Narrative  Report  –  2013  Joint  Learning  Fund    

   

               

Joint  Learning  Fund  (JLF)  Activity  Impact  Assessment,  Jan  –  Dec,  2013    Narrative,  Evaluation,  &  Feedback  

INTRODUCTION    The  Joint  Learning  Network  (JLN),  funded  by  Rockefeller  Foundation,  instituted  the  Joint  Learning  Fund  (JLF)  which  is  a  flexible  pool  of  fund  to  support  activities  for  JLN  member  countries  in  their  efforts  to  gain  further  knowledge  and  skills   in  efforts   towards  Universal  Health  Coverage   (UHC).  The  network  provides  access   to   resources  across  JLN  member  countries.  JLF  also  supports  the  JLN  technical  tracks1  to  leverage  on  the  available  JLF  for  their  work  with  member  countries.  Currently,  ACCESS  Health  manages  the  Joint  Learning  Fund  (JLF),  instituted  by  the  JLN  and  funded  by  the  Rockefeller  Foundation.  JLF  is  a  flexible  pool  of  funds  to  support  activities  by  JLN  member  countries  in  their  efforts  to  gain  further  knowledge  and  understanding  of  UHC  reform  efforts  from  other  countries  and  to  gain  practical  experiences  in  technical  areas  in  other  countries.      JLF  also  supports  the  JLN  technical  tracks2  for  their  work  with  member  countries  if  the  request  for  support  comes  from   the   member   countries.   Applications   are   submitted   by   representatives   of   government   or   other   affiliated  institutions  (NGOs,  academic  institutions,  etc.)  in  JLN  member  countries  to  ACCESS  Health  International  endorsed  through  the  respective  country  core  groups.  Proposals  related  to  work  by  the  technical  tracks  are  shared  with  the  respective  track  lead  for  review  and  further  inputs  after  approval  from  the  country  core  groups.  JLF  has  supported  activities  to  help  design  and  implement  reforms  through  practitioner  to  practitioner  learning  exchanges  and  also  have   enriched   knowledge   of   member   countries   through   expert   driven   collaborative   exercises   and   supporting  practitioners  for  building  capacities  within  certain  technical  areas  of  priority.      In  addition  to  the  four  JLN  technical  tracks,  JLF  supports  proposals  from  member  countries  for  activities  such  as:  

! Funding   experts   to   work   with   member   countries   in   any   of   the   focus   areas   as   per   country  requirements.    

! Study   tours   and   secondments   for   capacity   building   of   the   team   involved   in   planning,   design   and  implementing  of  the  reform  process.  

! Regional  events  to  better  understand  and  analyze  challenges  facing  two  or  more  countries  in  a  region  and  explore  opportunities  for  collaboration  

! Supporting  participation  at  capacity  building  technical  training  workshops    All  the  listed  activities  below  were  carried  out  with  prior  consultation  and  coordination  with  country  core  groups  and  technical  tracks  leads  to  make  sure  their  plans  are  important  and  supported.    As  part  of  the  monitoring  and  evaluation  of  the  JLF  supported  activities,  impact  assessments  are  conducted  after  six  months  of  the  JLF  activities.    An  assessment  tool  has  been  designed  to  capture  general   impact   in  relation  to  how  the  activities   influenced  or  changed  the  participants’  understanding  and  knowledge  on  the  technical   issues  for  advancing  the  health  reform  and  how  did  the  member  country  applied  new  knowledge  to  the  challenges  they  were  facing  before  the  JLF  activity.    In-­‐depth  interviews  with  key  stakeholders  from  different  task  working  groups  and  participants  from  the  supported  activities  due  for  assessment  from  Jan  -­‐  Dec,  2013  were  conducted  to  assess  their  specific  learnings  from  the  JLF  activities,  how  the  activities  have  changed  their  plans  to  overcome  the  gaps  in  leadership  for  health  reform,  how  the  participants  feel  inspired  and  motivated  by  being  part  of  the  joint  learning  network  activities  and  to  know  the  feedback  on  the  JLF  support  and  the  quality  of  the  JLN  products  and  events.      

1  Provider  Payment  Mechanisms,  Quality,  Information  Technology  and  Expanding  Coverage  2  On  Provider  Payment  Mechanisms,  Quality,  IT  an  expanding  converge.        

JLF  APPLICATIONS  SUPPORTED  &  EVALUATED      1. INDONESIA  -­‐    UNDERSTANDING  NATIONAL  ID  INTEGRATION  -­‐  THAILAND    

A  delegation  of   10   representatives   from  different   departments   and  ministries   of   Indonesia   visited   Thailand  12th   –   16th  November,   2012   for  one  week   to  understand   the   integration  of  National   ID  with   social   security  number  of  health  insurance  and  the  information  technology  operation  system  in  Thailand.    

 The   Ministry   of   Home   Affair   (MOHA)   in   Indonesia   is   mandated   by   the   law   to   manage   the   National   ID  integration.   It   is   being  discussed   in   the  draft   of   the   Law  of  National  Health   Insurance   that   there  will   be   an  integration  of   the  existing  schemes  on   the  basis  of  basic  benefit  package  and  there  will  be  a  single   identity  number  of  social  security  (SIN)  eventually  in  Indonesia      The   main   objectives   of   the   study   visit   were   to   understand   the   National   ID   integration   with   the   health  insurance  number  and  its  IT  system,  to  identify  success  factor  and  challenges  in  implementing  the  system  at  national   and   regional,   its   link   to   other   stakeholders   and   to   learn   lessons   for   policy   formulation   and   IT  development   to   achieve   universal   health   coverage   in   Indonesia.   The   study   visit   was   organized   by   the  International   Health   Policy   Program   (IHPP)   and   National   Health   Security   Office   (NHSO)   in   Bangkok   and  supported  by  the  JLF.      The  experts   in  Thailand  requested  an  overview  of   the  current  systems   in   Indonesia   to  better  customize   the  study   visit.   A   needs-­‐assessment   tool   was   developed   by   ACCESS   Health   with   inputs   form   the   experts   in  Thailand.   The   focal   point   in   Indonesia  made   sure   the   needs   assessment  was   carried   out   and   all   questions  answered.   This   assessment   was   critical   both   for   the   design   of   the   visit   and   also   helped   everyone   in   the  delegation   to   have   a   common   view   of   the   current   situation   in   Indonesia.   As   the   representatives   in   the  delegation   came   from   different   departments   few   of   them   had   the   overview   that   the   needs   assessment  provided.    EXPERIENCE  SUMMARY    -­‐  INDONESIA      “JLN-­‐IT   study   visit   challenged   and   enabled   the   team   to   improve   their   capacity   of   human   resource   to  become  a  centre  of  excellence  for  IT  UHC.”    “JLN   is   a   neutral   platform   where   it   has   helped   facilitate   bringing   on   board   public   and   private   sector  representatives   and   buy-­‐in   from   key   stakeholders   which   otherwise   is   too   hard   to   coordinate   and   time  consuming”    The  participants  felt  that  there  were  strong  aspects  of   joint   learning  both  between  the  countries  and  also  between   the   delegates   from   Indonesia.   One   delegate   also   said   it   would   be   encouraging   to   see   similar  sharing  and   learning  within   the  country  and   regular  discussions  between   the  private  and  public   sector.   It  was  said  that  JLN  definitely  is  a  knowledge-­‐sharing  platform.        “The  JLF  support  has  helped  push  the  reform  process  for  Indonesia  which  otherwise  would  have  taken  lot  of  time.”    According   to   the   participants,   the   study   visit   was   very  well   organized.   The   needs   assessment   conducted  before   the   study   visit   was   useful   for   the   delegation   to   prepare   themselves   for   the   visit.   Quality   of  discussions  in  Bangkok  were  very  rich  and  useful,  especially  the  field  visits  to  the  hospitals.      “It   is  expected  that  the  new  BPJS-­‐Health  will  address    people’s  need  and  give  health  benefit   to  them.  We  have  very   less  time  to  plan  and   implement  UHC  by  2014.  So,   from  the  beginning,    a  good  strategic  action  plan    related  to  UHC  should  be  decided  involving    all  stakeholhers.”  

 An  in-­‐country  core  team  for  implementing  the  roadmap  for  Indonesia  is  imperative  which  should  be  built  on  more   coordination,   exchange   of   knowledge   and   dessimination   of   information   from   the   central   to   the  province  level.  The  participant  in  the  Bangkok  study  visit   learned  that  NHSO  monitored  day-­‐to-­‐day  system  operations   continuously,   including   registration   and   statistical   reporting   functions,   the   network   of  registration  offices,  personnel  issues,  equipment  and  supplies,  and  other  facilities.  The  knowledge  and  skills  required   for   data   processing,   analysis,   interpretation   and   problem-­‐solving   are   given   attention   that   affect  data  collectors  and  users  work  in  their  specific  environments  and  organizational  cultures.    

 In   addition   to   the   activities   above   are   there   several   ongoing   areas   of   engagement   in   Indonesia   under   this  grant:  PT  Askes,  the  company  that  will  manage  the  new  BPJS-­‐health,  is  in  process  to  develop  IT  Master  Plan  with  the  technical  support  of  JLN  IT  track  and  the  resource  of  ACCESS  Health  in  Indonesia,  supported  through  this   grant.   PT   Askes   and  Home  Affairs   have   signed   an  MOU  with   nine   different   stakeholders   representing  different   departments   and  ministries   to  work   in   coordination   for   the   national   ID   integration.   Immediately  after   the   study   visit   an   operational   plan   was   made   following   to   two   meetings   but   not   been   followed  afterwards  The  enthusiasm  has  dropped  after  a  few  months  of  the  roadmap  design  and  the  working  groups  are  not  in  sync  with  each  other.  Isolated  working  group  and  after  the  team  they  got  together.  

     2. MALAYSIA    -­‐  CO  –  SPONSORED  HTAsiaLink  CONFERENCE    

A  request  from  the  School  of  Pharmaceutical  Sciences,  Universiti  Sains  Malaysia,  to  the  JLF  was  approved  to  support  part  of  the   logistics   for  hosting  the  2nd  HTAsialink  Annual  Conference   in  Penang  on  the  13th  –  15th,  May  2013  for  over  120  delegates,  global/regional  HTA  experts,  policy  makers,  and  junior  HTA  researchers.      HTAsiaLink,  a  network  of  Health  Technology  Assessment  agencies  and  institutions  in  Malaysia,  Thailand,  South  Korea,  China,   Singapore,   Japan  and  Taiwan  was   formed   to  help  and  collaborate   in  nurturing   the   talent  and  activities  in  Asia.  The  network  is  supported  and  recognized  by  various  international  body  including  the  World  Health  Organization,  INAHTA,  HTAi,  and  International  Society  of  Pharmacoeconomics  and  Outcomes  Research  (ISPOR)  as  the  leading  group  of  HTA  organization  in  Asia.      The  participants  also  included  the  JLN  member  countries  such  as  Malaysia,  Thailand,  Philippines  and  Vietnam.  This  event  not  only  gives  an  opportunity   to  share  and   learn   from  other  knowlede  countries  outside  the  JLN  but   also,   gives   a   platform   for   the   member   countries   to   brainstorm   common   problem   areas   to   work   in  collaboration.  Fourteen  countries  with  104  delegates  participated  in  this  two  day  conference.    The  objectives  of  the  annual  conference  were  to:  • Encourage   new   generation   HTA   scholars   to   form   international   network   and   interact   with   experienced  

researchers  as  well  as  decision  makers  within  and  outside  the  region.  • Share  and   impart  knowledge  and  expertise   in   the  area  of  HTA  with  colleagues   (practitioners  and  policy  

makers)  in  the  Asia  region  who  are  committed  in  improving  public  spending.    • Sensitize   key   stakeholders   of   respective  member   countries   on   the   importance  of  HTA   in  managing   and  

utilizing  effectively  the  limited  resourses  that  we  have  so  that  it  can  be  harnessed  in  ways  and  means  that  will  enable  us  to  achieve  better  quality  and  wider  coverage  of  healthcare.    

