Basic Health Care Provision Fund (BHCPF) implementation. The data analysis was conducted on survey datasets obtained from the stratified random sampling based on Integrated Supportive Supervision survey, (n=127) that received Decentralized Facility Financing (DFF) not after the 30th of September, 2022 from a population of 220 PHCs eligible for DFF) . Evaluative research is crucial to improving systems and services at 220 BHCPF designated sites, to ensure that strengths are rewarded, weaknesses observed compared to the expectations for outcomes in the intervention linked to risk factors compared to SDGs targets
Task shifting refers to the strategic redistribution and decentralization of health care tasks from one group to another(including lay workers), the latter usually deemed as having lesser training and qualifications, and is an approach that isutilized to address the shortage and imbalance of the health workforce within a certain geographic area, thereby ensuring apopulation’s access to care.1 Task shifting can involve extending the role of a particular group (enhancement), exchanging workbetween groups (substitution/delegation), or creation of new jobs (innovation).2 While the primary conceptualization of taskshifting is from professional to lay health workers, it must be stated that task shifting can also involve shifting of tasks fromprofessionals to patients; from health workers to technology; and between different types of health workers.2 Task shifting hasbeen implemented in a variety of settings and for different programs/conditions, such as HIV/AIDS treatment3, cancer care4,mental health5, ultrasonography for antenatal care6, surgical care7, and non-communicable disease management8, similar to thecontext of the report by Tamayo and Reyes9 in this issue of Acta Medica Philippina. In addition to bridging the health humanresources gap, it has been proposed that task shifting may address health equity by broadening access to essential health services,contribute to enhancing the quality of care that is aligned with the changing societal needs, and yield cost savings particularlyfor the delivery of routine activities.10,11 Despite its widespread application, touted benefits, and the seeming preference of many organizations to use task shiftinga default solution to the health workforce challenge, three things must be pointed out. First, task shifting should be properly seen as a temporary solution to the health workforce challenge confronting countriesand health systems.12,13 Better and more comprehensive planning and management of human resources for health at the systemlevel is needed so that we can address the underlying problems that resulted to the implementation of task shifting in the firstplace – shortage, maldistribution, skill-mix balance, and sub-optimal working conditions that are, in turn, driven, by both healthsystem and contextual factors.14 Second, in situations where task shifting is perceived to be the better policy alternative, the program should be implementedin an ethical manner, considering respect for persons (i.e., free and informed decision making to take part in task shifting,recognition of recipients of tasks as critical contributors to the health program), justice (i.e., adequate guidance and supervision,fair remuneration, minimization of undue burden), beneficence (i.e., promoting health and welfare of workers, minimizingharm to workers and communities), proportionality (i.e., assignment of workload and responsibility commensurate to skillsand resources available), and cultural humility (i.e., cultural competency and humility on the part of dominant institutions),especially when the recipient of tasks are volunteer community health workers.15 Lastly, task shifting should be implemented as a comprehensive package of interventions, rather than a single activity.At the outset, the necessary conditions and important considerations for launching a task shifting program should be present,as outlined in the Concepts and Opportunities to Advance Task Shifting and Task Sharing (COATS) Framework.16 The keyelements for successful implementation (i.e., collaboration and coordinated care, financing, patient preference, shared decisionmaking,provider empowerment, training and competency, clear process outcomes, and supportive organizational system) oftask shifting should also be present.17 Recommendations on how and when to adopt task shifting as a strategy have also beenpublished by various organizations such as the World Health Organization1 and the World Medical Association18. The success of a task shifting strategy will require, among others, that health workers be actively engaged in the process,ensuring that the planned task shifting is aligned with their personal values, and creating an enabling environment19 that willallow them to carry out their tasks effectively, efficiently, and in a safe manner. In short, one of the requirements is that, aspointed out in the paper by Tamayo and Reyes9, stakeholders find task shifting an acceptable strategy.
