Browsing by Author "Dzapasi, Broadway Mazwi"

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    Assessing causal linkages to identify factors affecting Universal Health Coverage outcomes using qualitative comparative analysis
    (Stellenbosch : Stellenbosch University, 2019-04) Dzapasi, Broadway Mazwi; De Kock, Imke; Bam, Louzanne; Stellenbosch University. Faculty of Engineering. Dept. of Industrial Engineering.
    ENGLISH ABSTRACT: Universal Health Coverage (UHC) is one of the Sustainable Development Goals (SDGs). UHC forms part of the targets concerned with population health and well-being under SDG 3. This global call for UHC has led to a number of countries taking the initiative to transition towards UHC. Health financing plays an important role in ensuring the realisation of UHC goals. This calls for robust evaluation tools to inform the health financing policy options that countries embark on. In order for countries to implement effective health financing policies, there is need to understand the causal relationships between the factors that shape the UHC financing landscape. Such an understanding enables countries to develop and plan effective interventions aimed at achieving UHC. UHC, as an intervention to existing health systems, exhibits the complex properties of the health system. As a complementary intervention to health systems, UHC is also affected by contextual factors outside the jurisdiction of the health system. This implies that there is a need to also understand how health financing arrangements interact with the broader context within which the health system operates. These health financing arrangements that have to be considered are: (i) revenue raising; (ii) pooling; (iii) purchasing; and (iv) benefits design. The aim of this research was thus to identify causal pathways in the UHC financing landscape and their relationships with specific UHC goals This implies an understanding of the causal relationships between factors that shape the UHC landscape. In order to formulate the requirement specifications for selecting a method to assess causality to inform UHC financing, a literature review was conducted to: (i) identify the dimensions embedded in UHC; and (ii) to identify the key contextual factors affecting UHC, leading to the identification of the key properties that influnce UHC. This resulted in the four dimensions that define UHC, namely: (i) the right to healthcare; (ii) access to healthcare; (iii) universal coverage; and (iv) financial protection. The key contextual factors identified were: (i) governance; (ii) fiscal context; (iii) education; (iv) employment; (v) inequality; and (vi) poverty. From further literature analysis it was concluded that UHC exhibits the complexities found in health systems due to the fact that UHC is an intervention to existing health systems. This characterisation led to the development of a list of requirements that the method of causality assessment in the UHC financing landscape must adhere to. A literature, and subsequent comparative analysis, of complex causality methods resulted in Qualitative Comparative Analysis (QCA) - more specifically the crisp-set QCA variant (csQCA), a mixed-method approach - being deemed an appropriate method to assess causal linkages between factors that influence UHC financing. QCA is both a research approach and an analytical method. The research approach perspective of QCA involves the identification of the causal conditions (input variables), outcomes (output variables) and scoring based on the performance of each of the conditions and outcomes. Three output variables were considered, namely: (i) health service coverage; (ii) quality of care; and (iv) financial protection. The input variables included: (i) health financing arrangements (i.e. revenue raising, pooling, and purchasing); and (ii) key contextual factors (i.e. fiscal space, education, employment, and inequality). For each variable, a subsequent literature search was conducted to identify indicators for measurement(s) for each of the identified variables. 17 cases were selected for this study, followed by data collection for each case. Composite indices for each of the variables were then created, by means of normalisation and aggregation techniques. Data for each variable was then calibrated and a scoring criterion was established in line with the csQCA variant. The analytical approach perspective of QCA involves the identification of necessary and sufficient conditions as well as the different causal pathways to achieving UHC outcomes. The results showed that no single condition was necessary nor sufficient to achieving each of the outcomes. However, outcomes are achieved by combinations of conditions. Central to these combinations are the availability of prepaid revenues and the management thereof. Meaning that relationships between health financing arrangements and contextual factors that guarantee sources of revenue are key to achieving UHC goals. The results suggest that it is not sufficient for countries to only focus on policies that view the health system in isolation of the broader context of the country. Rather, countries should address the politics that arise due to the complex nature of the health system and its dependence on the context of the country. Fiscal space and a lack of inequality along with the health financing arrangements are integral to achieving health service coverage. This shows that the existence of prepaid health revenues and the presence of sources of revenue are key factors to achieving health service coverage. Analysis of causal pathways to achieving quality of care showed that employment is a key consideration when attempting to improve the quality of care. Finally, to achieve financial protection, countries need to strengthen their revenue base, meaning that enhancing the sources of revenue and the collection and the management of the revenues, through effective pooling and purchasing practices.