• Appropriate  use  of  medical   technologies  and   services   for  high  quality  healthcare   system  and   improving  the  processes  and  methods  for  setting  priorities    

Some  of  the  topics  discussed  during  the  conference  are  as  follows:    • HTA  and  value  judgements:  is  context  the  determining  factor?  • HTA  and  Value  -­‐  Understanding,  Measuring  and  Using  Value  in  Decisions  on  the  Availability  • and  Price  of  Treatments:  HTAi  Policy  Forum  Perspectives.  • HTA  in  Asia  Pacific:  Past,  Present  and  Future  • HTA  experience  from  Brazil  and  other  Latin  American  countries  systems?  

• Willingness-­‐to-­‐Pay  Threshold  in  Asia    

The   conference   aimed   to   groom   local   talents   in   HTA   that   is   lacking   in   the   Asia   region   by   offering   a  more  comfortable   learning   platform   than   those   other   international   conferences   that   are   often   packed   with  programs  including  industrial  sponsored  activities.  The  conference  encouraged  new  generation  HTA  scholars  to   form   international  network  and   interact  with  experienced   researchers   as  well   as  decision  makers  within  and  outside  the  region.   In  addition,  this  conference  was  an  avenue  to  share  and   impart  our  knowledge  and  expertise  in  this  area  of  HTA  with  our  colleagues  (practitioners  and  policy  makers)  in  the  Asia  region  who  are  committed   in   improving   public   spending.   The   conference   also   aimed   to   sensitize   key   stakeholders   of  respective   member   countries   on   the   importance   of   HTA   in   managing   and   utilizing   effectively   the   limited  recourses  that  we  have  so  that  it  can  be  harnessed  in  ways  and  means  that  will  enable  us  to  achieve  better  quality  and  wider  coverage  of  healthcare.    The   objectives   were   in   line   with   the   aspiration   of   Joint   Learning   Network   that   promotes   the   process   of  learning  from  one  another,   jointly  solving  problem,  and  collectively  produce  and  use  new  knowledge,  tools,  and  innovative  approaches  to  accelerate  country  progress  towards  universal  health  coverage.  Furthermore,  to  the   extent   appropriate   use   of   medical   technologies   and   services   is   a   cornerstone   of   any   high   quality  healthcare  system,  the  conversation  about  improving  the  processes  and  methods  for  setting  priorities  is  a  key  one  to  be  had  in  the  context  of  the  JLN,  within  the  Quality  Track  and  beyond.  

 EXPERIENCE  SUMMARY    -­‐  MALAYSIA    There  were  nine  Asian  and  South  Asian  countries  who  participated  and  the  target  was  to  nurture  the  human  resource   in   HTA   in   the   region.   This   conference   spurred   interest   in   starting   collaborative   HTA   looking   at  quality  of   life  across   countries.  Additional   training   in   Jan,  2014,  Thailand  along   the   sidelines  of   the  PMAC  conference  has  been  planned  on  HTA  for  the  participants  to  work  within  their  respective  countries  in  more  detail  and  build  capacities  and  expertise.      “Some   countries   have   raised   funds   to   work   on   specific   objectives   on   HTA  work   and  managed   to   attract  attendance  from  the  top  people  from  their  respective  Ministries  of  Health.”        HTAsiaLink  is  offering  scholarships  for  formal  training  in  HTA  within  the  ministry  of  health,  Malaysia  and  the  key  priority  is  to  monitor  learning  experience.  

 A  newsletter  is  in  the  making  with  updates  on  the  website  with  all  the  learning  experience  shared.  Recently,  Thailand   went   to   Vietnam   and   Philippines   to   train   on   HTA.   HTAsiaLink   has   initiated   virtual   meetings   with  country  representative  to  guide  and  monitor  the  progress  in  these  countries  

     3. INDIA,  PHILIPPINES,  MALI,  NIGERIA,  &  KENYA    -­‐    ACCREDITATION  AS  AN  ENGINE  FOR  IMPROVEMENT  –  IHI  –  

THAILAND      

The  joint  learning  fund  supported  eight  additional  participants  from  India,  Philippines,  Mali,  Nigeria  and  Kenya  for  a  three  day  workshop  organized  by  the  Institute  for  Healthcare  Improvement  (IHI),  one  of  the  co-­‐leads  for  the  quality  technical  track  of  the  JLN  in  April,  2013.      

 Five  JLN  member  countries  expressed  interest  in  sending  additional  participants  to  attend  the  “Accreditation  as   an   Engine   for   Improvement”  Workshop   to  be  held   in  Bangkok,   Thailand   from  9th   –   11th  April,   2013.   The  proposed  participants  represented  different  national  level  accreditation  bodies  and  health  insurance  schemes  such   as   the   Philippine   Health   Insurance   Corporation   (PhilHealth)   Philippines,   Vajpayee   Aarogyashree  Scheme(VAS)   managed   by   Suvarna   Arogya   Suraksha   Trust   (SAST)   Karnataka,   India,   the   National   Health  Insurance  Scheme  (NHIS)  Nigeria,    National  Hospital  Insurance  Fund  (NHIF),  Kenya.  The  role  of  these  proposed  

participants   is   instrumental   in  the  reform  process  of  their  respective  countries  and  their  participation  at  the  accreditation  workshop  enabled  them  understand  various  aspects  of  designing,  developing  and  implementing  key  accreditation  processes  and  ways  of  overcoming  challenges.        As  countries  move  toward  universal  health  coverage,  health  care  delivery  systems  must  continuously  improve  to   match   the   increased   demand   they   face   from   patients.   Empanelment,   accreditation,   and   other   external  evaluation  systems  are  widely-­‐used  tools  for  assuring  a  standard  level  of  quality  of  care.  A  modern  health  care  system  requires   that  providers   continuously   improve   their   services;   accreditation  and  empanelment   can  be  harnessed  to  drive  genuine  improvement  in  care  delivery.      Nearly   60   Quality   track   members   convened   in   Bangkok,   Thailand   to   participate   in   the   JLN   Quality   track  workshop,  Accreditation  as  an  Engine  for  Improvement,  hosted  by  the  Healthcare  Accreditation  Institute  and  Capacity  Building  Program   for  Universal  Health  Coverage  of  Thailand.   JLN  members  prepared  presentations  and   discussions   on   leadership   and   strategy   to   promote   improvement   using   accreditation,   effective  accreditation   standards,   overcoming   challenges   to   implementation,   and   encouraging   accurate   and   useful  collection   of   data.  The   meeting   was   led   by   experts   from   within   the   JLN   countries   and   other   partners.  Participants  explored  highly-­‐functioning,   improvement-­‐oriented  accreditation  systems,  and  designed  action-­‐plans   for   application   in   their   own   settings.   Emphasis   was   placed   on   designing   of   a   measurement   system,  appropriate  standard-­‐setting,  surveyor  training,  and  leadership  for  improvement.  

 EXPERIENCE  SUMMARY    -­‐    NIGERIA    The  National  Health  Insurance  Scheme  (NHIS),  Nigeria  is  a  body  corporate  established  under  an  Act  of  the  Nigerian   National   Assembly   (Act   35   of   1999).   Objectives   of   the   NHIS   include   ensuring   easy   access   to  qualitative   and   affordable   healthcare   services   to   all   Nigerians.   The   NHIS   is   currently   involved   in   the  accreditation   of   healthcare   facilities   to   participate   in   the   Nigerian   Health   Insurance   programs   which   are  designed  to  achieve  universal  coverage  for  the  citizens  of  the  country  and  its  accreditation  is  widely  sought  in   the   country   especially   as   the   access   to   the   health   insurance   funds   in   itself   is   a  major   incentive.  Many  accreditation   programs   around   the   world   face   similar   challenges   in   designing   and   implementing   a  sustainable   and   effective   accreditation   program   and   so   opportunity   exists   to   learn   from  other   countries’  success  stories.      An  example  of  such  common  challenge  is  the  making  of  a  decision  about  the  continued  operation  of  poor  performing   hospitals   or   clinics   especially   when   other   facilities   to   offer   better   services   don’t   exist.  Accreditation  is  an  educational  process,  not  just  an  inspection  and  there  is  room  for  different  accreditation  programs  to  be  run  simultaneously  in  a  country.  Opportunity  exists  to  use  aggregate  data  on  accreditation  performance   of   healthcare   facilities   to   be   used   to   inform   future   health   policy   in   the   country.   The  management  of  a  healthcare  facility  is  critical  to  improving  healthcare  in  any  facility  and  to  achieve  success,  a  balance  of  quick  win  and  long  lasting  achievements  should  be  pursued.      The  financial  incentive  inherent  in  NHIS  accreditation  of  healthcare  facilities  is  a  major  leveraging  factor  for  quality   improvement.   Without   keeping   adequate   records,   quality   improvement   from   our   various  accreditation   exercises   cannot   be   assured.   Membership   of   ISQUA   will   be   of   an   immense   advantage   in  building   the   capacity   of   accreditation   surveyors   and   there   are   several   dimensions     to   quality   and   while  attempting  to  attain  specified  standards  in  each  of  these  dimensions;  efforts  must  be  made  to  ensure  there  is   an   integration   of   all   these   in   order   to   achieve   overall   quality.   While   the   argument   for   or   against   the  involvement  of  Governments  in  the  process  of  accreditation  goes  on,  for  a  country  like    Nigeria,  it  cannot  be  ruled  out  as  most  professionals  would  rather  deal  with  an  approved  government  agency  than  a  privately  run  agency  especially  when  such  accreditation  is  tied  to  some  financial  incentive.    After  the  discussions  and  the  presentations  of  others  countries,  it  made  clear  that  there  are  no  international  

standards  or  guidelines  that  can  be  seen  as  a  panacea  for  the  moment  about  accreditation  in  Mali.  So  it  is  the  decision  of  the  Authorities  of  middle  and  low  income  countries  to  set  their  systems,  to  determine  the  inputs,   processes   and   products   of   their   accreditation   programs.   Doing   so,   the   key   points   below  must   be  taken  into  account:  

• The  accreditation  program  must  have  a  specific,  clear  reason;  • The  commitment  of  all  stakeholders  is  necessary  to  achieve  the  goal;  • The  results  indicators  must  be  measurable  and  significant,;  • In  terms  of  human  resource,  the  challenge  is  to  find  a  group  of  people  with  the  knowledge,  skill  and  

desire  to  collect  and  monitor  data;  • The  possibility  to  apply  sanction  if  the  standards  are  not  met  after  some  time  of  implementation;  • The   continuity   and   sustainability   of   improvement,   policy   and   funding   should   both   be   in   place   to  

ensure  continuous  monitoring  of  the  health  system.    