Fortune Benjamin Effiong, Chiemela Prosper Ogbonna, Prosper Ifunanya Agughalam, Miracle O. Okwukwu · 7 authors
Universal health coverage (UHC) is aimed at ensuring that individuals and communities have affordable access to essential health care services without facing financial hardship. Achieving UHC and the third sustainable development goal of the United Nations requires that health systems transition from a vertical, top-down, curative approach toward one that puts people at the core of health care services, such as community-centered health interventions. Nigeria operates a decentralized health care system with the least focus on primary health care, making access to quality, and affordable health care for several citizens a challenge as the major percentage of the Nigerian population relies on primary health care services. The limited number of health care workers, the poor economic state, the inadequate health financing structures and high illiteracy rates have led to challenges such as low health service availability, hesitancy to utilize health interventions, high out-of-pocket expenditure rates, and health misinformation. These can be effectively tackled at the community level by revamping primary health care services, adequate and sustainable health financing, establishing Ward Development Committees, and the involvement of community stakeholders in health policy implementation. Employing such community-based approaches will ensure continuous progress of the Nigerian health care system toward UHC.
During the transition from a planned economy to a decentralized, market socialist economy, the Chinese healthcare system has evolved from a centralized, egalitarian public system (1949-1979) to one which is largely self-governed and can be characterized as 'public identity, private behavior' healthcare system (1980-1999). With blurring of the distinction between public and private governing systems, and a shift in norms towards profit orientation, major concern has arisen about the extent of high cost, high volume services being offered through excessive entrepreneurial practices. This thesis is concerned with the regulatory strategies and options to reach 2010 health reform objectives of equity and efficiency under a mixed public/private market. While possible lessons can be drawn from established economies and transitional economies, China faces some unique challenges, given the diverse market structures and fragmented healthcare system across the country, and the underdeveloped framework for the rule of law. The thesis reviews policy documents from 1949 to 2004 and draws from interviews with senior health policy-makers and hospital directors in three different locations, in order to explore the role of the state in market regulation, the effectiveness of technical and social regulations, and how policy implementation and regulatory compliance occur. The research has found that the dynamics of the healthcare system are shaped by the financing arrangements for healthcare and the absence of arms-length governance of hospitals by health departments. Without an effective state health financing tool, nor mature market institutions, China is not able to use neither performance-based regulation nor technology-based regulation. China has adopted a management-based regulatory strategy but the absence of effective governance structure hinders effective regulation. If the reform objectives of improving healthcare quality while costs are to be attained, China will need to develop purchasing tools to alter the current perverse incentives for provider behavior. Government will also need to work with civil society organizations to develop tools for clinical governance, such as clinical audit for risk management and hospital accreditation programs. To do so requires establishing arms-length governance mechanisms between health departments and hospitals, and appropriate corporate governance structures within hospitals. Specifically, MOH needs to establish a technical policy think tank to investigate all the policy issues arising from the announcement of the 1997 health reform, including coordination with other line ministries and provincial authorities, and formulation and implementation of a policy research agenda, in order to attain a market-based governance system for health by 2010.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
User committees, such as Health Facility Governing Committees, are popular platforms for representing communities and civil society in holding service providers accountable. Fiscal decentralization via various arrangements such as Direct Health Facility Financing is thought to strengthen Health Facility Governing Committees in improving accountability in carrying out the devolved tasks and mandates. The purpose of this study was to analyze the status of accountability of Health Facility Governing Committees in Tanzania under the Direct Health Facility Financing setting as perceived by the supply side. In 32 different health institutions, a cross-sectional design was used to collect both qualitative and quantitative data at one point in time. Data was collected through a closed-ended questionnaire, an in-depth interview, and a Focus Group Discussion. Descriptive statistics, multiple logistic regression, and theme analysis were used to analyze the data. According to the findings, Health Facility Governing Committees' accountability is 78%. Committees have a high level of accountability in terms of encouraging the community to join community health funds (91.71%), receiving medicines and medical commodities (88.57%), and providing timely health services (84.29%). The health facility governance committee's responsibility was shown to be substantially connected with the health planning component (p = 0.0048) and the financial management aspect (p = 0.0045). This study found that the fiscal decentralization setting permits Committees to be accountable for carrying out their obligations, resulting in improved health service delivery in developing nations.