Philosophiae Doctor - PhD / Universal Health Coverage (UHC) has provided the impetus for the introduction of publicly-funded health insurance (PFHI) schemes, involving the private sector, especially in low-and middle-income countries with mixed health systems. Although equity is considered as being core to UHC, the implication of UHC interventions for equity in access (availability, affordability and acceptability) beyond financial protection is inadequately researched. India introduced a national PFHI scheme (Rashtriya Swasthya Bima Yojana) in 2007 which has since then been expanded considerably through the Pradhan Mantri Jan Aarogya Yojana (PMJAY) scheme. However, contestation remains as to whether PFHI schemes are the most appropriate interventions for UHC in India. Evidence so far provides cause for concern regarding their impact on financial protection and health equity. With PFHI schemes burgeoning globally, there is an urgent need for a holistic understanding of the pathways of impact of these schemes, including their roles in promoting equity of access and achievement of UHC objectives. The state-funded universal health insurance scheme (RSBY/MSBY) in Chhattisgarh State provided the opportunity to explore these pathways of impact, especially on vulnerable communities, as the State has a universal health insurance scheme. This PhD aims to study equity, access and utilisation in the state-funded universal insurance scheme in Chhattisgarh State of India, in the context of Universal Health Coverage. It is presented as a thesis by publications.

Philosophiae Doctor - PhD / South Africa has not responded well to recommendations in national evaluation reports to address human resource challenges associated with the implementation of nutrition programmes and improved service delivery. Twenty-four years have passed since the dawning of democracy and the nutrition situation within the population has actually deteriorated, with persistently high levels of stunting in young children and the growing prevalence of overweight and obesity in all age groups. These conditions not only rob people of their potential, but they carry a high cost for the state and society as a whole. This study aimed to develop a comprehensive and empirically sound nutrition workforce development planning framework for the public health sector so that it is better equipped to address the nutrition-related burden of disease in South Africa. The study explored the provision of nutrition services in South Africa, focusing on the nutrition-specific work components of health personnel ‒ doctors, nurses, dietitians, nutritionists, health promoters and community health workers working at the primary health care level in the public health sector. Evidence-based workforce information was collected through a mixed methodology comprising: literature reviews, document reviews, analysis of scopes of practice, job descriptions, competencies, workforce surveys, key informant interviews and consensus assessments through the application of the Delphi technique. Permission was obtained to adapt and use questionnaires from an Australian workforce study. Ethical approval, permission to conduct the study and informed consent were obtained prior to the commencement of the interviews. Data was then analysed using descriptive statistics, content and thematic analysis and triangulation of all findings, followed by consensus assessments to describe the nutrition workforce and delineate the roles and functions thereof. The comprehensive planning framework that was developed was applied to the Western Cape province.

acase@tulane.edu / The Sustainable Development agenda, which will be driving the development discourse of the world in next fifteen years, has 17 goals and 169 target. Goal 3 is related to health and it has 13 targets. Target 3.8 states “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. This target - related to universal health coverage (UHC) is considered the linchpin of all other health targets. Although more than 100 countries across the world are pursuing UHC reforms, there is no one-size-fits-all approach to achieving UHC. It has been recommended that governments should develop approaches that fit the social, economic, demographic, and political context of their countries. Pakistan, the sixth most populous country in the world, underwent its first democratic transition after elections 2013. The 18th constitutional amendment of devolution has made health a provincial subject in the country. As promised in election manifestoes, all the three major political parties ruling provincial governments have recently committed to health financing reforms for achieving UHC. Though the existing literature provides a few key health financing indicators at the national level, there is a paucity of evidence for planning and monitoring UHC reforms at the provincial level. This dissertation, comprised of three papers, addressed this gap by providing empirical evidence on: i) incidence and determinants of catastrophic health expenditure, ii), efficiency of division level health systems in producing UHC tracer indicators. and iii) provincial progress towards Universal health coverage and associated in-equities from 2001-14. / 1 / Faraz Khalid

On January 1st, 2014, Indonesia began implementing universal health coverage. Despite the fact that the density of human resources for health (HRH) is far lower than the International Labor Organization’s benchmark, the Indonesian government is ambitiously committed to providing equal, quality, and extended healthcare services to an estimated population of 257.5 million people by 2019 without putting them in financial hardship. In addition, the government expects to ensure a minimum of 85% of the health recipients is satisfied with attained healthcare services. With respect to nurses, the massive international migration of qualified and motivated Indonesian nurses that has taken place over the last decade is alleged to be one of the factors responsible for the low density. However, at this point, very little publicly available information exists that comprehensively displays the phenomenon. As such, to help stakeholders understand the phenomenon, mitigate the recurrence of massive international migration of Indonesian nurses, and make relevant data-driven HRH policies, a proposal for a series of studies to reveal the phenomenon of the international migration of Indonesian nurses is developed. An 18-month research project with various sampling methods, research instruments, and research methods will be conducted to explore four main international nursing migration issues from multiple study populations. The study populations include migrating and returning Indonesian nurses, nursing organizations both in Indonesia and in four foreign countries, local recruitment agencies, two government agencies in Indonesia, and several Indonesian embassies overseas.