EXPERIENCE  SUMMARY    -­‐    MALI  Mali  plans  to  establish  a  capacity  building  program  for  accreditation;  make  common  accreditation  standards  to  all  the  health  care  system  and  unify  all  accreditation  bodies  in  a  single  agency.  Mali   is   in  the  process  of  reviewing  of  the  legal  texts  ruling  the  health  sector  to  find  the  statements  related  to  the  quality  of  services  and   healthcare   and   orienting   everyone   familiar   with   the   accreditation   vocabulary   and   constructing   a  lobbying   document   for   the   decision-­‐makers   at  MoH   and   National   Assembly   level   and   exploring   how   the  NHAA  to  be  an  accreditation  body  for  the  country.    

 EXPERIENCE  SUMMARY    -­‐    INDIA    (KARNATAKA,  ANDHRA  PRADESH,  &  KERALA)  Rajiv   Aarogyasri   Scheme   (RAS)  managed   by  Aarogyasri   Health   Care   Trust   (AHCT),   Vajpayee  Aarogyashree  Scheme  (VAS)  managed  by  Suvarna  Arogya  Suraksha  Trust  (SAST)  and  the  Kerala  accreditation  standards  for  Hospitals  (KASH)  Government  of  Kerala  in  India  aim  to  improve  access  of  both  urban  and  rural  poor  families  towards   quality   secondary   and   tertiary   medical   care   for   treatment   of   identified   diseases   involving  hospitalization,  surgery  and  therapies  through  an  identified  network  of  health  care  facilities.  The  states  and  the   national   insurance   program   RSYB,   planned   in   discussion   with   the   National   Accreditation   Board   of  Hospitals   an   autonomous   body,   to   align   the   empanelment   standards   of   different   government   sponsored  insurance  programs  to  the  national  accreditation  standards  and  work  towards  improving  the  quality  for  all  levels  of  care  Promotion  amongst  health  professionals  utilizing  incentives  and  disincentives  and  deciding  the  nature  of  incentives  for  providers  to  achieve  high  levels  of  quality,(financial  and  non-­‐financial)  is  also  crucial  which  will  be  taken   in  the  near  future.  Some  of  the   issues  which  the  country  participants  were   looking  to  find  answers  were  on:  

• How   can   providers   become   committed   to   internal   quality   improvement   –   e.g.   incentives   and  culture?  

• What   programs   exist   external   to   hospitals/clinics   –   e.g.   registration   of   staff,   hospitals   and  statutory  inspectorates?  

• What   standards   have   been   adopted   –   e.g.   for  meeting   patients’   expectations   and   for   clinical  practice?  

• How   compliance   with   these   standards   is   measured   –   e.g.   patient   surveys,   clinical   audit   and  indicators?  

• What  training  would  be  needed,  for  whom?  • Who  would  provide  this  training?  • How  much  time  should  clinicians  devote  to  quality  improvement?  • How  could  this  be  incorporated  into  routine  clinical  activity?  • What   information  is  available  about  quality   improvement  methods  –  e.g.  at  national  and  local  

level,  libraries  and  resource  centers?  • How  could  this  information  be  made  more  accessible  and  exchanged?  • What  data  are  collected  locally  which  could  measure  quality?  

• To  know  the  cost  implications  of  the  accreditation  and  cost  –  benefit  analysis?    

 EXPERIENCE  SUMMARY    -­‐    PHILIPPINES    Philippines   is   in   the  process  of   implementation  of  accreditation   like   the  other  participating   JLN  countries.  Although,   Philippines   have   only   implemented   it   three   years   ago,   the   BenchBook,   which   contains   the  standards   of   quality   and   safety,   is   a   very   good   tool   that   has   been   developed   to   achieve   good   health  outcomes   in   our   health   care   facilities.   Further,   while   it   is   a   major   challenge   for   other   countries,   in   the  Philippines,   it   is  not  quite  difficult   to  engage  health  care  providers   to  embrace  accreditation  because   it   is  tied   with   reimbursement.   Accreditation   whether   implemented   by   a   private   or   government   entity   is   an  important  tool  for  improvement  in  health  care  facilities.  Accreditation  promotes  quality  and  safety  in  health  care.   To   promote   quality   in   health   care,   there   should   be   an   active   participation   among   all   sectors,  government  and  private  and  should  be  a  top  to  bottom  approach.  The  indicators  and  measurements  should  be   in   place   because   these   will   help   managers   gauge   if   there   is   improvement   in   the   facility   after   the  implementation   of   standards.   As   implementers   of   accreditation   and   payors   of   health   expenditures   of  PhilHealth  members  in  the  Philippines,  it’s  identified  that  the  following  priority  areas  for  improvement  are  crucial.    • Need  to  revisit  the  BenchBook  and  come  up  with  standards  that  are  more  geared  towards  process  and  

outcomes.  • Need  to  enhance  the  system  of  monitoring  and  evaluation  of  our  Quality  Assurance  Program.  • Need  to  enhance  our  IT  systems  to  be  responsive  to  all  stakeholders;  • Need  to  re-­‐calibrate  our  surveyors  for  a  uniform  interpretation  and  implementation  of  the  BenchBook  

standards.  • Need  to  develop  a  system  of  incentivizing  facilities  for  good  performance.  • Need  to  expand  the  implementation  of  QA  standards  to  facilities  other  than  hospitals  

 EXPERIENCE  SUMMARY    -­‐    KENYA  The   National   Hospital   Insurance   Fund   (NHIF),   Kenya   has   applied   the   accreditation   system   in   providing  benefits   to   its   members.   Considering   that   there   has   not   been   an   organized   accreditation   system   in   the  country,   NHIF   has   filled   this   gap   by   taking   advantage   of   its  mandate   of   providing   quality   services   to   the  members  through  declaration  of  health  care  facilities  as  per  the  legislated  Revised  NHIF  Act  of  2008.  Since  the  year  2005  NHIF  has  used  the  Kenya  Quality  Model  as  a  vehicle  for  quality  improvement.  This  is  what  has  informed  the  current  status  of  accreditation  at  NHIF.      NHIF  needs   to  continue  with   the  KQMH  standards   that   the  ministry  of  Health  has  adapted   into   to  policy.  This  will  also  be  further  developed  by  making  deliberate  efforts  to  further  develop  these  standards  and  tie  it  to   the   financing  mechanism.   In   this   regard   the  ministry  will   try   to   lobby   for   the   inclusion  of  accreditation  into  the  drafting  of  the  new  health  Act  that  is  soon  to  be  tabled  in  parliament.  NHIF  is  will  further  look  into  how   the   standards  will   be  made  more   robust   by   setting   a   path   towards   ISQua  Accreditation  of   the  NHIF  standards  of  accreditation.  This  will  be  done  in  collaboration  with  PharmAcess  International  in  the  Safecare  programme   Following   the   improve   work   on   the   standards   in   India   and  Malaysia.   NHIF   team  will   closely  follow   these   three   country’s   accreditation   institutes   and   look   for   possible   learning   areas   that   can   be  adapted  to  the  Kenyan  system.    NHIF  has  done  well   in  having  a   system  of  accreditation   through   the  KQM  and  with   twelve  dimensions   to  measure.  By  following  the  discussions  and  presentations  from  Thailand  and  India  it  was  observable  that  we  need  to  improve  from  the  broad  areas  of  measurement  to  being  more  specific.  This  calls  for  further  review  into  exactly  what  and  how  else  we  need   to  measure.  The   India’s  64   indicators  as  used  by   the  Aarogyasri  Health   care   Trust   is   something   that  NHIF   can   adapt   as   it   appeared   very   specific   compared   to   the   KQM’s  broad   12   dimensions.   Picking   the   indicators   will   require   an   improvement   of   the   database   from   the  

accredited   facilities.   There   has   not   been   benchmarking   in   the   NHIF   system.   By   identifying   and  making   a  report  of  a  few  of  these  indicators  we  can  start  benchmarking.  Bench  marking  will  go  along  way  in  fostering  the  culture  of  learning  through  sharing.    Each  country  is  unique  and  will  need  to  chart  it  own  direction.  This  calls  for  a  system  that  will  give  a  whole  picture  of  the  health  system  and  particularly  patient  system.  The  current  system  is  heavy  on  empanelment  and  has  allowed  healthcare  providers  entry   into  NHIF  but  has  not  been  able   to   fully  embrace   the  quality  improvement   aspects   of   accreditation.   The   key   point   will   be   for   the   country   to   harness   all   the   positive  aspects   of   the   current   system   and   build   it   towards   greater   response   to   all   the   stakeholders.   NHIF   will  therefore  have  a  more  patient  focused  system  by  clearing  identifying  the  quality  improvement  objectives.      As  Kenya  prepares  a  move  toward  universal  health  coverage  (UHC),  it  has  become  clear  that  NHIF  will  be  a  key  vehicle  in  its  delivery.  From  the  experiences  of  Thailand  it  will  be  important  to  relook  at  NHIF’s  delivery  system  that  must  continuously  improve  to  match  the  increased  demand  expected  in  the  provision  of  quality  services  from  the  members  and  government.  The  work  shop  highlighted  the  importance  of  empanelment,  accreditation,  and  other  external  evaluation  systems  as  widely-­‐used   tools   for  assuring  a   standard   level  of  quality  of  care.  In  making  necessary  adaptations  like  the  linking  of  accreditation  system  to  the  district  health  Information  management  system  (DHIMS)  will  go  a   long  way   in  ensuring   that   the  system   is   responsive   to  the  needs  of  the  patients  and  be  harnessed  in  driving  genuine  improvements  in  care  delivery  

 4. NIGERIA    -­‐    INTERNATIONAL  FORUM  ON  QUALITY  &  SAFETY  IN  HEALTHCARE  –  LONDON,  UK    

As  part  of  the  effort  to  develop  and  implement  a  comprehensive  quality  strategy,  the  FMOH  attended  a  five  day   study   visit   for   a   delegation   of   seven   representatives   from   the   Nigerian   Federal   Ministry   of   Health  (FMOH)   was  supported  by  the  JLF  to  participate  at  the  2013   International   Forum   on   Quality   and   Safety   in  Healthcare,   co-­‐sponsored   by   IHI   and   the   BMJ   Publishing   Group   from   16th   –   19th,   April,   2013,   in   London,  England.      