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Users Committees such as Health Facility Governing Committees (HFGCs) are one of the popular mechanisms used to represent communities and civil societies in holding service providers into account. This study embarked on assessing the status of accountability of HFGCs under the DHFF context in Tanzania as experienced by the supply side (HFGCs members). A cross-sectional design was employed in collecting both qualitative and quantitative data at one point in time in 32 selected health facilities. A closed-ended questionnaire, in-depth interview and FGDs were employed to collect data. Data were analyzed through descriptive statistics and Multiple logistics regression, and thematic analyses. The study found high accountability of HFGCs by 78%. specifically, HFGCs have high accountability in mobilizing the community to join community health funds 99.71%, receiving medicines and medical commodities 88.57% and timely health services 84.29%. It was reviled that the accountability of the health facility governance committee was significantly associated with the health planning aspect (p=0.0048) and financial management aspect (p=0.0045). This study concluded that the fiscal decentralization context empowers HFGCs to be accountable in accomplishing their responsibilities hence improving health service delivery in developing countries. This study recommends more efforts to be directed in supporting HFGCs addressing challenges of managing health facilities works and mobilization of resources from other stakeholders.
Improving health system efficiency for better health outcomesThe World Health Organization (WHO) placed "value for money" as an important element to move countries towards Universal Health Coverage (UHC) in its 2010 World Health Report, stressing that health systems should pay attention to improving efficiency of using existing funding for better health outcomes (1).A significant amount of health resources are wasted, which would saving millions of lives if they were used wisely and efficiently.The efficiency of using available funding, along with the innovations to generate new resources for health, is critical for achieving UHC.This special series compiles studies that aims to improve the health system efficiency in Afghanistan, Nigeria, Ukraine, Haiti, Botswana and Zimbabwe.Zeng and colleagues evaluate the cost-effectiveness of two financing programs in Nigeria: one is performance-based financing that tied payments to performance indicators, and the other is decentralized facility financing program where payments to health facilities were unconditional.Both programs show promising results in providing essential maternal and child health services.The result suggests that financial incentives can improve the use of underutilized essential services in low-and middle-income countries.Shepard et al. investigate the cost-effectiveness of a similar program in Zimbabwe.The evaluation combined the impact of the performance-based financing on both quality and quantity of target health services.The study shows that the program was associated with the improvement of use of key maternal and child health services.However, the impact of the program on quality improvement was minimal.Overall, the program demonstrates a cost-effective health system investment.In the same country, Mutasa et al. focus on the effect of the performance-based financing program on quality of care only.The result is consistent to what reported in Shepard's article, showing that the performance-based financing program only has an impact on quality for care for institutional deliveries.However, there are a wide variety of contextual variables that may affect the program's effectiveness, including population wealth and availability of human resources.The article highlights that incentive payment programs should be accustomed to the local context to maximize their potential.At the health facility level, Avila and colleagues examine the efficiency of providing antiretroviral treatment (ART) services in Botswana and find a wide range of performance in delivering ART services in the country.One important finding is that the performance of ART services is lower in hospitals than health posts, suggesting the potential to scale up the ART to the lower level of health systems to improve the coverage of the care.The authors suggest decentralizing ART services to primary health care delivery points for better efficiency.In Haiti, Mekonen and colleagues evaluate health facility efficiency of delivering primary health services.The study identifies the critical association between health workforce and the efficiency of health facilities in the county.As many countries are facing a shortage of health human resources and challenges of disruptive medical health services, this study sheds light on strengthening health human resources as a means to improve the efficiency of primary health care systems.In Ukraine, Avila reviews the evolvement of health financing policies in the country.The article highlights the weaknesses of health financing system in the past, and describes the process of health financing reforms that have been undertaken.The review highlights the critical role of strategic purchase as a lever to overhaul the health system in Ukraine to promote the efficiency improvement.In Afghanistan, Farewar and colleagues take the angle of equity to assess the disparity of use of health care services.After health care reforms for more than a decade, there exist inequity in using health care services.The inequity is more salient in using inpatient care and private health services than outpatient care.As Afghanistan still heavily relies on the private sector to provide essential health services, addressing the concern of unequal access to care becomes a prominent issue in the country.In summary, efficiency is an important topic in strengthening health systems, and approaches to evaluating the efficiency have been evolving.The articles that are compiled in this specifical series provide empirical evidence of efficiency evaluation at the health facility and health system levels, and methodology to conduct the evaluation.