PROBLEM: As part of Indonesia’s strategy to achieve the goal of Universal Health Coverage (UHC), large investments have been made to increase health access for the poor. These have resulted in the implementation of various public health insurance (PHI) schemes, including Jamkesmas, the largest health insurance program in Indonesia in 2012, targeted towards the poor and near-poor. In the backdrop of Indonesia’s aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. With the implementation of various pro-poor PHI programs in Indonesia, there is limited understanding of how these programs impact maternal health services among poor women. METHODS: This study used a mixed-methods design. The quantitative component entailed secondary analysis of the Indonesian Demographic and Health Survey (IDHS) from 2007 and 2012 on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). Qualitative interviews (n=55) were conducted from May-Aug 2015 in the province of Jakarta and Banten among community representatives and key stakeholders to describe the successes and challenges of health insurance membership and maternal health services among the poor. RESULTS: Controlling for all independent variables, poor women with Jamkesmas were 21% (OR=1.21 [1.05–1.39]) more likely to have HFD and 20% (OR=1.20 [1.03–1.39]) more likely to have SBD compared to poor women without health insurance. Qualitative interviews provide some explanation to the modest effect of Jamkesmas health insurance on HFD and SBD seen in the quantitative analysis, including: the preference for pregnant women to deliver in their parents’ village; the use of traditional birth attendants; lack of proper documentation for health insurance registration, distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation. CONCLUSION: Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings indicate that pro-poor PHI schemes may be able to reduce financial barriers to care. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.

Philosophiae Doctor - PhD / This study is a philosophical analysis of the National Health Insurance (NHI) policy and legislation, including the related NHI Fund, with a view to assessing its prospects in realising Universal Health Coverage (UHC). The NHI system is about ensuring universal access to quality healthcare for all. The rationale is to provide free healthcare for all at the point of care/service. This legislation has the potential to transform, on the one hand, the relationship between the public and private healthcare sectors and, on the other, the nature of public funding for healthcare. Part of the challenge with the NHI system is that it seeks to provide healthcare for all, but by seeking to integrate the private sector it runs the risk of commercializing healthcare. The study is philosophical in that it holds that ideas have consequences (and conversely actions have presuppositions with certain meanings). In part, it aims to show that an implementing mechanism of the NHI system as presently envisaged has socio-political and economic implications with fundamental contradictions within it; for it seeks to incorporate the private healthcare sector in offering free public healthcare services. This introduces a tension for private healthcare services operate with a neoliberal outlook and methodology which is at odds with a public approach that is based on a socialist outlook. The analysis may make explicit conceptual and ideological tensions that will have practical consequences for healthcare. Much of the commentary on the NHI system have focused on the practical consequences for healthcare; my intervention is to explore and critically assess the various philosophical assumptions that lie behind these practical concerns. Some of these practical consequences are related to the possibility that healthcare is likely to become commercialized and the public healthcare sector will remain in a crisis. This study argues for the provision of access to high quality healthcare facilities for all members of the South African population. Healthcare must be provided free at the point of care through UHC legislation or by the setting up of the NHI Fund as financing mechanism. The study provides reason for the decommercialization of healthcare services completely – that is for eliminating private healthcare from contracting with the NHI Fund. Essentially, it argues for the claim that healthcare should not be traded in the market system as a commodity and that the NHI system in its current incarnation seeks to do precisely that. I further argue that in theory and in practice the neoliberal and socialist assumptions underlying the NHI system in its present formulation do not fit together. On the contrary, rather than a two-tiered system incorporating the private and public healthcare sectors, the dissertation argues for a different way of conceptualizing the NHI system that privileges the latter.

Magister Legum - LLM / In South Africa, there are two health systems through which health services are delivered,1 namely private and public. These two systems were inherited from the apartheid regime.2 With South Africa’s political change from a system of parliamentary sovereignty to a constitutionally supreme system in 1996, huge changes were bound to come including changes to the health sector.3 This meant the overhauling of health legislation, as the right of access to health care services became guaranteed in the Constitution of the Republic of South Africa, 1996.4 In 1997, the White Paper on the Transformation of the Health System (White Paper on Health)5 was introduced with the aim of developing a national health system.6 There has been a lot of progress made in reforming the health sector, however there are still many cracks that the national government aims to remedy through the realisation of universal health coverage (UHC).