 The  main   objectives   of   this   forum   were   to   provide   education,   exchange   of   sound,   practical   ideas,   and  serve   as   a  setting   for  deep  discussion  and  shared      learning  among  those  mandated  to  lead  improvements  in  healthcare   in  Nigeria.     Additionally,   this   forum  helped  build   the  healthcare   improvement  methodology  and  research  base  for  dissemination  and  implementation.    Presently   in  Nigeria,   attention   has   been   drawn   to   the   issue   of   care   quality   and   overwhelming   support   has  been   shown.  Participation   at   the   International   Forum   on   Quality   and   Safety   in   Healthcare   provided   the  participants   to   access   to   interact   with   international   experts   and   resources   that   will   be   heavily   utilized  throughout   Nigeria’s   quality   improvement   process.   The   Nigerian   Federal   Ministry   of   Health   (FMOH)   has  implemented   a   novel   and   aggressive   quality   improvement   and   clinical   governance   program.  Having   gained  support   and   buy-­‐in   from   stakeholders   across   the   health   delivery   and   financing   sectors,   the  momentum   to  drive   forward   an   intelligent   and   well-­‐constructed   quality   strategy   is   at   its   prime.   Members   of   the   FMOH  quality  improvement  team  sought  to  build  on  this  momentum  and  increase  the  country’s  quality  and  clinical  governance  capacity  through  attending  the  2013  International  Forum  on  Quality  and  Safety  in  Healthcare.  The  team   actively   participated   in   workshops,   reviewed   relevant   documents,   and   engaged   with   experts   from  various  geographical  regions  in  order  to  adopt  best  practices,  understand  key  process  requirements,  and  gain  access  to  other  critical  elements  of  quality  improvement  in  order  to  help  ensure  successful  execution  of  the  quality  improvement  initiative.    The  FMOH  team  entered  the  conference  with  several  key  goals:  

• To   be   exposed   to   current   best-­‐practice   and   innovative   approaches   in   the   field     of   health   quality  improvement;  

• To  identify  potential  deficiencies  in  the  current  thinking  and  preliminary    strategy  of  Nigeria’s  quality  

improvement  approach;  • To  identify  potential  collaborators  whose  expert  knowledge  may  be  beneficial;  and  • To   better   understand   the   experience   of   other   countries—particularly   other   Sub-­‐Saharan   African  

and/or   developing   countries—that   have   initiated   quality   improvement   and   quality   accreditation  programs.    

EXPERIENCE  SUMMARY    -­‐    NIGERIA    The  FMOH  quality  team  placed  a  premium  on  receiving  information  on  other  country’s  quality  improvement  experiences  as  a  key  objective  of  participating   in   the  Forum.  Having   insight   into   the  quality   improvement  experiences   of   other   countries   provides   a   wealth   of   information   on   the   pitfalls   and   best-­‐practices   for  developing  a  strategy  toward  patient  safety,  clinical  governance,  and  quality  improvement  plans.  To  achieve  this  objective,  the  FMOH  was  able  to  attend  a  series  of  formal  and  informal  meetings  with  members  from  the  quality  improvement  teams  from  other  Sub-­‐Saharan  African  countries  as  well  as  a  handful  of  emerging  market   teams   that  attended   the  Forum.   Information  was  obtained   from  a  number  of  African  countries,  a  team  of   Brazilian   presenters,   and   a  Malaysian   delegate,   amongst   others.   However,   the   insights   garnered  from   the   individuals   featured   below   were   the   most   relevant   and   instructive   for   Nigeria’s   quality  improvement   journey.   The   FMOH   Quality   team   had   the   opportunity   to   have   in-­‐depth   talks   with  representatives   from  teams   from  Malawi,  Ghana,  and  South  Africa  as  part  of  a  meeting  of  African  Forum  attendees  organized  by  the  IHI.  During  this  meeting,  each  team  discussed  their   journey  so  far  and  lessons  learned  throughout  the  process.    This  meeting  also   served  as  a  platform   for   fostering  connections   for  partnerships  beyond   the  days  of   the  Forum    Through  participation  at  the  Quality  forum  in  London,  Nigerian  Federal  Ministry  of  Health  (FMOH)  Clinical  governance  program  gained  support  and  buy-­‐in  and  engaged  experts  from  various  geographical  regions  in  order  to  adopt  best  practices,  and  gain  access  to  other  critical  elements  of  quality  improvement  in  order  to  help  ensure  successful  execution  of  the  quality  improvement  initiative  in  Nigeria.    “Although   initiatives   to   improve  quality  of  care  are   taking  shape   in  Nigeria,   there   is  currently  an  effort   to  adopt   a   coordinated   approach   that   aligns   all   quality   projects   as   a   single   integrated   quality   improvement  program   in   the   country.   Three   quality   tools   were   identified   during   the   international   quality   forum,   as  potential  quality   improvement  projects  to  fast-­‐track  through  the  planning  and  implementation  phases.  (1)  Global  Trigger  Tool  (2)  Waste  Identification  Tool  (3)  Checklists:  Surgical  Safety,  Accidents  &  Emergency,  Safe  Birth  and  a  National  Healthcare  Quality  Strategy  has  been  designed  as  a  result  of  consultation  with  Institute  for   Healthcare   Improvement   (IHI)   and   the   participation   at   the   International   quality   forum.     The  National  Quality  Strategy  is  under  review  by  the  health  minister  and  will  be  implemented  end  of  June,  2014.”    

 5. INDIA   (KARNATAKA)     –   UNDERSTANDING   STANDARD   TREATMENT   GUIDELINES   &   CLINICAL   PATHWAYS,  

NICE  INTERNATIONAL,  LONDON,  UK    A  one  week  study  visit  to  United  Kingdom  from  1st  –  5th  July,  2013  was  supported  by  the  Joint  Learning  Fund  for  a  delegation  of  six  representatives  from  the  state  of  Karnataka,  India  and  organized  by  National  Institute  for   Health   and   Care   Excellence.   The   delegation   comprised   of   three   administrative   staff   from   the   Vajpayee  Aarogyashree   Scheme   managed   by   Suvarna   Arogya   Suraksh   Trust   and   three   oncologists   representing   the  public  and  private  institutions  of  the  Vajpayee  Aarogyashree  Scheme  empanelled  hospitals  and  the  oncology  committee.   The   aim   of   this   study   visit   to   National   Institute   for   Health   Care   Excellence   and   other   relevant  divisions  of  the  National  Health  System,  United  Kingdom  was  to  understand  and  learn  to  design  and  develop  a  road  map   for  development  and   implementation  of   standard   treatment  guidelines  and   clinical  pathways   for  cancer   related   conditions   in   order   to   improve   the   quality   of   healthcare   services   within   the   Vajpayee  Aarogyashree  Scheme  network  hospitals.  

 The  objectives  of  the  study  visit  were:  • Understand  how  clinical  pathways  are  developed  by  National  Institute  for  Health  Care  Excellence  and  how  

they  are  implemented  in  the  wider  National  Health  Services  • Appreciate   what   information   technology   is   required   for   monitoring   the   uptake   and   use   of   clinical  

pathways  and  for  measuring  their  impact  on  quality  of  care?  • Understand  what   the   regulatory   arrangements   are   for   ensuring   best   practices.  Who   is   Responsible   for  

enforcing  best  practice  and  what  happens  when  there  is  a  lapse.  • Understand  how  clinical  pathways  are  communicated  to  service  users  • Explore  how  to  address  newer  chemotherapy  treatment  drugs  and  techniques    EXPERIENCE  SUMMARY    -­‐    INDIA    One   the   return   from   the  National   Institute   for  Health  Care  Excellence   study   visit   in   London,   the  Suvarna  Arogya   Suraksh   Trust   team,  with   the   aim   to   reduce   the   cost   of   overall   cancer  management   for  Vajpayee  Aarogyashree   Scheme   patients,   standardize   the   treatment   across   the   cancers   treated   within   Vajpayee  Aarogyashree   Scheme   and   improve   the   patient   outcomes   by   reducing   the   morbidity   and   mortality  associated   with   cancer   decided   to   take   few   steps   toward   for   improving   quality   of   cancer   care.   Suvarna  Arogya  Suraksh  Trust  formulated  six  working  groups  for  all  the  high  priority  cancers  such  as  Cervix,  Breast,  Ovary,   Oral   /   Head   &   Neck,   Esophagus   and   Pediatric   oncology   with   the   objective   to   develop   standard  treatment  guidelines  and  quality   standards   for  all  procedures  covered  by  Vajpayee  Aarogyashree  Scheme  for  these  identified  six  cancers.      Thirty   oncologists   from   ten   different   public   and   private   Vajpayee   Aarogyashree   Scheme   empanelled  hospitals  were  identified  to  form  the  working  groups.  The  working  groups  were  convened  by  one  Suvarna  Arogya  Suraksh  Trust  administrative  staff   in  each  group.  The  working  group  consists  of  a  multidisciplinary  team  of  oncologists  such  as  Surgical,  Medical  and  Clinical  (Radiotheraphy)  Oncologists  for  each  area  to  avoid  dominance   of   treatment   protocols   from   one   specialized   stream   of   oncologists   as   done   in   the   National  Health   Services.   The   working   groups   are   overseen   by   the   oncologists   who   visited   National   Institute   for  Health   Care   Excellence   and   the   Vajpayee   Aarogyashree   Scheme   oncology   committee   members.   The  identified  working  group  participants  were  invited  for  a  preliminary  discussion  to  disseminate  the  learnings  and  experience  from  the  National  Institute  for  Health  Care  Excellence  study  visit  and  planned  the  next  steps  for   drafting   the   standard   treatment   guidelines/clinical   pathways   for   the   identified   cancers.     The  working  group  were   provided  with   reference   guidelines   developed  by   Federation   of   India   Chamber   of   Commerce  and  Industry,  Indian  Council  of  Medical  Research  &  National  Institute  for  Health  Care  Excellence  for  the  six  cancers   identified.  The  working  groups  worked  on  drafting   the   standard   treatment  guidelines  and  quality  standards   for   each   cancer   are   now  piloted   in   all   the   empanelled  hospitals  within  Vajpayee  Aarogyashree  Scheme  providing  cancer  services  as  acceptable  minimum  standards  from  1st  of  Jan,  2014.  A  document  of  all  drafted  six  cancers  standard  treatment  guideline  and  clinical  pathways  has  been  developed  and  shared  with  all  Vajpayee  Aarogyashree  Scheme  empanelled  hospitals  for  implementation  and  compliance.    

 6. VIETNAM   -­‐   UNDERSTANDING   NATIONAL   HEALTH   SYSTEM   ORGANIZATIONS   ON   QUALITY,   NICE  

INTERNATIONAL,  LONDON,  UK    The  Government   of   Vietnam   is   committed   to   universal   coverage   and   passed,   in   2008,   the  National   Health  Insurance   Law,   aimed   at   strengthening/reforming   health   financing   and   expanding   health   insurance   and   at  achieving  Universal  Coverage  by  2014.  The  government’s  key  current  policy  priorities  include:    

• Improving  performance  management  of  providers   (including  overcrowding)  through   introducing,   for  example,  quality  indicators  across  hospitals;    

• Ensuring   appropriate   use   of   technology   and   referral   practices   between   primary   and  secondary/tertiary  tier  facilities;  

• Improving   user   experience   and   professional   conduct;   and,   based   on   evidence   of   clinical   and   cost-­‐

effectiveness   as   well   as   local   feasibility,   strengthening   financing   and   reforming   provider   payment  mechanisms  with  a  view  to  ensure  longer  term  financial  sustainability  of  the  insurance  scheme.  

• Institutional   reform   and   streamlining   of   responsibilities   of   the   major   players,   including   different  ministries   and   divisions  within  ministries;   training   and   capacity   building   amongst   professionals   and  technical   experts   supporting   the   Ministry   of   Health;   and   a   systematic   and   evidence-­‐informed  approach   to   the   design   and   maintenance   of   the   basic   package   covered   by   health   insurance,   are  additional  priorities.    

