Papers by T. Dmytraczenko
The recent increase in financing for HIV/AIDS care makes it important to ensure that the monies a... more The recent increase in financing for HIV/AIDS care makes it important to ensure that the monies are spent in a way that fulfills the goals of country policymakers and donors i.e. that resources are allocated in a way that provides needed goods and services to targeted populations. In most HIV-endemic countries stakeholders lack the data to track who is paying for HIV/AIDS care and who is benefiting from it: people living with HIV? at-risk groups? urban vs. rural? rich vs. poor? This paper discusses how beneficiary analyses of resource flows can inform policy. It describes how data can be collected and two methodologies -- National AIDS Accounts and the National Health Accounts Subanalysis for HIV/AIDS -- that estimate how public private and donor funds for HIV/AIDS flow through the health care system. The methodologies provide information that is valuable for monitoring how current HIV/AIDS care policy goals are being met and for informing future policy making. (authors)
In developing countries more than 500000 women die every year from complications related to pregn... more In developing countries more than 500000 women die every year from complications related to pregnancy and childbirth. Many other women suffer pregnancy- and delivery-related complications that result in long term health problems. A woman’s death during childbirth often means death for the newborn and both deaths and disabilities translate into emotional social and economic hardships for women’s older children their entire families and even their communities. Maternal and infant deaths can be prevented by ensuring that high quality maternal and newborn health care is accessible and that maternal health complications are recognized referred and treated by a skilled health care worker. However many women lack the financial means to pay for basic medical care or they are deterred from seeking care by cultural barriers such as the status of women within the family and in society. They may postpone their own treatment when sick in order to pay for care for family members or they may not s...
Insurance mechanisms -- such as private insurance social health insurance and community-based ins... more Insurance mechanisms -- such as private insurance social health insurance and community-based insurance -- are increasingly being created and expanded in developing countries. These new and existing insurance mechanisms can be leveraged to add RH services to benefits packages. However there are challenges to including RH services -- especially family planning and deliveries -- in health insurance. Since families are unlikely to purchase insurance just to cover RH risks it will be necessary to incorporate RH benefits into insurance programs with broader benefit packages. The purpose of this primer is to introduce decision makers to the basics of health insurance and outline some key issues related to leveraging insurance programs to include RH services. This primer explains what insurance is different types of insurance the challenges to developing viable insurance programs what is an insurable risk and how that relates to covering RH; it then describes several country examples. Thes...
The National Health Accounts (NHA) framework an internationally accepted tool that provides a com... more The National Health Accounts (NHA) framework an internationally accepted tool that provides a comprehensive estimate of national health expenditures has been adapted to enable “subanalyses” that can be used to capture data on specific diseases such as HIV/AIDS by breaking down expenditures on related individual services and disease areas. These guidelines describe the approach used by Partners for Health Reformplus to conduct an HIV/AIDS subanalysis within the context of a general NHA exercise in low- and middle-income countries. It discusses definitions and boundaries of HIV/AIDS expenditures suggests a NHA classification system adapted to HIV/AIDS describes the data collection process for capturing HIV/AIDS spending and addresses the specific issues of survey development to track for household spending on HIV/AIDS. Like the NHA methodology the subanalysis framework aims to offer an approach that provides both international comparability and national flexibility in tracking HIV/AID...
This study documents the Mexican experience in HIV/AIDS treatment in three different health subsy... more This study documents the Mexican experience in HIV/AIDS treatment in three different health subsystems—the Ministry of Health the Social Security Institutes and the National Institutes of Health. Ultimately the study will provide donors and policy makers the information necessary to guide planning and scaling up of comprehensive HIV/AIDS treatment. The study consisted of a multicenter retrospective patient chart review and the collection of complementary cost data to describe the utilization of services and to estimate costs of care for adult (18 years of age and above) HIV+ patients in the public sector who had at least one visit to a health facility between January 1 2000 and December 31 2001. Researchers found that since antiretroviral drugs are the greatest single component within treatment cost even a small reduction in drug costs would have a measurable impact on the overall cost of therapy. Other findings highlight several improvements that can be made in the quality of care ...
