India drew on its participation in the JLN’s Medical Audits Collaborative and adaptation of the Medical Audit Toolkit to implement a medical audit system that could be decentralized and scaled by India’s states to review claims, identify fraud, and ensure the quality of health services being provided to patients.
Mongolia’s use of the Empanelment Assessment Tool enabled a shift to a person-centered approach for PHC. Linking empanelment to a mobile technology initiative providing team-based PHC home visits has contributed to a national empanelment approach and shifts in health care seeking behavior. This case study profiles the use of the Empanelment Assessment Tool in Mongolia. Mongolia decided to implement person-centered integrated care (PCIC) best practices to improve health services and outcomes among underserved populations who faced geographic barriers to PHC because they live in extremely remote and rural provinces. They did this by building PCIC best practices into another project they were scaling up at the same time, a mobile health pilot project focused on home visits. Mongolia integrated two pillars of PCIC into the mobile health project: a multi-disciplinary approach to the home care visits and the rostering of all co-habitants. These new approaches, after participating in the JLN’s PCIC collaborative, helped the Mongolian Ministry of Health connect more members of nomadic or geographically dispersed populations to PHC providers, an important step toward universal health coverage.
Malaysia’s use of the Toolkit to Develop and Strengthen Medical Audit Systems shaped the operations for a new Medical Audit Section responsible for auditing PeKa B40 claims. The SOPs for the unit support identifying and deterring fraud and review of provider perfomance resulting in improved quality of health care screenings. This case study profiles the use of the Toolkit to Develop and Strengthen Medical Audit Systems in Malaysia. In 2019, the Malaysian Ministry of Health (MOH) launched the PeKa B40 scheme, a program designed to increase screening uptake for non-communicable diseases (NCDs) among Malaysians in the lower-income group; specifically the bottom 40% of the population by income level. Through PeKa B40 program, MOH was exposed for the first time to the claims processing. Claims processing in Malaysia was traditionally done by insurance companies in the private sector, but through ProtectHealth, the Ministry is responsible for PeKa B40 claims from both the public and private facilities. This is an opportunity to make the PeKa B40 claims process transparent and accountable. In April 2019, the Ministry established a Medical Audit Section within ProtectHealth to process and audit PeKa B40 claims. The team used the Toolkit to Develop and Strengthen Medical Audit Systems to design the systems for this new unit.
Malaysia’s use of the JLN UHC PHC Self-Assessment produced findings that were used to improve public private partnerships to increase PHC coverage. This case study profiles the use of the Universal Health Coverage Primary Health Care Self-Assessment Tool in Malaysia. Malaysia piloted this self-assessment tool as a cross-sectional study collecting both qualitative and quantitative data through in-person interviews and a written self-reported questionnaire. Through the findings, the team was able to assess how financial coverage institutions interact with other PHC actors and programs and identify opportunities to align health financing with PHC goals in Malaysia.
The tool, referred to as the “UHC-PHC Self-Assessment Tool,” is a multi-stakeholder survey that helps accomplish the following: Document and assess how health insurance or financial coverage institutions interact with other PHC actors and programs; Identify key areas of improvement and opportunities to align the health financing agency (HFA) or other health financing policymakers with PHC goals. The UHC-PHC Self-Assessment Tool is a rapid diagnostic instrument for identifying practical policy opportunities in the health system to improve the relationship between health financing and PHC efforts. The tool can be useful for improving coordination among health financing and PHC efforts in countries around the world. It is most suitable for locations in which (a) the government is not sufficiently prioritizing PHC efforts, (b) PHC efforts work poorly or are not coordinated with health financing mechanisms, and, especially, (c) communication among the relevant stakeholders is limited. The tool does not provide a complete evaluation or mapping of PHC or UHC in the country. It focuses strongly on UHC, not the entire PHC system, so it looks closely at the role and function of the HFA, which can be crucial to improving UHC-PHC alignment.