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Assessing causal linkages to identify factors affecting Universal Health Coverage outcomes using qualitative comparative analysis

dc.contributor.advisorDe Kock, Imkeen_ZA
dc.contributor.advisorBam, Louzanneen_ZA
dc.contributor.authorDzapasi, Broadway Mazwien_ZA
dc.contributor.otherStellenbosch University. Faculty of Engineering. Dept. of Industrial Engineering.en_ZA
dc.date.accessioned2019-02-14T22:47:59Z
dc.date.accessioned2019-04-17T08:33:40Z
dc.date.available2019-02-14T22:47:59Z
dc.date.available2019-04-17T08:33:40Z
dc.date.issued2019-04
dc.identifier.urihttp://hdl.handle.net/10019.1/106192
dc.descriptionThesis (MEng)--Stellenbosch University, 2019.en_ZA
dc.description.abstractENGLISH 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.en_ZA
dc.description.abstractAFRIKAANSE OPSOMMING: ‘Universal Health Coverage’ (UHC) is een van die Volhoubare Ontwikkelingsdoelwitte (Sustainable Development Goals (SDGs)). UHC maak deel uit van die doelwitte met betrekking tot bevolkingsgesondheid en welsyn onder SDG 3. Hierdie wêreldwye oproep vir UHC het gelei tot 'n aantal lande wat die inisiatief geneem het om ‘n oorgang na UHC op te neem. Gesondheidsfinansiering speel 'n belangrike rol om die verwesenliking van UHC-doelwitte te verseker. Dit vereis robuuste evalueringsinstrumente om die opsies vir gesondheidsfinansieringsbeleide wat lande ontwikkel, in te lig. Om te verseker dat lande doeltreffende gesondheidsfinansieringsbeleid implementeer, moet die oorsaaklike verband tussen die faktore wat die UHC-finansieringslandskap vorm verstaan word. So 'n begrip stel lande in staat om doeltreffende intervensies te ontwikkel en te beplan wat daarop gemik is om UHC te bereik. UHC, as 'n ingryping vir bestaande gesondheidstelsels, weerspiël die komplekse eienskappe van die gesondheidstelsel. As 'n aanvullende ingryping vir gesondheidstelsels word die UHC ook geraak deur kontekstuele faktore buite die jurisdiksie van die gesondheidstelsel. Dit impliseer dat daar ook 'n behoefte is om die interaksiete van gesondheidsfinansieringsreëlings met die breër konteks waarbinne die gesondheidstelsel funksioneer, te verstaan. Hierdie gesondheidsfinansieringsreëlings wat oorweeg moet word, is: (i) inkomsteverhoging; (ii) ‘pooling’; (iii) aankope; en (iv) voordele-ontwerp. Die doel van hierdie navorsing was dus om oorsaaklike roetes in die UHC finansieringslandskap te identifiseer, asook hul verhoudings met spesifieke UHC-doelwitte. Dit impliseer begrip van die oorsaaklike verwantskappe tussen faktore wat die UHC-landskap vorm. Ten einde die vereiste spesifikasies te formuleer vir die keuse van 'n metode om oorsaaklikheid te assesseer om UHC-finansiering te informeer, is 'n literatuuroorsig uitgevoer om: (i) die dimensies wat in die UHC ingebed is, te identifiseer; en (ii) om die sleutel kontekstuelefaktore wat UHC beïnvloed, te identifiseer, wat gevolglik lei tot die identifisering van die sleutel eienskappe wat UHC beïnvloed. Dit het gelei tot die vier dimensies wat UHC definieer, naamlik: (i) die reg op gesondheidsorg; (ii) toegang tot gesondheidsorg; (iii) universele dekking; en (iv) finansiële beskerming. Die sleutel kontekstuelefaktore wat geïdentifiseer was, is: (i) bestuur; (ii) fiskale konteks; (iii) onderwys; (iv) indiensneming; (v) ongelykheid; en (vi) armoede. Vanuit verdere literatuuranalise is daar bevind dat UHC die kompleksiteite wat in gesondheidstelsels voorkom vertoon as gevolg van die feit dat UHC 'n ingryping is vir bestaande gesondheidstelsels. Hierdie karakterisering het gelei tot die ontwikkeling van 'n lys vereistes wat die metode van oorsaaklikheidsevaluering in die UHC-finansieringslandskap moet nakom. 