This paper presents a summary report on the program conducted by the Bolivian National Insurance ... more This paper presents a summary report on the program conducted by the Bolivian National Insurance for Mother and Children in improving the access to health services of the under-privileged population. The program begun its operation in mid-1996 aiming to reduce maternal and child mortality by increasing utilization of formal health services. In achieving this goal the program provides key maternal and child health interventions free of charge thereby eliminating what was viewed as an important economic barrier to access. It was implemented through the joint effort of the Ministry of Health facilities municipality government nongovernmental organizations and social security; a 20% of national revenue allocation on a per capita basis was given to municipalities as provision for the needs of the local population. The financing scheme under the program differs from the previous system since it relies heavily on the financial provision of the municipalities. Another source is the revenue ...
Contraceptive security exists when people are able to choose obtain and use high quality contrace... more Contraceptive security exists when people are able to choose obtain and use high quality contraceptives and condoms when they want them for family planning and prevention of HIV/AIDS and sexually transmitted infections. In many countries people rely on the free or subsidized supplies made available by governments and international donor agencies. However there is a growing financing gap as current levels of government resources and donor support are inadequate to meet increasing demand for contraceptives and condoms. There is concern that recent changes in the way that donors provide foreign aid will adversely affect funding levels for reproductive health commodities. These changes include the emergence of global funds movement away from targeted projects toward general budget support and a new emphasis on poverty reduction. This paper presents findings from a study to examine the impact that two of these new mechanisms in development assistance – sector-wide approaches or SWAps and...
National Health Accounts (NHA) is a tool designed to inform the health policy process. It aims to... more National Health Accounts (NHA) is a tool designed to inform the health policy process. It aims to do so by providing policymakers with valuable information on the distribution of health funds within the system. NHA was introduced and implemented in a number of middle - and low-income countries in the mid- to late 1990s. As sufficient time has passed for NHA findings to penetrate the policy processes in these countries this study sets out to determine if NHA has actually met its principal goal of contributing to evidence-based policymaking. The paper examines the policy impact of NHA in 21 developing countries from the Latin America and the Caribbean region East and Southern Africa the Middle East and North Africa and the Asia Pacific region. The study describes how policymakers have used NHA and assesses the various factors and influences that determine the extent to which NHA impacts the policy process. It is hoped that lessons learned from this study can help other countries as th...
Health affairs (Project Hope), 2015
Two commonly used metrics for assessing progress toward universal health coverage involve assessi... more Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens' rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already…
Third-party content-The World Bank does not necessarily own each component of the content contain... more Third-party content-The World Bank does not necessarily own each component of the content contained within the work. The World Bank therefore does not warrant that the use of any third-party-owned individual component or part contained in the work will not infringe on the rights of those third parties. The risk of claims resulting from such infringement rests solely with you. If you wish to re-use a component of the work, it is your responsibility to determine whether permission is needed for that re-use and to obtain permission from the copyright owner. Examples of components can include, but are not limited to, tables, figures, or images.
The Lancet, 2015
Starting in the late 1980s, many Latin American countries began social sector reforms to alleviat... more Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide fi nancial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government fi nancing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens-with defi ned and enlarged benefi ts packages-and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-fi nanced universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.
Salud Pública de México, 2008
Objective. To determine the net effect of introducing highly active antiretroviral treatment (HAA... more Objective. To determine the net effect of introducing highly active antiretroviral treatment (HAART) in Mexico on total annual per-patient costs for HIV/AIDS care, taking into account potential savings from treatment of opportunistic infections and hospitalizations. Material and Methods. A multi-center, retrospective patient chart review and collection of unit cost data were performed to describe the utilization of services and estimate costs of care for 1 003 adult HIV+ patients in the public sector. Results. HAART is not costsaving and the average annual cost per patient increases after initiation of HAART due to antiretrovirals, accounting for 90% of total costs. Hospitalizations do decrease post-HAART, but not enough to offset the increased cost. Conclusions. Scaling up access to HAART is feasible in middle income settings. Since antiretrovirals are so costly, optimizing efficiency in procurement and prescribing is paramount. The observed adherence was low, suggesting that a proportion of these high drug costs translated into limited health benefits.