 The  Government  of  Vietnam  proposed   support   for  14   representatives   from  different   relevant   departments  and  ministries  for  a  one  week  study  visit  to  National  Institute  for  Health  Care  Excellence,  United  Kingdom  in  July,   2013   to   understand   National   Health   System   organizations,   challenges   faced   and   opportunities   for  improving   performance;   to   understand   the   process   and   methodology   adopted   by   National     Institute   for  Health  Care  Excellence  International  in  bringing  in  performance  improvement  and  quality  standards  and  also  how  Vietnam  can  prioritize  and  identify  appropriate  resources  by  learning  from  the  United  Kingdom.    The  specific  objectives  of  the  study  visit  were:  

• To  understand  the  British  National  Health  Service–  principles,  structures  and  financing  mechanisms  • To  understand  the  development  of  National  Institute  for  Health  Care  Excellence  guidelines  and  clinical  

pathways  Development  of  quality  standards  • Health   Technology  Assessment   in   the  United  Kingdom  and   the   role   of  National   Institute   for  Health  

Care  Excellence  • How  to  put  guidance  into  practice,  exploring  the  levers  and  tools  for  implementation  Measuring  the  

impact  of  guidance  • Understanding  the  role  of  Care  Quality  Commission,  working  with  the  Royal  Colleges  and  Professional  

Associations   and   engaging   patients   and   the   public   in   National   Institute   for   Health   Care   Excellence  guidance  

• To  understand  the  health  care  system  and  the  role  of  primary  health  care.  Lessons  from  a  pilot  project  in  India  

EXPERIENCE  SUMMARY    -­‐    VIETNAM    As   next   steps   for   Vietnam,   the   development   of   clinical   guidelines,   care   pathways,   quality   standards  according   to   the  method   implemented  by   the  National   Institute  of  Health  Care  Excellence  has  shown  the  progress   of   medicine,   evidence-­‐based,   with   the   participation   of   stakeholders   and   specialist   with   a  transparent  process  and  persuasive  for  clinicians.  However,  the  design  of  clinical  guidelines,  care  pathways,  quality  requires  time  and  significant  costs.  In  developing  countries  such  as  Vietnam,  these  guidelines  can  be  apply  applied  and  appropriate  to  the  economic  and  social  conditions.    

• Vietnam   proposed   to   pilot   a   number   of   clinical   guidelines,   care   pathways   and   quality   standards  developed   by   the   National   Institute   of   Health   Care   Excellence   with   technical   assistance   from  National   Institute   of  Health   Care   Excellence   to   gradually   learn   and   improve   the   quality   of   clinical  guidelines,  care  pathways  and  quality  standards  in  Vietnam.  

• Clinical  Audit  plays  an  important  role  in  promoting  the  quality  of  health  services.  Vietnam  proposed  to   develop   a   pilot   project   with   technical   assistance   from   the   National   Institute   of   Health   Care  Excellence  to  perform  clinical  audit   for  some  diseases   (i.e.  stroke  or  diabetes)   in  Vietnam  to   learn  and  then  continue  to  disseminate  this  method  to  other  diseases.  

• Health   Technology  Assessment   is   crucial,   particularly   for   expensive  new   technologies,   new  drugs,  and  new  techniques.  Vietnam  recommends  the  Minister  of  Health  to  assign  a  unit  to  pilot  National  Institute  of  Health  Care  Excellence  health  technology  assessment  to  learn  and  draw  experience.  

• Primary  health  care  network  based  on  general  practitioners  has  an   important  role   in  coordinating  patient  care  flow  at  grassroots  level  or  for  a  hospital  to  contribute  in  reducing  health  care  costs  and  promote  enhanced  quality  of  service  at  the  facility  level.  This  is  an  example  of  doctor  network  that  Vietnam  will  learn  and  apply.  

• The  database  of  health   information  is  a  critical  requirement  and  important  for  providing  objective  

and   transparent   information,   reliable  data   for   assessing  performance.   It   can  be  used   to  measure,  monitor   quality   (including   quality   and   compliance   with   prescribed   guidelines   of   clinicians)   and  provide   information  on  health  status,  people's  satisfaction  with  service  quality.  Vietnam  proposed  to  strengthen   the  health   information  unit,  and  even  establish  an   independent  Health   Information  Center  in  Vietnam.  

 7. MALAYSIA     –   MONITORING   &   EVALUATION   –   CAPACITY   BUILDING   PROGRAM   –   UNIVERSAL   HEALTH  

COVERAGE,  BANGKOK,  THAILAND    A   five   day  workshop   on   ICT   from  9th   –   13th   Sep,   2013   was   organized   by   the   Capacity   Building   Program  on  Universal   Health   Coverage   (CAPUHC),   Ministry   of   Public   Health,   Bangkok,   Thailand.   The   MOH   is   currently  studying  and  developing  a  proposal  and  implementation  plan  to  reform  the  Malaysian  health  system  in  order  to   address   the   challenges   and   issues   faced   by   the   health   system   while   aligning   its   development   to   the  aspiration  of  the  country  to  become  a  high  income  economy  by  2020.  The  MOH  has  accepted  the  clarion  call  of   the   Right   Honourable   Prime   Minister   to   transform   the   government   with   big   moves   and   bold   changes  affecting  a  system’s  solution  ahead  of  the  curve  of  development.    The  health  system  transformation  includes  the  development  of  a  single  payer  Social  Health  Insurance  scheme,  transformed   provider   payment  mechanism,   benefits   package,   an   integrated   information   system   as   well   as  developing  a  good  monitoring  and  evaluation  system  to  ensure  the  provision  of  universal  and  equitable  health  coverage  for  the  population  of  Malaysia.  The  workshop  in  Bangkok  is  a  good  platform  to  exchange  knowledge  and   learn   the   experience   of   other   countries   in   their   movement   towards   UHC   and   to   understand   the  development  of  effective  monitoring  and  evaluation  systems  in  supporting  UHC.  Hence,  Malaysia  would  like  to   learn   and   gain   in-­‐depth   understanding   of   the  monitoring   and   evaluation   system   developed   by   the   Thai  government   to   support   the   UC   scheme   and   also   the   experience   of   other   countries   participating   in   this  workshop.   Five   representatives   from   MOH,   Malaysia   were   supported   by   the   JLF   to   participate   at   this  Monitoring  &  Evaluation  training  workshop  in  Bangkok,  Thailand      The  general  objectives  of  the  study  visit  were:  

• To  better  understand  the  UC  scheme  in  achieving  Universal  Health  Coverage  (UHC)  in  Thailand    • To  understand  the  importance  of  monitoring  and  evaluation  in  assessing  health  system  

transformation      The  specific  objectives  of  the  study  visit  were:  

• To  exchange  experiences  of  policy  formulation,  implementation,  outcomes  and  remaining  challenges  of  the  UHC  focusing  on  UC  Scheme.    

• To  exchange  experience  of  other  countries  on  their  movement  towards  UHC  and  to  build  up  networking  among  the  participants.    

• To  understand  basic  information  systems  to  support  the  requirement  for  the  development  of  a  good  monitoring  and  evaluation  system    

• To  explore  data  structure  and  linkage  required  for  the  development  of  a  good  monitoring  and  evaluation  system    

• To  gain  in-­‐depth  knowledge  on  equity  dimension  of  universal  health  coverage,  practicing  on  real  data  such  as  Thai  data  or  similar  data  from  Malaysia    

• To  discuss  strengths/weaknesses  and  usefulness/challenges  of  these  monitoring  and  evaluation  mechanism    

• To  gain  in-­‐depth  understanding  on  monitoring  and  evaluation  mechanism  from  the  real  practices  including  indicator  and  basic  information  needed    

 EXPERIENCE  SUMMARY    -­‐    MALAYSIA    

There  is  no  such  thing  as  right  timing  to  introduce  UHC.  Thailand  was  able  to  introduce  UHC  in  the  midst  of  economic   downturn   and   during   an   election.   Regardless   of   whom   the   political   masters   were   there   was  persistent  commitment  from  the  technical  committee  to  push  for  UHC.  Advice  given  is  to  start  small  when  introducing   UHC   and   then   improve   coverage   and   deficiencies   along   the   way.     Capacity   and   capability  building  in  is  vital  in  ensuring  the  success  of  UHC.  Succession  plans  needs  to  be  in  place.  Multiple  champions  need  to  be  identified  for  each  niche  area.  Experience  and  passionate  people  need  to  be  recruited  to  drive  UHC.  Mobilize  scholarships  to  those  who  are  interested  in  health  service  research.  Get  the  NGOs  and  other  organization  to  help  ‘buy  the  rich  people’  into  accepting  UHC.      Government   should   be   committed   to   allocate  more   resources   to   health.   There  must   be   transparency   in  procurement   of   health   services   and   items.   Centralized   procurement   is   more   cost   effective.     Since   the  institution  of   the  National  Health  Services  Act   in  2002,   the  rights  and  responsibilities  of  every  Thai  citizen  were   clearly   defined.   All   citizens   have   the   right   to   obtain   free   healthcare  with   their   preferred   registered  providers  at  primary  care  level.  In  the  event  of  an  emergency,  these  citizens  can  still  obtain  health  care  at  the  nearest  available  provider.  With  the  introduction  of  gatekeeping  under  the  UHC;  more  people  are  seen  at  the  primary  care  level  and  less  by-­‐pass  the  system.  The  Thai  statistics  have  shown  that  the  introduction  of  UHC  has  prevented  impoverishment  among  the  poor  and  low  middle  income  in  the  event  of  a  catastrophic  illness.      An  integrated  timely  health  information  system  (HIS)  is  vital  to  ensure  the  success  of  UHC,  Analysis  of  both  population  and  health  facility  raw  data  are  essential  for  the  purpose  of  monitoring  and  evaluation.  We  must  make   optimum   use   of   the   existing   technology   (WIFI/  WHATS   APS).   These   technologies   should   be   easily  accessible   however   not   necessarily   expensive.   The   Thai   experience   shows   that   real   time   data   is   not   a  prerequisite   to   ensure   of   the   success   of   UHC.   Software   systems   need   to   be   developed   locally   and   one  should  not  to  depend  on  vendors.  46      To  ensure  good  governance,  the  body  that  that  governs  UHC  needs  to  be  autonomous.  Board  of  directors  must   be   representatives   of   Stakeholder   in   health.   The   running   of   the   new   organization   regulating   UHC  needs  to  be  transparent.  There  must  be  efficient  use  of  resources  to  ensure  low  administrative  cost.      WAY  FORWARD  FOR  HEALTH  SECTOR  REFORM  IN  MALAYSIA    

• Population   based   data   from   the   Registry   Department   and   Health   Facility   data   needs   to   be  centralized,   shared   and   easily   accessible   by   all   relevant   stake   holders.   The   birth   and   death  registration   needs   to   be   timely   updated   and  preferably   electronically   to   prevent   duplication.   The  illegal  immigrants  must  be  registered  for  proper  analysis  of  health  data.    

• With  our  current  system  in  Malaysia,  we  already  can  identify  our  civil  servants  through  HRMIS,  and  private   sector   through   EPF   and   SOCSO   contributions.   Our   next   step   is   we   need   to   find   an  appropriate  mechanism   to   identify   the   informal   sector.   It   is   also   recommended   that  we   need   to  register  all  illegal  immigrants.    

• The   new   organization   to   manage   the   health   reform   should   not   be   involved   in   collection   of  additional   funds   to   minimize   administrative   cost.   Collection   of   funds   should   be   through   general  taxation,  where   the   financial   burden   is   not   easily   felt   by   the  population.  Good   sales   tax   could  be  introduced   for   certain   items   but   it   must   be   done   with   care   since   it   could   be   regressive   for   the  nation.    

