Which conditions treated by neurosurgeons cause the worst economic hardship in low middle-income in countries? How can public health financing be responsive to the inequities in the delivery of neurosurgical care? This review article frames the objectives of equity, quality, and efficiency in health financing to the goals of global neurosurgery. In order to glean provider perspectives on the affordability of neurosurgical care in low-resource settings, we did a survey of neurosurgeons from Indonesia and the Philippines and identified that the care of socioeconomically disadvantaged patients with malignant intracranial tumors were found to incur the highest out-of-pocket expenses. Additionally, the surveyed neurosurgeons also observed that treatment of traumatic brain injury may have to require greater financial subsidies. It is therefore imperative to frame health financing alongside the goals of equity, efficiency, and quality of neurosurgical care for the impoverished. Using principles and perspectives from managerial economics and public health, we conceptualize an implementation framework that addresses both the supply and demand sides of healthcare provision as applied to neurosurgery. For the supply side, strategic purchasing enables a systematic and contractual management of payment arrangements that provide performance-based economic incentives for providers. For the demand side, conditional cash transfers similarly leverages on financial incentives on the part of patients to reward certain health-seeking behaviors that significantly influence clinical outcomes. These health financing strategies are formulated in order to ultimately build neurosurgical capacity in LMICs, improve access to care for patients, and ensure financial risk protection.

OBJECTIVEIn the Philippines during recent months, a neurosurgical center that caters primarily to socioeconomically disadvantaged patients has encountered unprecedented changes in practice patterns brought about by the COVID-19 pandemic. In particular, the usual task of outpatient care has shifted to the telemedicine format, bringing along all of its attendant advantages and gargantuan challenges. The authors sought to determine the responsiveness of this telemedicine setup to the needs of their disadvantaged patients and explored the application of Bayesian inference to enhance the use of teleconsultation in daily clinical decision-making.METHODSThe authors used the following methods to assess the telemedicine setup used in a low-resource setting during the pandemic: 1) a cross-sectional survey of patients who participated in a medical consultation via telemedicine during the 16-week period from March 16, 2020, to July 15, 2020; 2) a cost-benefit analysis of the use of telemedicine by patients; and 3) a case illustration of a Bayesian approach application unique to the teleconsultation scenario.RESULTSOf the 272 patient beneficiaries of telemedicine in a 16-week period, 57 responded to the survey. The survey responses regarding neurosurgical outpatient care through telemedicine yielded high ratings of utility for the patients and their caregivers. According to 64% of respondents, the affordability of the telemedicine setup also prevented them from borrowing money from others, among other adverse life events prevented. There were realized financial gains on the part of the patients in terms of cost savings and protection from further impoverishment. The benefit-cost ratio was 3.51 for the patients, signifying that the benefits outweighed the costs. An actual teleconsultation case vignette was reported that is meant to be instructive and contributory to the preparedness of the neurosurgeon on the provider end of the service delivery.CONCLUSIONSTelemedicine holds promise as a viable and safe method for health service delivery during the pandemic. In the setting of a health system that is continually challenged by shortages of resources, this study shows that an effective telemedicine setup can come with high benefit-cost ratios and quality of care, along with the assurance of patient satisfaction. The potential for high-quality care can be enhanced by the inclusion of the Bayesian framework to the basic toolkit of remote clinical assessment. When confronted with choices in terms of differential diagnosis and tests, the rigor of a simple application of the Bayesian framework can minimize costs arising from uncertainties.

No abstract

In strengthening eHealth in the Philippines to support the universal health care (UHC) law, the scaling up and full adoption of electronic medical record (EMR) systems was strategically scheduled and supposedly completed in 2020. The Covid-19 pandemic, however, delayed these strengthening efforts. We wanted to assess the status of EMR adoption in primary clinics of rural health units (RHUs) and understand the frequency of use, particularly during the pandemic. Through analyses of EMR usage logs from selected RHUs in 2020, we estimated frequency of EMR usage based on duration of use and tested if this was influenced by the performing RHU and pandemic event. We also determined the most frequent EMR activities through process maps and tested if there were differences in the conduct of these activities before and during the pandemic. Results showed that EMR use during work hours was significantly dependent on the performing RHU (p<0.001). High-performing RHUs used EMRs more than 3 hours/day while low-performing RHUs used the systems for less. The pandemic either significantly decreased or increased EMR use during work hours by around 5 hours/day in some RHUs (p<0.01). Process maps revealed that there were additional activities performed by RHUs during the pandemic. Except for Update Patient Profile and Add Patient EMR features, significant differences (p<0.01) were observed in accessing frequently used features before and during the pandemic. The results suggest some uneven level of utilization of EMRs at the primary care level which can impact readiness to support full implementation of the UHC law. The study shows the potential of using a more granular approach in studying adoption to help improve the quality of EMR use and contribute to improving health service delivery and financing.

The 2019 Philippine UHC Act provides one of the most recent examples of contractualization of health care. Despite the significant change it brings, it regulates contracting only marginally, so that the purpose and deployment of this mechanism remain largely unclear. This study examines how contracting under the new law can contribute to achieving the reform goals and, to this end, subjects the UHC Act and its Implementing Rules and Regulations to a socio-legal analysis. In the process, it becomes apparent that, contrary to the general trend, the law adheres to a decidedly hierarchical form of contracting, which is in a certain state of tension with the network-like organization it promotes and the use of contracting to realize development-oriented goals. To effectively implement the law's contracting concept, the authors suggest underpinning it with a more relational approach, a stronger management orientation of the executing entities, and the development of appropriate network governance concepts.