Health Affairs, 2012
Donor nations and philanthropic organizations increasingly require that funds provided for a spec... more Donor nations and philanthropic organizations increasingly require that funds provided for a specific health priority such as HIV should supplement domestic spending on that priority-a concept known as "additionality." We investigated the "additionality" concept using data from Honduras, Rwanda, and Thailand, and we found that the three countries increased funding for HIV in response to increased donor funding. In contrast, the study revealed that donors, faced with increased Global Fund resources for HIV in certain countries, tended to decrease their funding for HIV or shift funds for use in non-HIV health areas. More broadly, we found many problems in the measurement and interpretation of additionality. These findings suggest that it would be preferable for donors and countries to agree on how best to use available domestic and external funds to improve population health, and to develop better means of tracking outcomes, than to try to develop more sophisticated methods to track additionality.
MEDICC review
A fi nes de la década de 1980, muchos países de América Latina comenzaron reformas en el sector s... more A fi nes de la década de 1980, muchos países de América Latina comenzaron reformas en el sector social para aliviar la pobreza, reducir las desigualdades socioeconómicas, mejorar los resultados de salud, y proporcionar protección ante el riesgo fi nanciero. Particularmente, a partir de la década de 1990, las reformas encaminadas a fortalecer los sistemas de salud para reducir las desigualdades en el acceso a la salud y en los resultados, se centraron en la expansión de la cobertura universal de salud, especialmente para los ciudadanos pobres. En América Latina, las reformas del sistema de salud han creado un acercamiento distinto a la cobertura universal de salud, apoyado en los principios de equidad, solidaridad y acción colectiva para superar las desigualdades sociales. En la mayoría de los países estudiados, el fi nanciamiento del gobierno permitió la introducción de intervenciones relacionadas con la oferta para ampliar la cobertura de seguro para los ciudadanos no asegurados —c...
The International Journal of Health Planning and Management, 2012
This paper illustrates the importance of collecting facility-based data through regular surveys t... more This paper illustrates the importance of collecting facility-based data through regular surveys to supplement the administrative data, especially for developing countries of the world. In Bangladesh, measures based on facility survey indicate that only 70% of very basic medical instruments and 35% of essential drugs were available in health facilities. Less than 2% of officially designated obstetric care facilities actually had required drugs, injections and personnel on-site. Majority of (80%) referral hospitals at the district level were not ready to provide comprehensive emergency obstetric care. Even though the Management Information System reports availability of diagnostic machines in all district-level and sub-district-level facilities, it fails to indicate that 50% of these machines are not functional. In terms of human resources, both physicians and nurses are in short supply at all levels of the healthcare system. The physician-nurse ratio also remains lower than the desirable level of 3.0. Overall job satisfaction index was less than 50 for physicians and 66 for nurses. Patient satisfaction score, however, was high (86) despite the fact that process indicators of service quality were poor. Facility surveys can help strengthen not only the management decision-making process but also the quality of administrative data.
An effective fight against HIV/AIDS necessitates a comprehensive understanding of existing financ... more An effective fight against HIV/AIDS necessitates a comprehensive understanding of existing financing of national HIV/AIDS services (including public private and donor components). Yet many countries most affected by the epidemic lack data which increases the risk of inappropriate allocation of funds and suspension of donor funding. National Health Accounts (NHA) is a policy tool for tracking national spending on health care. The NHA HIV/AIDS subaccounts framework allows for more detailed examinations of spending on HIV/AIDS which can inform national HIV/AIDS strategic plans and then measure progress toward planned goals. With the NHA tool rapidly becoming institutionalized in many countries that also receive major international HIV/AIDS grants the subaccount framework can be used for the financial monitoring that these grants require. This paper reports on subaccount findings for 2002 from Kenya Rwanda and Zambia all of which face generalized HIV/AIDS epidemics. Estimates show that ...
The 131st Annual …, 2003
This study examines the national HIV/AIDS treatment program in three health sub-systems in Mexico... more This study examines the national HIV/AIDS treatment program in three health sub-systems in Mexico and estimates total costs of providing ARV treatment (previous studies have focused on drug costs). Primary data on resources utilization was obtained from medical records ...
