Trends and projections of universal health coverage indicators in Iraq, 2000-2030: A national and subnational study.
Iraq has had limited access to healthcare services due to successive conflicts and political turmoil. Since 2018, Iraq has embarked on a new reconstruction process which includes a goal of 100% immunisation against certain diseases in 2030. We aimed to undertake a comprehensive assessment of Iraq's progress towards universal health coverage (UHC) targets that could contribute to Iraq's policy and strategies.
We estimated the coverage of UHC indicators from six nationally representative population-based household surveys in Iraq during 2000-2018. We employed 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. We used a Bayesian hierarchical regression model to estimate the trend and projection of health service indicators.
Improved water sources, adequate sanitation, institutional delivery, skilled birth attendants, and BCG reached the 80% targets in 2018, and are projected to maintain their status in 2030 at national and subnational levels. Family planning needs satisfied, acute respiratory infection treatment for pneumonia, and oral rehydration therapy will be much less than 80% in 2030. 12% of Iraqi households incurred catastrophic health expenditures in 2012, which was a fourfold increase from 2007. Some governorates faced ten- to twentyfold increases in catastrophic health expenditures, for example, from 0.8% to 15.9% in Diala. Approximately 3% of non-poor households became poor due to out-of-pocket (OOP) payments in 2012.
Without proactive strengthening of the healthcare systems, achieving UHC in Iraq by 2030 would be a challenge. Worsened trends were observed in both conflict-affected and underdeveloped areas in health service coverage and financial risk protection. Recovery of GDP spending on health and pre-pooled financing mechanisms should be introduced for OOP payment reduction. Prioritising nationwide primary healthcare services and regulating public-private role-allotment in the health sector are crucial in improving low coverage indicators and decreasing disparities among governorates.
Taniguchi H
，Rahman MM
，Swe KT
，Hussain A
，Shibuya K
，Hashizume M
... -
《-》
Equity and determinants in universal health coverage indicators in Iraq, 2000-2030: a national and subnational study.
Equity is one of three dimensions of universal health coverage (UHC). However, Iraq has had capital-focused health services and successive conflicts and political turmoil have hampered health services around the country. Iraq has embarked on a new reconstruction process since 2018 and it could be time to aim for equitable healthcare access to realise UHC. We aimed to examine inequality and determinants associated with Iraq's progress towards UHC targets.
We assessed the progress toward UHC in the context of equity using six nationally representative population-based household surveys in Iraq in 2000-2018. We included 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. Bayesian hierarchical regression model was used to estimate the trend, projection, and determinant analyses. Slope and relative index of inequality were used to assess wealth-based inequality.
In the national-level health service indicators, inequality indices decreased substantially from 2000 to 2030. However, the wide inequalities are projected to remain in DTP3, measles, full immunisations, and antenatal care in 2030. The pro-rich inequality gap in catastrophic health expenditure increased significantly in all governorates except Sulaimaniya from 2007 to 2012. The higher increases in pro-rich inequality were found in Missan, Karbala, Erbil, and Diala. Mothers' higher education and more antenatal care visits were possible factors for increased coverage of health service indicators. The higher number of children and elderly population in the households were potential risk factors for an increased risk of catastrophic and impoverishing health payment in Iraq.
To reduce inequality in Iraq, urgent health-system reform is needed, with consideration for vulnerable households having female-heads, less educated mothers, and more children and/or elderly people. Considering varying inequity between and within governorates in Iraq, reconstruction of primary healthcare across the country and cross-sectoral targeted interventions for women should be prioritised.
Taniguchi H
，Rahman MM
，Swe KT
，Islam MR
，Rahman MS
，Parsell N
，Hussain A
，Shibuya K
，Hashizume M
... -
《International Journal for Equity in Health》
Trends in, and projections of, indicators of universal health coverage in Bangladesh, 1995-2030: a Bayesian analysis of population-based household data.
Many countries are implementing health system reforms to achieve universal health coverage (UHC) by 2030. To understand the progress towards UHC in Bangladesh, we estimated trends in indicators of the health service and of financial risk protection. We also estimated the probability of Bangladesh's achieving of UHC targets of 80% essential health-service coverage and 100% financial risk protection by 2030.