Open access
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
This empirical study addresses the role of economic and institutional determinants on population health, estimated by life expectancy and accessibility to good quality medical services. Several national health systems are described descriptively and analytically. The practical application considers 30 European countries for which data on all necessary variables are available. The data are provided by international institutions such as the World Bank, Insurance Europe, Global Health Security and national institutions from the sampled countries. The results of the OLS cross-country regressions clearly demonstrate the positive role of health financing and the decentralization of the national health system. Instead, the role of private health insurance remains debatable, as does its complementarity or substitutability in relation to public funding. Based on the main results, recommendations are formulated regarding possible adjustments for an increased efficiency of the medical system and possible future research directions, especially regarding the role of the financing structure and the type of decentralization of the medical services.
Introduction Argentina is the third most populated country in South America with an estimated population of 44,494,502. Despite having an area of 2,780,400 km2 (eighth largest in the world), 90% of the population resides in urban areas, with the majority concentrated in and around Buenos Aires. Life expectancy is 79.7 years in women and 73.6 years in men, with cardiovascular disease as the leading cause of mortality. Argentina spends approximately 10% of its gross domestic product on health care (1). There are 3.94 physicians and 4.5 hospital beds per 1000 inhabitants in Argentina (2). The physician-patient ratio is similar to that of Australia, Italy, Spain, and Switzerland, and is double than Brazil and almost four times than Chile and Peru. Argentina has a multitiered, decentralized health care system that is plagued by fragmented management and financing. There are national, provincial, and municipal government–sponsored health care insurances, which together with union-sponsored insurances, provide health care coverage to nearly 22 million people. An additional approximately 10% of the population has private health insurance, leaving nearly 36% of the population without health care coverage or the financial means to pay for private insurance. These individuals are cared for at cost-free public hospitals and community facilities (1,2). The first hemodialysis (HD) treatment in Argentina dates back to 1955. Five years later in 1960, the Argentine Society of Nephrology was founded (3). Epidemiology The incidence and prevalence of CKD and ESKD have been growing steadily, most likely because of increasing rates of diabetes and obesity as well as an aging population. Indeed, CKD is now the seventh leading cause of mortality in Argentina, and CKD-related deaths have increased by 15% between 2007 and 2017 (4). The National Transplantation Institute (INCUCAI) supports a National Dialysis and Transplant Registry (5,6). Patient reporting is obligatory; therefore, national data are valid and representative. Reporting is the responsibility of the dialysis center director, and it is provided online. Patient identity is preserved by data security systems. The annual incidence of ESKD is 160 patients per million population, with diabetes and hypertension as the most common etiologies (Table 1). At the end of 2018, there were 29,929 patients with ESKD on chronic dialysis, representing a prevalence rate of 673 patients per million population (Figure 1) (5,6). Of these, approximately 93.5% are on in-center HD, 6.5% on peritoneal dialysis (PD), and none are on home HD. Of the patients on HD, 70% receive dialysis via an arteriovenous fistula, 15% receive dialysis via an arteriovenous graft, and 15% receive dialysis via central venous catheters. First year and annual mortality rates on dialysis are 18% and 16.4%, respectively (Table 1), with cardiovascular cause being the most common (6). Annual mortality rate has been above 16% for the last 4 years (Figure 2). RRT in Argentina has incidence and prevalence rates above the mean for Latin America, most likely because dialysis and transplant are