Table 1 Inputs into the framework and research questions
Category | Key concepts, frameworks and principles | Research questions | References |
|---|---|---|---|
UHC and its critiques and alignment of the PFHI scheme with UHC objectives | - Three core UHC goals of financial protection, coverage of population and of services In addition: - Importance of equity within the above - Focus on appropriateness and quality of services - Acknowledgement of:  • The right to health for all  • Social determinants of health  • Strengthening of public health systems  • Promotion of health as a social good and not a commodity - Emphasis on universal health systems rather than UHC Value base: - Right to health - Human rights - Equity of access - Equity of outcome | Do the objectives of the PFHI scheme take into account financial protection, coverage of population and of services, and have equity considerations? Do the objectives refer to the health system as a whole? Is there foregrounding of equity in monitoring and evaluation of the PFHI scheme? Does it cover a limited package of health services or does it talk about UHC and systems? Are appropriateness and quality of services made explicit and addressed? Is the scheme aligned with the idea of health being a fundamental right? Does the scheme promote health as a social good and a right or as a commodity? Are the social determinants of health and structural drivers of health inequity acknowledged and addressed within the scheme? Has the scheme led to equitable access? Has the scheme led to equitable outcomes? | |
Design of PFHI | Key design issues include: - Population coverage - Benefit package - Administrative arrangements - Provider selection, intermediaries - Provider payment mechanisms - Monitoring, regulation and contracts - Transparency, access to information and accountability | Who is covered under the PFHI scheme and what does it mean in terms of equity of coverage? What kinds of services are covered? What are the administrative and implementation arrangements? Who pays? How is the payment of premiums organised? How will the provider be paid? How is the provider selected? Are both the private and the public sectors to provide services under the scheme? What are the systems for monitoring, regulation and contracts? To what extent are equity considerations central to the design? Is information on all aspects of the scheme publicly available? What systems of public accountability are in place? | [78] |
Impact on health system | Building blocks: - Financing - Human resources - Service delivery arrangements - Information - Equipment and supply chains - Governance and leadership Importance of studying: - Interactions between the building blocks - Both hardware (building blocks) and software (values, relationships) - Health systems as complex adaptive systems | What has been the impact of the PFHI scheme on financing, service delivery, human resources and supply chains? Has it been different for the private and public sectors? Have there been any equity implications of the above, especially with regards to changing resource allocations and use of earmarked funds for vulnerable groups? What have been the interactions among the building blocks of health systems, both among the system’s hardware (organisational, policy, legal and financing frameworks) and software (norms, traditions, values, roles and relationships)? How effective are the systems for monitoring, transparency and accountability? | |
Impact on people and populations | - Dimensions of access: availability, affordability and acceptability - Three dimensions of access interact with each other to create the opportunity for utilisation and the possibility of improved health outcomes - Access needs to be defined in relation to health needs - Acceptability as under-studied, including empowerment, agency, capacities to ‘navigate and negotiate’ and understanding interactions, perspectives and contexts | Is the availability of health facilities and health services, which includes quality (‘effective coverage’) and appropriateness of services, equitable? What has been the out-of-pocket expenditure, including catastrophic expenditure, incurred by the patient/family for healthcare or while utilising insurance? Is it higher or lower for vulnerable people/groups? Is a conducive service delivery environment being provided under the PFHI scheme with mechanisms for negotiating and navigating the system, and providing information, transparency, accountability and agency to patients? What is the nature of the grievance redressal system? Is it effective, especially for the poor and more vulnerable groups? How do the three dimensions create the opportunity for utilisation and what is the implication for equity? | |
Public/private sector interactions | - In health systems and schemes that have a public–private mix in provision of health services, it is critical to examine the role of each sector separately in ensuring access and equity and furthering the objectives of UHC | Has the impact of the PFHI scheme been different on the private and public sectors? Has the introduction of a PFHI scheme altered the healthcare provision practice of private and public sector providers? What have been the implications for equity in access? | |
Policy process | - Policy change as a political process - Process of agenda-setting, decision-making, formulation, implementation and evaluation - Role of context, actors, interests, ideas, power relations and institutions - Located within the political economy of development | Who are the key actors in the policy process? How does power play out amongst these actors? What is the impact of social structures and power differentials on the functioning of the scheme? What is the nature of the political economy of healthcare within which this scheme has been introduced and how does that influence equity? |