We estimated the coverage of UHC indicators-13 prevention indicators and four treatment indicators-from 19 nationally representative population-based household surveys done in Bangladesh from Jan 1, 1991, to Dec 31, 2014. We used a Bayesian regression model to estimate the trend and to predict the coverage of UHC indicators along with the probabilities of achieving UHC targets of 80% coverage of health services and 100% coverage of financial risk protection from catastrophic and impoverishing health payments by 2030. We used the concentration index and relative index of inequality to assess wealth-based inequality in UHC indicators.
If the current trends remain unchanged, we estimated that coverage of childhood vaccinations, improved water, oral rehydration treatment, satisfaction with family planning, and non-use of tobacco will achieve the 80% target by 2030. However, coverage of four antenatal care visits, facility-based delivery, skilled birth attendance, postnatal checkups, care seeking for pneumonia, exclusive breastfeeding, non-overweight, and adequate sanitation were not projected to achieve the target. Quintile-specific projections showed wide wealth-based inequality in access to antenatal care, postnatal care, delivery care, adequate sanitation, and care seeking for pneumonia, and this inequality was projected to continue for all indicators. The incidence of catastrophic health expenditure and impoverishment were projected to increase from 17% and 4%, respectively, in 2015, to 20% and 9%, respectively, by 2030. Inequality analysis suggested that wealthiest households would disproportionately face more financial catastrophe than the most disadvantaged households.
Despite progress, Bangladesh will not achieve the 2030 UHC targets unless the country scales up interventions related to maternal and child health services, and reforms health financing systems to avoid high dependency on out-of-pocket payments. The introduction of a national health insurance system, increased public funding for health care, and expansion of community-based clinics in rural areas could help to move the country towards UHC.
Japan Ministry of Health, Labour, and Welfare.
Rahman MS
，Rahman MM
，Gilmour S
，Swe KT
，Krull Abe S
，Shibuya K
... -
《Lancet Global Health》
Progress and scenario-based projections of health service availability and coverage towards UHC in the post-conflict and post-pandemic Iraq: a Bayesian hierarchical regression approach.
Two decades have passed since the beginning of the Iraq War in 2003. Iraq has long suffered from conflicts and instability, where the people have limited access to healthcare. The coronavirus disease (COVID-19) pandemic brought additional disruption to health service provision.
At the midpoint towards universal health coverage (UHC) in 2030, this study aims to gain a better understanding of the trends of UHC progress in Iraq in the context of the conflicts and the COVID-19 pandemic and to indicate possible pragmatic options.
This study employed Bayesian hierarchical regression models to estimate trends and projections of health service availability and coverage indicators up to 2030. Furthermore, for health service coverage, four scenarios were defined based on the availability of health services, and projections were made for each scenario up to 2030.
Our approach used the yearly data from the Ministry of Health and four nationally representative household surveys between 2000 and 2020. We evaluated the subnational-level progress in three health service availability indicators and 13 health service coverage indicators in 18 governorates in Iraq from 2000 to 2030.
The findings from 2000 to 2020 revealed a lack of progress in the indicators of health facility and inpatient bed, and pronounced detrimental effects from major conflicts and the pandemic on all measured health service coverage indicators. Despite these setbacks, several health service coverage indicators demonstrated resilience and elasticity in their recovery. The projected trends for 2021 to 2030 indicated limited alternations in the health service availability. By 2030, five health service coverage indicators will achieve the designated 80% targets. A scenario-based analysis predicts improved coverage of antenatal care, and child immunisation and treatment if health service availability is bolstered to globally recommended standards. Under this scenario, several governorates-Anbar, Baghdad, Nainawa, Qadissiyah, Salahaddin, Thiqar and Wasit-presented improved health service coverage in more indicators.
Strengthened health service availability has the potential to significantly improve fragile health service coverage indicators and in more vulnerable governorates.
Taniguchi H
，Rahman MM
，Hussain A
，Nomura S
，Devanathan G
，Hashizume M
... -
《BMJ Open》
ResearchGate
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