Health financing policies implemented by nations around the world vary based on who receives coverage and what health system resources are covered. Although, many health systems are attempting to move towards Universal Health Coverage, part of their populations continue to incur out-of-pocket payments for using all or some health services. Some health systems restrict health insurance for certain migrant populations, providing coverage for emergency care only, or none at all. Other health systems fail to provide coverage for prescription drugs, leaving those without the ability to pay out-of-pocket for medications behind. The lack of financial protections against catastrophic or impoverishing healthcare expenditures for these patients may deter them from seeking the care they need or increase the risk of severe financial hardships. This dissertation addresses these migrant and drug coverage gaps by examining the impacts of health financing policies and how these can be changed to move health systems towards Universal Health Coverage. First, this dissertation examines restrictions to refugee health policy in Canada by conducting an interpretive policy analysis to reveal how political actors strategically use causal stories to enact policy change. Second, quantitative studies assessing the effects of health insurance on migrants’ health-related outcomes are systematically reviewed. Third, this dissertation explores a provincial health system without universal prescription drug coverage to establish associations between health services use, prescription drug coverage and immigrant category. Finally, given migrants experience health outcome and health services utilization disparities, an exploratory analysis of factors that impede or assist migrants’ access to prescription drugs is conducted to uncover how these factors influence their health. While each study is distinct, together, these chapters build on each other using mixed methodological approaches to identify ways that address health financing policy gaps to reduce health inequities, build inclusive and cost-effective health systems and strengthen global health security. / Dissertation / Doctor of Philosophy (PhD)

The research project intends to investigate the issue of health care accessibility with respect to financial obstacles focusing on the case study of Uganda, where impoverishing effects due to health services utilisation are critical for the population well-being. The thesis consists of three independent chapters aimed to examine multiple aspects which are relevant for health coverage and financial protection. In the first chapter, a political economy perspective is adopted to analyse the country experience of health financing reforms for Universal Health Coverage through a desk review and Key Informant Interviews. In the second chapter, household data from a rural district are employed to explore how the provision of social support through social networks operates at the behavioural level for overcoming barriers to health care utilisation and coping with financial hardship due to health expenditures. The analysis presented in the third chapter relies on a longitudinal household survey to assess the impact of a Community Health Financing pilot program on health expenditures and coping strategies. Overall, the thesis can contribute to the current debate on health coverage in Low- and Middle-Income Countries. On one side, the new evidence based on the collection of primary data and the adoption of innovative methodologies allows to advance the academic knowledge on financial protection. On the other side, the main research findings have the potential to inform policy design and policy making to effectively improve health coverage outcomes in informal settings.

This dissertation includes four papers— two conceptual and two empirical— on universal health coverage introduced in global health as a policy concept to improve access to health care. The conceptual papers review the selection process for the Sustainable Development Goal indicator on universal health coverage and propose parameters to guide an evaluation framework for universal health coverage. The first two papers show that including participants from as many sections of the health sector and policy community is recommended in policy formulation and evaluation, and recognize that decision-making might be slower as a result. While the first two papers focus on the third Sustainable Development Goal to achieve universal health coverage, the following two empirical papers focus on the sixth Millennium Development Goal which committed to provide universal access to treatment and care for people living with HIV. The first empirical paper shows how physicians in six Eastern Caribbean countries (Antigua and Barbuda, Dominica, Grenada, St. Kitts and Nevis, St. Lucia and St. Vincent and the Grenadines) cope with the lack of resources for treatment and care. Access was implemented broadly emphasizing the availability of HIV treatment and care while ensuring that everyone who needed antiretrovirals did not incur out-of-pocket costs. In most cases, this meant receiving care in the public system which was mostly centralized and where people living with HIV had concerns about their privacy being compromised in societies where HIV stigma was prevalent. The second empirical paper shows that in St. Lucia, third-line antiretrovirals could be unaffordable to as much as 98 % of the population, depending on how affordability is measured. The papers collectively demonstrate how the Millennium Development Goals provided an opportunity for policy learning by comparing the implementation of universal access for HIV treatment and care with universal health coverage in the Sustainable Development Goals. / Thesis / Doctor of Philosophy (PhD) / The dissertation recognizes the challenges with defining and measuring universal health coverage and with providing access to treatment and care for human immunodeficiency virus (HIV) in the Eastern Caribbean. The first conceptual paper documents the process of selecting indicators for universal health coverage in the Sustainable Development Goals. The second conceptual paper advances recommendations for evaluating universal health coverage. The following two studies then empirically assess the challenges with access to health care for people living with HIV in the Eastern Caribbean. The third paper shows how physicians cope with the lack of appropriate resources and highlights the issue of privacy for patients. The fourth paper uses data from St. Lucia to assess the affordability of antiretrovirals and highlights the difficulties of measuring financial affordability.