• Capacity  and  capability  of  the  nation  should  be  built  and  retain  to  ensure  persistent  and  consistent  efforts  in  done  towards  improving  the  healthcare  system  of  Malaysia.    

     8. MALAYSIA  –  ICT  –  CAPACITY  BUDILING  PROGRAM  –  UNIVERSAL  HEALTH  COVERAGE,  BANGKOK,  THAILAND  

 A   five  day  workshop  on   ICT   from  19th  –  23th   Sep,  2013  was  organized  by   the  Capacity  Building  Program  on  Universal   Health   Coverage   (CAPUHC),   Ministry   of   Public   Health,   Bangkok,   Thailand.   The  MOH,  Malaysia   is  currently  studying  and  developing  a  proposal  and  implementation  plan  to  reform  the  Malaysian  health  system  in  order  to  address  the  challenges  and  issues  faced  by  the  health  system  while  aligning  its  development  to  the  aspiration  of  the  country  to  become  a  high  income  economy  by  2020.  The  MOH  has  accepted  the  clarion  call  of   the   Right   Honorable   Prime   Minister   to   transform.   Two   representatives   from   MOH,   Malaysia   were  supported  by  JLF  to  participate  at  the  ICT  training  workshop  in  Bangkok,  Thailand      Malaysia’s  health  care  system  is  acknowledged  internationally  as  a  successful,  modern  government-­‐regulated  health   system   that   provides   effective   health   services   particularly   in   rural   areas.   Despite   the   accolades  received,  Malaysia,  like  many  other  countries,  is  apprehensive  that  the  present  system  of  health  care  delivery  and  financing  may  not  be  sustainable  in  the  long  term.  It  is  now  timely  to  restructure  the  system  in  order  to  align  performance   to   the  needs  and  expectation  of   the  nation.  The   transformation  of   the  Malaysian  health  system  called  1Care  for  1Malaysia  is  the  restructured  national  health  system  that  is  responsive  and  provides  choice  of  quality  health  care,  ensuring  universal  coverage  for  the  health  care  needs  of  the  population  through  the  spirit  of  solidarity  and  equity.  Malaysia  seeks  to  undertake  a  comprehensive  health  system  transformation  in  organization,  delivery  and  financing.  In  developing  the  blueprint,  it  is  crucial  to  learn  from  other  countries’  experiences   and   apply   international   best   practices.   The   study   program   is   a   platform   to   gain   in-­‐depth  understanding  on  UHC  and  information  systems.  Hence,  it  would  be  of  great  benefit  for  Malaysia  to  apply  the  lessons  learnt  as  we  plan  to  transform  the  health  system.      The  general  objectives  of  the  study  visit  were:  

• To  better  understand  Universal  Health  Coverage  (UHC)  in  Thailand    • To  understand  the  information  system  to  support  UHC  in  Thailand    

 The  specific  objectives  of  the  study  visit  were:  

• To  exchange  experiences  of  policy  formulation,  implementation,  outcomes  and  remaining  challenges  of  the  UHC  focusing  on  UC  Scheme.    

• To   exchange   experience   of   other   countries   on   their   movement   towards   UHC   and   to   build   up  networking  among  countries.    

• To  understand  basic  information  systems  supporting  the  including  the  UHC  three  main  sources  which  are    

o routine  administrative  dataset  of  healthcare  providers    o household  survey    o civil  registration    

• To  explore  data  structure  and  linkage  of  these  information  systems    • To  exchange  experiences  of  the  applications  of  these  information  systems  to  support  UHC    • To  discuss  strengths/weaknesses  and  usefulness/challenges  of  these  information  systems    • To  gain  in-­‐depth  understanding  on  information  management  from  the  real  practices    

   EXPERIENCE  SUMMARY    -­‐    MALAYSIA    The  inputs  from  this  workshop  were  shared  with  the  relevant  teams  within  the  MOH,  Malaysia.    

• A   good   IT   system   is   essential   to   support   the   UHC   not   just   for   reimbursements   but   also,   capture  information   on   providers,   beneficiaries,   fund   management,   performance   and   quality   of   care,  customer  feedback  and  auditing  purposes.    

• Before   a   system   and   application   is   developed,   there   is   need   to   finalize   the   whole   structure   and  process  of  the  UHC  

• Collaboration  with  other  agencies,  especially  the  National  Registration  Department  and  Department  of  Statistics  is  vital  as  system  integration  will  be  needed.  Policy  on  data  sharing  should  be  discussed  

at  an  early  stage.    • Internal  capacity  building  should  be  on  going  activity,  especially  to  build  implementation  capacity.    • Do  not  wait  for  everything  is  perfect    before  taking  the  first  step  towards  health  transformation  

 9. GHANA,  MALI,  KENYA,  &  NIGERIA    –  ADDITIONAL  PARTICIPANTS  -­‐  AeHIN  IT  –  UHC  CONFERENCE  MANILA,  

PHILIPPINES      

Many  countries  in  Asia  and  Africa  have  begun  the  push  to  achieve  universal  health  coverage,  yet  are  hindered  by  the  need  for  policies,  plans,  capacity,  resources,  and  infrastructure  to  manage  the  task.  To  help  countries  address  these  challenges,  multiple  development  partners  are  coming  together  to  support  a  conference  on  the  topic   IT4UHC.  This  conference  was  aimed  at  bringing   this   important   topic   to   the  attention  of  policy  makers  and  health  sector  stakeholders  working  to  achieve  Universal  Health  Coverage  (UHC)  and  to  highlight  success  stories  which  could  be  emulated.  A  three  day  conference  from  25th  –  27th  Sep,  2013  was  organized  by  the  JLN  IT   technical   track   lead   PATH   and   eight   additional   participants   from   Ghana,   Mali,   Kenya   and   Nigeria   were  supported  by  JLF  in  Manila,  Philippines.      Conference  objectives  were:  

• Encourage  policy  debate  on  operationalization  of  UHC  strategies  with  IT;  at  both  the  international  and  national  level.  

• Promote  strategic   thinking  on  use  of  and  build   regional  networks  on   IT   for  UHC,  capitalizing  on   the  existing  ones  such  as  AeHIN  and  the  JLN.  

• Sharing  of  regional  experiences  on  how  to  plan,   implement  and  continuously  operate  IT  systems  for  social  health   insurance,   including  challenges  faced  and   lessons   learned  during  the  different   levels  of  development.  

• Explore  needs,  contributions  and  what  can  be  done  regionally  for  country-­‐level  impact.  • Harmonize  development  assistance  efforts.  

 This  conference  provided  an  opportunity  for  these  individuals  to:  

• Networked  with  other  leaders  and  partners  in  the  field  of  IT  for  health:  the  conference  was  attended  by   digital   health   leaders,   practitioners,   development/technical   partners,   academic   institutions,   and  donors  from  around  the  world.    

• Exchanged  best  practices:  The  conference  featured  presentations  on  how  countries  in  Asia  got  started  with  IT  for  universal  health  coverage,  and  what  progress  they’ve  made  and  lessons  they’ve  learned.  It  also  featured  “learning  cafes”,  providing  participants  with  opportunities  to  share  practical  experiences  on  specific  topics  with  panels  of  experts.    

• Learned   about   innovation   in   the   field:   the   second   day   of   the   conference   featured   an   innovation  marketplace,  with  presentations  and  demonstrations  on  software  and  hardware  solutions,  as  well  as  how  to  adapt  policy  to  effectively  support  innovation  and  investment  in  IT  for  health.  

 The   JLN  members  are  now  able   to  access   information  and  connections   from  around  the  world   that  will  better  equip  them  to  move  their  country’s  agenda  for  universal  health  coverage  forward.  They  can  share  their  learnings  with  their  colleagues  in  their  home  country,  and  with  the  broader  JLN  IT  Initiative  at  future  engagements.    

 10. MALI    –  UNDERSTANDING  NATIONAL  HEALTH  INSURANCE  SCHEME,  ACCRA,  GHANA      

Mali  has  undertaken  a  very   large  and  ambitious  health  reform  with  the  aim  of  attaining  universal  access   to  health  care  for   its  entire  population.  Mali  has  faced  difficulties   in  the  course  of   its  reform,  mainly  related  to  the  fragmentation  of  health  coverage,  which  includes  on  the  one  hand  the  insurance  systems  established  to  target  the  formal  sector,   informal  and  rural  and  secondly  of  exemption  mechanisms  related  to  services    and  

people,   such   as   cesarean   sections,   malaria   or   entitlements   for   the   elderly.   This   resulting   dispersion   of  resources  with  increased  management  expenses  results  in  the  inefficiency  of  the  health  system.    Also,  the  absence  of  a  national  health  financing  policy,  resulting  in  the  poor  financing  of  health,  as  evidenced  by  the  failure  of  the  Abuja  commitment  that   is  to  devote  at   least  15  %  of  the  state  budget  to  health,  partly  justifies   the   current   difficulties   of   rapid   progress   in   universal   health   coverage.   Today,   the   rate   recorded  coverage  remained  very  low  and  does  not  bode  well  for  the  performance  of  the  overall  system.    Finally,   local  authorities,  primarily  responsible   for  health   issues  at  the   local   level,  have  so  far  remained  very  timid,  both  in  identifying  the  poor  and  in  the  financing  of  their  health  coverage.  Today,  Mali  is  committed  to  overcoming   these   challenges.   And   discussions   are   underway   for   the   establishment   of   a   single   pool   of  management  of  the  insurance  system  also  with  the  inclusion  of  certain  exemptions.  Also,  work  has  started  to  develop  on  a  national  policy  for  funding  health  insurance  coverage  and  for  the  accreditation  of  structures  in  the  framework  of  the  quality  of  health  services.    Based  on  these  achievements  and  challenges,  and  the  real  intention  of  the  Government  of  Mali  to  undertake  reforms,   perceptible   through   the   initiatives   of   the  Ministries   of   Labor   and   Social   and  Humanitarian  Affairs,  Health  and  Public  Hygiene,  supported  by  civil  society,   the  JLN  Country  Core  Group  of  Mali  proposes  making  two   visits   to   Ghana.     The   first   visit   will   be   a   scoping   mission   aimed   at   gaining   a   broad   overview   and  understanding  of  the  Ghanaian  health  reform  context,  and  identifying  key  areas  of  interest  for  more  in-­‐depth  exchange   between   the   Ghanaians   and   the   Malians.   The   second   visit   will   focus   on   very   concrete   areas   of  discussion  that  were  identified  during  the  first  visit.    The   overall   objective   of   the   study   visit   was   to   learn   from   the   main   organizations   and   actors   driving   and  implementing  the  Ghanaian  health  reform  and  efforts  to  achieve  UHC.    During  the  first  visit  (scoping  visit),  the  participants   attended  a  3-­‐day   conference   in   commemoration  of   the  10th   anniversary  of  health   insurance   in  Accra,  Ghana   from  2nd  –  7th  Nov,  2013.   This  will   enable  key   representatives   from  Mali   to  network  with   the  Ghanaian  experts  working  on  the  reform  process  and  identify  areas  of  the  reform  they  wish  to  learn  about  in  greater  detail.  The  specific  objectives  of  the  first  proposed  visit  are  as  follows:      

1. Gain  a  better  understanding  of  efforts  to  achieve  UHC  in  Ghana  and  results  to  date;  2. Identify  success  factors  of  the  health  reform  and  their  determinants;  3. Identify  the  difficulties  of  ‘the  journey’  and  the  solutions  that  have  been  implemented;  4. Determine   a   set   of   key   issues   and   questions   from   the   Ghanaian   experience   that   are   particularly  

relevant  to  Mali’s  health  reform  context;  5. Develop  a  list  of  key  institutions  and  individuals  in  Ghana  that  the  Malians  would  like  to  meet  with  on  

a  return  visit  after  the  conference.      