'n Literatuur- en daaropvolgende vergelykendeanalise van komplekse oorsaaklikheidsmetodes het gelei tot ‘Qualitative Comparative Analysis’ (QCA) - meer spesifiek die ‘crisp set’ QCA-variant (csQCA), 'n gemengde-metode benadering, wat as 'n geskikte metode beskou word om oorsaaklike verband tussen faktore wat UHC finansiering beïnvloed te bepaal. QCA is beide 'n navorsingsbenadering en 'n analitiesemetode. Die navorsingsbenadering perspektief van QCA behels die identifisering van die oorsaaklike toestande (inset veranderlikes), uitkomste (uitset veranderlikes) en tellings gebaseer op die prestasie van elk van die voorwaardes en uitkomste. Drie uitsetveranderlikes is oorweeg, naamlik: (i) gesondheidsdiens dekking; (ii) gehalte van sorg; en (iv) finansiële beskerming. Die inset veranderlikes sluit in: (i) gesondheidsfinansieringsreëlings (d.w.s. inkomsteverhoging, ‘pooling’ en aankope); en (ii) sleutel kontekstuelefaktore (d.w.s. fiskale ruimte, onderwys, indiensneming en ongelykheid). Vir elke veranderlike is 'n verdere literatuursoektog uitgevoer om aanwysers vir metings vir elk van die geïdentifiseerde veranderlikes te identifiseer. Daar is 17 gevalle vir hierdie studie gekies, gevolg deur data-insameling vir elke geval. Saamgestelde indekse vir elk van die veranderlikes is dan deur middel van normalisasie- en aggregeringstegnieke geskep. Data vir elke veranderlike is dan gekalibreer en 'n tellingskriterium is in lyn met die csQCA-variant bepaal. Die analitiesemetode perspektief van QCA behels die identifisering van die nodige en voldoende toestande, sowel as die verskillende oorsaaklike roetes om UHC-uitkomstes te bereik. Die resultate het getoon dat geen enkele toestand nodig is, of voldoende is, om elk van die uitkomste te bereik nie. Uitkomstes word egter bereik deur kombinasies van toestande. Sentraal by hierdie kombinasies is die beskikbaarheid van voorafbetaalde inkomste en die bestuur daarvan. Bedoelede dat, verhoudings tussen gesondheidsfinansieringsreëlings en kontekstuele faktore wat inkomstebronne waarborg, is die sleutel tot die bereiking van UHC-doelwitte. Die resultate dui daarop dat dit nie voldoende is vir lande om slegs te fokus op beleide wat die gesondheidstelsel in isolasie van die breër konteks van die land beskou nie. Lande moet eerder die politieke kwessies aanspreek wat ontstaan as gevolg van die komplekse aard van die gesondheidstelsel en die afhanklikheid daarvan van die konteks van die land. Fiskale ruimte en 'n gebrek aan ongelykheid, tesame met die gesondheidsfinansieringsreëlings, is 'n integrale deel van die dekking van gesondheidsdienste. Dit toon dat die bestaan van voorafbetaalde gesondheidsinkomste en die teenwoordigheid van inkomstebronne belangrike faktore is vir die dekking van gesondheidsdienste. Ontleding van oorsaaklike roetes vir die behaling van gehalte van sorg het getoon dat indiensneming 'n belangrike oorweging is in die poging om die gehalte van sorg te verbeter. Ten slotte, om finansiële beskerming te bewerkstellig, moet lande hul inkomstebasis versterk, wat beteken dat die inkomstebronne en die invordering en bestuur van inkomste deur middel van effektiewe ‘pooling’- en aankooppraktyke verbeter kan word.af_ZA
dc.format.extentxx, 221 pagesen_ZA
dc.language.isoen_ZAen_ZA
dc.publisherStellenbosch : Stellenbosch Universityen_ZA
dc.subjectUniversal Health Coverage -- Managementen_ZA
dc.subjectHealth services -- Financeen_ZA
dc.subjectCausationen_ZA
dc.subjectQualitative comparative analysisen_ZA
dc.subjectSustainable developmenten_ZA
dc.subjectQualitative researchen_ZA
dc.subjectUCTD
dc.titleAssessing causal linkages to identify factors affecting Universal Health Coverage outcomes using qualitative comparative analysisen_ZA
dc.typeThesisen_ZA
dc.rights.holderStellenbosch Universityen_ZA


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