readily available in the country (Table 2). Nevertheless, PD is relatively less used compared with the rest of Latin America (7–9). Table 1. - Characteristics of patients on dialysis in Argentina Characteristic Value Country population 44,494,502 Patients on hemodialysis 29,929 Patients on peritoneal dialysis 1945 Patients with functioning kidney transplant 11,486 Prevalence of hepatitis B, % 0.2 Prevalence of hepatitis C, % 1 Prevalence of HIV, % 0.8 Prevalence of diabetes, % 28 Membrane dialyzer (reuse), synthetic/substituted cellulose/cellulose, % 83/14/4 Type of vascular access, native AVF/prosthetic AVF/catheter 70/15/15 Prevalence of patients with ESA, % 87 No. of hemodialysis centers 597 Hospital-based dialysis units, % 25 Nonprofit dialysis units, % 11 No. of peritoneal dialysis centers 79 Dialysis covered by insurance, % 100 Out-of-pocket expenses, % 0 Dialysis unit staffing, nurses/technicians, % 95/5 Payment per hemodialysis session, USD 55 Patient-nurse ratio in hemodialysis units, adult/pediatric 4–5/2–3 Average length of dialysis session, h 4 Minimum patient evaluation by physician per mo 4 No. of transplant centers 55 Adjusted annual mortality dialysis rate, % 16.48 Etiology of ESKD, % Diabetes 36.5 Nephroangiosclerosis 20 Unknown cause 17 GN 9 Myeloma and amyloidosis 1 Obstructive uropathy 6 Polycystic kidney disease, adult type 5 Epidemic uremic hemolytic syndrome 0.5 Other 5 Cause of death, % Cardiovascular 50 Infection 25 Neoplasia 6 Other 19 Source: Argentinean Registry of Dialysis and Transplantation (5,6). AVF, arteriovenous fistula; ESA, erythropoiesis-stimulating agents; USD, United States dollars. Figure 1.: Annual prevalence of dialysis patients ( 5 , 6 ).Figure 2.: Annual dialysis mortality rate . Rate is expressed in deaths per 100 patients at risk with 95% confidence interval bars. Source: Argentinean Registry of Dialysis and Transplantation (5,6). Table 2. - Comparison of RRT between Argentina and Latin America Argentina Latin America Prevalence of patients with ESKD under RRT (dialysis and transplant) a 976 805 Dialysis incidence rate a 160 154 Kidney transplant rate a 30 21 Patients on peritoneal dialysis, % 6.5 11.5 Nephrologist a 30 18 aRates are expressed per million population. Source: Latin American Registry of Dialysis and Transplantation (7). Structural Organization and Logistics of Dialysis Argentina has dialysis units in both hospital and private settings. There are a total number of 597 dialysis centers in the country. Eleven percent (68 centers) of these centers are government owned, 377 (63%) are independent dialysis centers, and the rest (152 centers; 26%) are owned by foreign dialysis companies. One hundred eighty-seven dialysis units are in the province of Buenos Aires, and the rest are located throughout the rest of the country. Dialysis is covered by patients’ union health system or health insurance; ultimately, the government pays if the patient does not have insurance. Government coverage is universal if a patient does not have union or health insurance. This includes illegal immigrants, noncitizens, and refugees. Payment for HD and PD is capitated at approximately United States $700 per month or United States $55 per HD session. Physicians across the country are paid by monthly salaries, and some also have private practice. PD solutions are not manufactured in the country and are, therefore, imported. Bundle HD and PD payment includes vascular access, erythropoietin, appropriate vaccination, and transfer to and from the dialysis unit. Monthly reimbursement is irrespective of procedure number. Average HD sessions last for 240 minutes, with 95% of patients receiving three or more dialysis sessions per week (5,6). Online hemodiafiltration has been recorded since 2015. Approximately 20% of HD centers have this technology. Although 70% of patients on incident dialysis start with a temporary catheter as their vascular access, at 6 months into treatment most have permanent vascular access. Seventy percent of prevalent patients have an arteriovenous fistula. Nephrologists insert all temporary catheter access. Permanent HD catheters are placed by nephrologists also but mostly by vascular surgeons. Arteriovenous fistulas are 100% done by vascular surgery. Interventional nephrologists do not perform arteriovenous fistulas. Almost 87% of