EXPERIENCE  SUMMARY    -­‐    MALI  At   the   end   of   his   participation   in  the   conference   to   commemorate   the  10th  anniversary   of   the   sickness  insurance   scheme  of  Ghana,   the  Malian  delegation  has  had   the  opportunity   to  understand   the   scheme  of  the  entire  system  of  Ghanaian  health  insurance  for  universal  coverage.      Despite  the  progress  made  by  the  Ghana  in  its  market  for  universal  coverage,  the  arrangements  put  in  place  continues  to  face  major  challenges  to  be  met.  It  is  specifically  to:  • From  the  coverage  of  the  informal  sector,  • The  maintenance  of  the  members  of  the  informal  sector,  • Equity  between  the  different  categories  of  the  population  in  the  financing  of  health  insurance,  • For  the  containment  of  health  costs,  • The  improvement  in  the  quality  of  health  services  provided  to  the  insured.  

 The  present  mission  has  enabled   the  Malian  delegation  to  obtain  more   insights  on   the   sickness   insurance  system  of  Ghana,  to  better  clarify  the  centers  of  interest  for  the  next  trip  to  trade  in  Ghana  and  to  identify  the   key   actors  with  whom   she  would   like   to   have   in-­‐depth   exchanges   during   the   next   study   visit.   In   the  margin  of  the  commemorative  conference  of  10years,  4  representatives  to  the  first  visit  have  met  with  Mr.  Collins  Akuamoah  and  the  two  parties  have  agreed  to  withhold  5  major  themes  on  which  the  second  visit  should  be  focused.  It  is:    • From  the  coverage  of  the  informal  sector,  • Mechanisms  for  innovative  financing,  • For  the  accreditation  of  training  public  and  private  health,  • The  use  of  information  technologies  and  communication  in  the  procedures  for  recording  and  liquidation  

of  benefits,  • The  involvement  of  civil  society  organizations  in  the  system  of  registration  of  insured.    At  the  end  of  the  study  visit,  the  delegation  was  able  to  better  understand  the  process  of  establishment  of  the   national   health   insurance   scheme   (NHIS)   of   the   Ghana,   its   successes,   difficulties,   the   challenges   it   is  facing  today,  the  prospects  of  future  evolution.  The  JLF  supported  study  visit  also  allowed  the  delegation  to  learn   from   the   experiences   of   various   health   funding   for   health   coverage.   All   the   members  of   the  delegation  had  the  opportunity  to  establish  contacts  with  the  peers,  engage  in  discussions  really  thorough  with  the  experts  present;  all  things  that  they  will  be  led  to  put  in  used  to  consolidate  the  actions  undertaken  in  Mali  for  progress  toward  universal  coverage.  The  next  study  visit  is  schedule  for  second  week  of  Jan,  2014  

 11. INDIA    –  QUALITY  –  CAPACITY  BUILDING  PROGRAM  –  UNIVERSAL  HEALTH  COVERAGE,  BANGKOK,  THAILAND  

 Over  the   last   few  years,   increasing  attention  has  been  directed  toward  the  problems   inherent  to  measuring  the   quality   of   healthcare   and   implementing   benchmarking   strategies.   Besides   offering   accreditation   and  certification   processes,   recent   approaches  measure   the   performance   of   healthcare   institutions   in   order   to  evaluate   their   effectiveness,   defined   as   the   capacity   to   provide   treatment   that  modifies   and   improves   the  patient's   state   of   health.   Demand   for   accreditation   are   increasing   and   changing   rapidly   around   the   world.  Traditional  accreditation  must  adapt  to  these  demands  in  order  to  survive  and  to  thrive  as  a  vehicle  that  links  internal   self-­‐development   with   external   regulation.   All   experiences   in   this   direction   will   contribute   to   the  promotion  of  accreditation,  if  they  are  shared.    Countries   have   taken   different   approaches   to   ensuring   quality   and   improving   standards   in   health   care  services.   A   statutory   national   accreditation   program   is   considered   impractical,   as   health   care   is   the  responsibility  of  individual  states.  The  processes  and  underlying  standards  for  accreditation  must  be  designed  with   regard   to   the   needs   and   expectation   of   each   country.   These  will   be   impacted   by   the   types   of   health  system,   the   level   of   care   it   aspires   to   provide,   national   rules   and   cultural,   social,   political   and   religious  requirements.  However,   given   that   the  core  business  of  health   systems   is   very   similar  across   countries  and  health   systems,   there   definitely   will   be   good   learnings   from   existing   system   especially   those,   which   are  relatively  well-­‐established  like  in  Thailand.      A  five  day  study  visit  for  a  delegation  of  eight  representatives  from  different  state  sponsored  health  insurance  programs   in   India  was   supported   by   JLF   from  25th   –   29th   Nov,   2013   in   Bangkok,   Thailand.   Rajiv   Aarogyasri  Scheme   (RAS)   managed   by   Aarogyasri   Health   Care   Trust   (AHCT),   Vajpayee   Aarogyashree   Scheme   (VAS)  managed  by  Suvarna  Arogya  Suraksha  Trust  (SAST),  Chief  Ministers  Comprehensive  Health  Insurance  Scheme  (CMCHIS)  Government  of  Tamil  Nadu  and  the  Kerala  accreditation  standards  for  Hospital  (KASH)  Government  of  Kerala  aim  to  improve  access  of  both  urban  and  rural  poor  families  towards  quality  secondary  and  tertiary  medical  care  for  treatment  of   identified  diseases  involving  hospitalization,  surgery  and  therapies  through  an  identified  network  of  health  care  facilities.    

 • To    learn  how  states  need  to  draft  an  action  plan,  assess  the  human  resource  available,  hand  holding  

and  motivation  for  Accreditation  of  the  hospitals  from  Thailand  and  other  participant  groups?    • To  learn  how  states  need  to  partner  with  state  level  hospital  associations  and  understand  how  were  

the  dynamics  in  Thailand-­‐HAI?    • To   learn   and   understand   the   dynamics   between   the  Accrediting   agency   (NABH/HAI)   and   the   payor  

(AHCT/SAST/  CMCHIS/KASH/Thai  payor)?    • To  understand  the  road  map  to  build  capacity  for  taking  forward  the  Accreditation?    • To  know  how  states  need  to  collaborate  with  various  government  agencies  and  how  to  impress  upon  

them  the  need  for  quality   in  Govt.  hospitals,   the  competition  with  private  hospitals  on  and  the  way  forward  for  accreditation  on  par  with  best  corporate  facilities?    

• To  understand  any  need  for  legislation  and  law,  and  the  role  of  political  and  administrative  leadership  in  Accreditation?    

• To  know  the  cost  implications  of  the  Accreditation  and  Cost  benefit  analysis?      

The  methodology  adopted  during  the  program  included  presentations  on  the  subject  matters  by  experts  from  several   agencies,   interactive   group   discussions   and   exchange   of   experiences   and   perspectives,   and   public  hospital  visit   to  see  the  real  situation  and   implementation  of  the   lessons   learnt.  The  focus  of  this  one  week  program  was  to  learn  from  each  other  and  share  knowledge  according  to  country  context.  There  were  seven  countries   (Cambodia,   China,   India,   Indonesia,   Lao   P.D.R.,   Myanmar,   and   Thailand)   representatives   from  different  schemes  and  national  institutes  responsible  for  preparing  the  UHC  reform.  

 EXPERIENCE  SUMMARY    -­‐    INDIA  (KARNATAKA,  KERALA,  ANDHRA  PRADESH,  &  TAMIL  NADU)  All  countries  are  starting  from  somewhere  and  either  by  design  or  accident  and  most  of  the  countries  are  building   on   specific   segments   of   the   reform   process   e.g.   Tertiary   care   by   Vajpayee   Arogyashree   and  Aarogyasri  on  IT  system.  Lower  out  of  pocket  expenditure  was  the  main  motive  for  India  and  the  countries  have  to  be  clear  about  where  they  want  to  go  and  what  would  be  the  medium  of  approaching  UHC.  UHC  is  not   only   a   task   but   also   an   opportunity.   The   participants   appreciated   the   Thai   model   of   how   different  institutions  and  departments  are  integrated  and  coordinated  for  data  sharing  and  analysis.      The   processes   meticulously   planned   and   implemented   in   hospital   accreditation   and   its   successful  monitoring   was   well   appreciated   and   received.   Through   presentations   and   group   discussions,   the  participants  were  enabled  to  understand  in  detail  the  various  nuances  involved  in  HA.  The  introduction  of  importance   of   spiritual   healing   in   Thailand’s   HA   process   was   a   new   learning   experience   in   allopathic  treatment.  Financial  incentives  to  physicians  to  serve  in  rural  and  remote  areas  is  well  practiced  in  Thailand.  It  was   also   highlighted   the   crucial   role   of  Household   Surveys,  Monitoring   and   Evaluation,   documentation  and  data  analysis  for  policymakers  in  the  health  sector  to  understand  the  outcome  of  health  expenditures  and   comparisons.       Thailand   has  made   tremendous   progress   by   increasing   the   government   spending   on  health  and  financial  risk  protection,  providing  equity  in  health  care  use  &  distribution  of  government  health  subsidies,   improving  quality  of  health   service  provision  and  using  evidence   for  monitoring  and  evaluation  and  decision  making.      There  is  tremendous  personal  commitment  and  accountability  to  the  roles  and  responsibilities  people  have  been   assigned   to   for   years   and  have   efficiently   used   the   available   resources   and   captured   the   lessons   at  every   level.   This   has   been   possible   by   continuously   documenting   their   reform   process.   Thailand   is   an  example  for  many  countries  to  emulate.  The  five  day  program  was  well  appreciated  by  all  the  participants  and  was  rated  excellent  by  all  participants  in  terms  of  achievements  and  documentation  of  health  outcomes  in   Thailand.     From   the   success   of   the   Thai  model   it   is   very   clear   that   universal   coverage   combined  with  quality  health  care  is  achievable  in  developing  countries  and  all  the  people  in  the  unorganized  sector  can  be  covered  through  accessible  and  quality  health  services.    Key  lessons  learnt  and  its  applicability  to  the  Indian  

context:    • Ways  and  means  of  achieving  UHC  • Monitoring  and  Evaluation  to  assess  standard  health  indicator  on  an  ongoing  bases  annually  • Strengthen  and  expanding  the  hospital  accreditation  and  empanelment  criterion  