This paper illustrates the importance of collecting facility-based data through regular surveys t... more This paper illustrates the importance of collecting facility-based data through regular surveys to supplement the administrative data, especially for developing countries of the world. In Bangladesh, measures based on facility survey indicate that only 70% of very basic medical instruments and 35% of essential drugs were available in health facilities. Less than 2% of officially designated obstetric care facilities actually had required drugs, injections and personnel on-site. Majority of (80%) referral hospitals at the district level were not ready to provide comprehensive emergency obstetric care. Even though the Management Information System reports availability of diagnostic machines in all district-level and sub-district-level facilities, it fails to indicate that 50% of these machines are not functional. In terms of human resources, both physicians and nurses are in short supply at all levels of the healthcare system. The physician–nurse ratio also remains lower than the desirable level of 3.0. Overall job satisfaction index was less than 50 for physicians and 66 for nurses. Patient satisfaction score, however, was high (86) despite the fact that process indicators of service quality were poor. Facility surveys can help strengthen not only the management decision-making process but also the quality of administrative data.
A fines de la década de 1980, muchos países de América Latina comenzaron reformas en el sector so... more A fines de la década de 1980, muchos países de América Latina comenzaron reformas en el sector social para aliviar la pobreza, reducir las desigualdades socioeconómicas, mejorar los resultados de salud, y proporcionar protección ante el riesgo financiero. Particularmente, a partir de la década de 1990, las reformas encaminadas a fortalecer los sistemas de salud para reducir las desigualdades en el acceso a la salud y en los resultados, se centraron en la expansión de la cobertura universal de salud, especialmente para los ciudadanos pobres. En América Latina, las reformas del sistema de salud han creado un acercamiento distinto a la cobertura universal de salud, apoyado en los principios de equidad, solidaridad y acción colectiva para superar las desigualdades sociales. En la mayoría de los países estudiados, el financiamiento del gobierno permitió la introducción de intervenciones relacionadas con la oferta para ampliar la cobertura de seguro para los ciudadanos no asegurados —con paquetes de beneficios defi nidos y expandidos— y para ampliar la prestación de los servicios de salud. Países como Brasil y Cuba introdujeron sistemas universales de salud financiados mediante impuestos. Estos cambios fueron combinados con intervenciones de demanda dirigidas a mitigar la pobreza (focalizando muchos determinantes sociales de salud) y mejorando el acceso de las poblaciones más desfavorecidas. Por lo tanto, las características distintivas de los sistemas de salud para el fortalecimiento de la cobertura universal de salud y las lecciones de la experiencia latinoamericana son relevantes para los países que avanzan hacia la cobertura universal de salud.
Starting in the late 1980s, many Latin American countries began social sector reforms to alleviat... more Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide fi nancial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government fi nancing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens—with defi ned and enlarged benefi ts packages—and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-fi nanced universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.
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Papers by T. Dmytraczenko
In Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Select Countries, the authors show that evidence from an analysis of 54 household surveys corroborates that investments in extending coverage are yielding results. Although the poor still have worse health outcomes than do the rich, disparities have narrowed considerably—particularly in the early stages of life. Countries have reached high levels of coverage and equity in utilization of maternal and child health services. The picture is more nuanced, and not nearly as positive, regarding adult health status and prevalence of chronic conditions and illnesses. Coverage of noncommunicable disease interventions is not as high, and service utilization is still skewed toward those who are better off. Prevalence of noncommunicable diseases has not behaved as expected given the drop in mortality; better access to diagnosis among wealthier individuals may be masking changes in actual prevalence.
Catastrophic health expenditures have declined in most countries. The picture regarding equity, however, is mixed, pointing to limitations in the measure. Although the rate of impoverishment owing to health expenditures is low and generally declining, 2–4 million people in the countries studied still fall below the poverty line after health spending.
Efforts to systematically monitor quality of care in the region are still in their infancy. Nonetheless, a review of the literature reveals important shortcomings in quality of care, as well as substantial differences across subsystems. Improving quality of care and ensuring sustainability of investments in health remain an unfinished agenda.