the patients are on erythropoietin or similar agents, and synthetic HD membranes are most commonly used. (Table 1) (5,6). The advent of technologic advancement, biosecurity implementation, and specific treatment has decreased the prevalence of hepatitis B, hepatitis C, and HIV in the dialysis population (0.2%, 1%, and 0.8%, respectively). Isolation of patients with hepatitis B is mandatory. No formal end-of-life care support programs are available in Argentina. Staffing of Dialysis Units Argentina is third among Latin American countries considering nephrology physicians per million inhabitants (Table 2) (7,8). There is one nephrologist for every 40 patients, and a nephrologist must be present in the dialysis unit at all times. There are approximately 80 renal fellows in training per year. Most patients are seen daily or at least four times a month. In continuous ambulatory peritoneal dialysis, they are seen once a month. Historically, non-nurse technicians accounted for the majority of dialysis personnel, but this has progressively decreased to approximately 5%. Nurses now provide the lion’s share of dialysis care. The main driving force for this change occurred 10 years ago when regulations were changed to increase the number of dialysis nurses taking care of these patients. The nurse to patient ratio is four to five adult patients per nurse in HD units and two to three children per nurse in pediatric units. In PD, the ratio is 20 adult and 15 pediatric patients per nurse (5,6). No formal dialysis nurse certification is in place in the country. Transplantation in Argentina The International Registry of Organ Donation and Transplantation reports that in 2019 there were approximately 1674 kidney transplants (1325 from deceased donors and 349 from living donors) in Argentina. There were 69 simultaneous kidney-pancreas transplants, 19 kidney-liver transplants, and 5 kidney-heart transplants. More men (62%) were transplanted than women. The availability of kidney transplants differs regionally around Argentina, with approximately 6546 patients with ESKD currently on the transplant list waiting for a new kidney. Average waiting time on the transplant list is over 4 years. Swap living kidney transplants have occurred, but there are very few cases (5). Transplantation is regulated by the INCUCAI (5,6). Since 2004, the INCUCAI has supported a National Dialysis and Transplant Registry. Patient reporting is obligatory, and therefore, national data are valid and representative. The INCUCAI in conjunction with the Argentine Society of Nephrology analyzes and reports the data of the National Dialysis and Transplant Registry (5,6). The INCUCAI, the Argentine Society of Nephrology, and the Argentine Transplant Society promote organ donation campaigns regularly. A recent law has declared the general population as presumed donors, and this has increased donation by 20%–25%. There are barriers to donation, but none are due to social or cultural barriers. Some of these barriers include logistics of organ harvesting and transportation in a large country, insufficient organ harvesting teams in some regions, etc. Future Directions and Challenges RRTs are accessible and available in Argentina, and utilization rates are acceptable compared with other countries in the region. It will be challenging to improve what is currently available with limited economic resources. An advanced kidney care program is not available nationwide and needs to be designed and implemented to guarantee early and programmed dialysis initiation and preemptive transplant when possible. PD is underused in Argentina for many reasons: peritoneal solutions are not manufactured in the country and are expensive, and most nephrologists have not been trained in PD because HD has been the predominant form of dialysis historically. Because many patients still begin dialysis without previous planification, the preferred dialysis modality used in urgent situations is HD through temporary catheter access. Training and economic incentives will help develop PD further. Home HD will most likely be set aside for some time. This technology is not available yet, and no reimbursement plans are underway for this dialysis modality. Disclosures G.J. Rosa Diez is employed by Fressenius. The remaining author has nothing to disclose. Funding None.