 12. INDIA,  VIETNAM,  INDONESIA,  PHILIPPINES,  &  GHANA    –  DRG  FORUM,  MALAYSIA      

In   January  2012  the   JLN  PPM  technical   initiative  convened  a  Collaborative  on  Costing  of  Health  Services   for  Provider  Payment   to   create  an  opportunity   for  member   countries   to   share  and   synthesize   their   experience  conducting   costing   exercises   for   provider   payment.     The   Collaborative   members   have   convened   for   4   in-­‐person  meetings.  During  the  last  meeting  in  Hanoi  in  September  2013,  the  group  decided  there  was  interest  and   demand   among   the   Collaborative   members   to   convene   a   meeting   dedicated   to   the   technical   issues  surrounding  hospital  payment.    The  Ministry  of  Health  of  Malaysia  took  the  initiative  to  convene  the  meeting  from  1st  –  3rd  Dec,  2013  and  covered  the  local  venue  costs  and  local  costs  for  some  participants  and  request  JLF  to  support  travel  for  12  participants  from  India,  the  Philippines,  Vietnam,  Indonesia  and  Ghana.        Forum  Objectives  

• To   understand   the   principles   of   hospital   payment,   and   in   particular   the   principles   and   uses   of  diagnosis-­‐related  groups  (DRGs)  

• Understand  the  steps  in  developing  DRGs  and  share  experience  with  the  different  approaches  taken  by  JLN  member  countries  

• Discuss   the   principles   of   costing   for   hospital   payment   and   DRGs   and   share   experience   with   the  different  approaches  taken  by  JLN  member  countries  

• Discuss  common  challenges   implementing  DRGs  for  hospital  payment  and  creative  approaches  used  by  JLN  member  countries  

 The   participants   in   the   forum   are   leading   efforts   to   select,   design   and   implement   health   care   provider  payment  systems  to  support  universal  health  coverage  objectives.    Many  countries  are  using  or  are  planning  to  use  DRG-­‐based  hospital  payment  systems.    The  forum  provided  an  excellent  opportunity  for  participants  to  discuss  detailed  practical  challenges  and  gain  insights  and  ideas  to  manage  these  challenges  from  their  peer  country   experts.   The   forum   was   organized   around   panel   sessions   to   allow   maximum   opportunity   for  participants   to  share  experiences  and  good  practices,  as  well  as   to  promote  networking  opportunities.    The  meeting  was  facilitated  by  JLN  PPM  technical  initiative,  which  also  provided  the  opportunity  to  draw  on  wider  international  experience  and  possibly   identify  specific  resources  to  meet  the  challenges  and  technical  needs  that  are  identified  through  the  forum  discussions.        The   forum  had   a   judicious  mix   of   theory   and   practice   in   DRGs.   It   provided   an   opportunity   to   understand   the  theoretical  and  practical  nuances  of   implementing  DRGs   in  developing  countries.  The   forum  provided  a   strong  network   to   continue   the  DRG   initiatives   and   to   interact  with   the   best   available   experts   in   this   critical   area   of  health  care  reform.  The  learning  from  Malaysia  will  be  disseminated  among  the  study  teams  in  India.  Steps  will  be  planned   to   liaison   with   the   health   system   administrators   and   implementing   agencies   to   take   up   initiatives   in  building  up  DRGs  for  initiating/streamlining  provider  payment  systems  in  the  country.    EXPERIENCE  SUMMARY    -­‐    INDIA,  PHILIPPINES,  VIETNAM,  INDONESIA,  GHANA  Technical  topics  discussed:  1. Case  based  groups  is  complex  2. There  is  no  single  prescription  that  can  be  used  in  every  country.    3. Grouper  should  be  tailored  into  the  country  settings  4. Case  groups,  cost  weights,  and  base  rates  are  developed  from  a  combination  of  developing  from  

scratch,  borrowing,  and  adapting.  It  requires  ongoing  analysis  and  refinement  as  experience  and  more  

data  become  available  5. There  have  been  some  unintended  consequences,  so  more  discussion  is  needed  about  complementary  

measures    Areas  of  challenges:    1. There  is  a  need  to  have  systematic  training  about  coding  system  and  create  a  critical  mass  of  coders  2. Information  system  deemed  necessary  to  be  strengthened  to  make  it  functioning  3. Changing  the  mindset  of  providers  from  fee  for  service  to  prospective  payment  system;  these  two  

different  system  pose  very  different  incentives  and  frequently  totally  in  opposite.    4. Monitoring  impacts  and  unintended  consequences  is  necessary  5. Developing  political  committment  and  communication  strategy.  

 JLF  APPLICATIONS  IN  PIPELINE    

 13. KENYA     –   UNDERSTANDING   POVERTY   IDENTIFICATION   AND   FINANCIAL   PROTECTION   POLICIES   AND  

MECHANISMS  –  VIETNAM  &  THAILAND      Kenya   is   on   the   path   towards   Universal   Health   Coverage   (UHC)   evidenced   by   the   formulation   and  development   of   Sessional   Paper   No.   7   of   2012.   This   policy   document   complimented   by   the   Healthcare  Financing   Strategy   strives   to   ensure   that   every   Kenyan   has   access   to   affordable   and   quality   healthcare.  Poverty   targeting   in   Kenya   is   currently   undertaken   by   the   Social   Protection   Secretariat   (SPS),   under   the  Ministry  of  Labour,  who  enroll   the  poor  and  vulnerable  persons   in  the  Cash  transfer  Programs.  The  SPS  use  the  proxy  means  testing  to  establish  the  level  of  poverty  however  errors  of  inclusion  and  exclusion  have  been  experienced.  This  notwithstanding,  various  interventions  and  programs  have  in  the  past  leveraged  on  the  SPS  database  to  reach  the  targeted  population.  There  is  need  to  conduct  a  comparative  study  with  other  countries  to   share   experiences   on   poverty   targeting   mechanisms   as   well   as   key   innovative   financial   protection  strategies.      Kenya   has   made   strides   towards   UHC   evidenced   by   the   development   of   the   UHC   policy   as   well   as   other  metrics  such  as  reduced  Out  of  Pocket  Expenditure  over  the  years  from  51%  to  30%.  However,  ill  health  is  still  a   major   cause   of   poverty   with   100,   000   households   becoming   impoverished   annually   as   a   result   of  catastrophic  health  expenditures.  With  only  10%  of   the  population  having   some   form  of   insurance,  NHIF   is  looking  for  ways  to  expand  and  deepen  coverage  to  the  lowest  quintile  of  the  population,  approximately  19%.  It   is   envisaged   that   the   study   tour   will   promote   partnerships   to   fight   poverty   through   knowledge   sharing,  advocacy   and   capacity   building.   Further,   the   peer   exchange   will   provide   an   opportunity   for   Kenya   to  understand  the  mechanisms  implemented  to  identify  and  target  the  poor.      Key  objectives  of  this  study  tour  include:-­‐  

• To  identify  and  document  effective  poverty  identification  and  targeting  mechanisms  and  the  eligibility  criteria  used.  

• To  study  the  various  financial  strategies  employed  to  remove  financial  barriers  to  access  for  the  poor.  • To  study  the  suitability  and  sustainability  of  the  benefit  package    

 A   delegation   of   eight   representatives   from  MOH,   Kenya   and  National   Hospital   Insurance   Fund   (NHFI)   have  proposed  for  a  one  week  study  visit  each  in  Vietnam  and  Thailand  sometime  in  April  –  May,  2014      Expected  outcomes  &  Follow-­‐up  

• Review  of  poverty  identification  tools  of  Thailand,  Vietnam  and  Kenya.    • Establish  network  with  Kenya,  Thailand  and  Vietnam  colleagues  for  new  partnership  opportunities;    • Upon   return,   representatives   from   Kenya   will   converge   a   debriefing   meeting   to   exchange   lessons  

learnt  and   thereafter  organize   for  a  dissemination  meeting  with   respective  government  agencies   to  guide   the   process   of   the   development   of   a   framework   to   strengthen   existing   institutional  arrangements.    

• Implement  best  practices  in  the  work  of  National  Hospital  Insurance  Fund  (NHIF)    14. GHANA    –  UNDERSTAND  AUDIT  &  ACCREDIATION  SYSTEM  -­‐  THAILAND  

 As  part  of  a  cost  containment  strategy,  the  National  Health  Insurance  Authority  established  a  Claims  &  Clinical  Audit  Division  with  the  main  objectives  of  conducting  claims  verification  to  determine  whether  the  insurance  claims   submitted   are   in   accordance  with   the   services   rendered  with   respect   to   the   attendance,   procedure,  investigations  or  medicines  given.  The  quality  of   care   is  also  assessed   to  determine  whether   it   conforms   to  internationally  and  nationally  accepted  standards.  All  these  are  aimed  at  ensuring  the  financial  sustainability  of  the  National  Health  Insurance  Scheme  in  Ghana.      After  the  establishment  of  the  division  in  2009,  it  was  divided  into  2  components  –  Clinical  Audit  and  Claims.  The  2  divisions  have  conducted  audits  in  over  800  facilities  across  the  country  ranging  from  Community  Health  Planning   Services   (CHPS)   Centres   through   Health   Centres   all   the   way   to   tertiary   institutions   like   teaching  hospitals.   This   has   resulted   in   the   NHIA   recovering   about   20   million   Ghana   Cedis   (=   USD   6   million)   from  accredited  providers  for  claims  bills  already  paid.  These  were  from  anomalies  like  overbilling,  upcoding  of  the  tariff,  billing  for  items  and  services  not  on  the  NHIS  list,  inadequate  record  keeping  and  irrational  prescribing.  There  have  also  been  numerous  claims  verification  exercises  checking  on  the  veracity  of  the  attendances.  This  has  been  done   in  over  100   facilities   resulting   in  criminal  prosecutions,   suspension  and  the  recovery  of  over  GH¢2  million  (=  USD  660,000).    Ghana   has   developed   its   own  manuals,   policies   and   guidelines,   tools   and   working   papers   with   regards   to  these   verification   exercises.   The   participants   are   drawn   from   the   clinicians   within   the   NHIA   and   from   the  stakeholder   groups   as   well   as   ICT,   financial   and   statistical   staff   within   the   NHIA.   The   methodology   has  sometimes   come   under   scrutiny   from   the   health   facilities   leading   to   disputes  with   regards   to   the   findings.  There   is   therefore   the   need   to   bring   transparency   and   credibility   to   the   methodology   being   used   by   the  teams.      The  NHIA  used   to  process   the   claims  at  over  150  different  district   centers.    We   currently   receive   about  28  million  claims  annually.  The  fragmented  decentralized  process  was  fraught  with  difficulties  and  it  was  deemed  wise  to  set  up  Claims  Processing  Centers  to  centrally  process  the  claims.  The  CPC’s  now  manage  42%  of  the  national  claims.    The  NHIA  has  also  recently  started  accepting  electronic  claims  and  this  equates  to  2%  of  the  national   claims   submission.   The   providers   are   mainly   the   high   volume,   high   cost   providers   for   which  verification  is  extremely  important  for  sustainability.    A  delegation  of  five  representatives  from  NHIA  and  GHS  have  proposed  for  a  two  week  attachment  program  in  Thailand  with  the  objectives    

• To  understudy  the  audit  system  under  the  NHSO  in  Thailand.  •  To   learn   the  audit   practices   in   that   country   and   to   see  how  best   to   incorporate   some  of   the  audit  

practices  into  the  verification  &  audit  processes  in  Ghana.  • To  study  the  Thailand  accreditation  system  as  regards  to  the  development  and  revision  of  standards,  

surveyor   training   and   survey   process,   grading   of   facilities,   incentives   for   high   scores,  post  accreditation  monitoring  etc.