Study design, review questions and definitions
We propose a systematic review of literature and will report on how SDGs declaration has influenced health financing reforms for UHC. Systemic review has a lower risk of bias in information synthesis compared to other review approaches (30). This protocol has been registered on the PROSPERO database (ref: CRD42020194090). PROSPERO was searched to ensure a similar systematic review study protocol has not been registered.
For this review, health financing reforms for UHC is conceptualized to refer to changes in policy objectives, strategies, or in arrangement and management of health financing system sub-functions of revenue collection, pooling, purchasing, and benefits design and rationing towards efficient and equitable system (31). These reforms should have linkage or can be attributed to global discussion on sustainable development Agenda or SDGs declaration.
In line with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guideline (32), we have defined the review questions; we shall also identify, select and appraise the documents, abstract and synthesize data, and interpret the results. The review questions are: - a) How has SDGs declaration influenced the processes of health financing reform for UHC at national level? b) What dimensions of health financing system have been influenced by SDGs declaration? and c) How have Ministries of Health and other stakeholders used SDGs declaration so far to influence health financing reforms for UHC?
Criteria for considering studies for this review
All study designs will be considered for the review to account for the complex nature of health financing reforms. Specifically, we will include randomized and non-randomized studies, evaluation studies, policy analyses, stakeholder analyses, and peer-reviewed case studies and commentaries. Proposals and studies published in abstracts only will be excluded.
The inclusion criteria will be based on population, intervention (exposure) and outcomes (PEO) elements (33). That is, the document to be included for review: (i) is on health systems reforms, or other government reforms where health financing is a part of the reform process, or is specifically on health financing reforms, and is published from 2012 onwards i.e. studies conducted after the 2012 Rio de Janeiro United Nations Conference on Sustainable Development, where the process of developing SDGs was initiated. They will form the study population; (ii) describes how sustainable development goals declaration has influenced reforms in health systems financing for UHC as the intervention; and (iii) reports on changes to at least one of the following health financing dimensions of management or organization i.e. revenue collection, pooling, purchasing and policy on benefits design and rationing as the outcomes.
Search methods for identification of studies
Databases search: A comprehensive electronic search will be conducted using indexed and free text words in the following databases: Ovid Medline, PubMed, EBSCO, Scopus, Web of Science. Previous experience has demonstrated to us that searching 5 databases on such a topic is adequate and the process of searching additional databases does not usually yield new documents. In searching the electronic databases, we shall combine various conceptual terms for “sustainable development goals" and "health financing". We will use the Boolean operators ‘OR’ to combine the terms within each concept and ‘AND’ to combine the two concepts. We will not use search filter for study type, language (we will use the google translate for non-English articles), country or geographical area in order to find as many studies on the topic as possible. The search strategy will be validated by a librarian.
Other searches: In addition, we will screen the reference lists of included studies and contact the authors of relevant articles for further information or additional material as necessary; and conduct manual search for relevant articles from publications on websites of WHO, journals (health system reforms, health policy and planning, UHC2030 partnership), and from search engine google scholar. This is likely to yield additional pool of relevant literature.
Pilot search
In order to gauge the viability of this review, a pilot electronic search was conducted on PubMed on 2nd June 2020 using the search strategy described under Search methods for identification of studies above. The search string was as below: -
Search: (((((((((((((((((((((((Health Financing Reform*) OR (Health system* financing)) OR (Health system* financing reform*)) OR (Health financing system*)) OR (Health financing system* reform*)) OR (Financing health system*)) OR (Financing healthcare)) OR (Financing health care)) OR (Health system* reform*)) OR (Health care reform*)) OR (Healthcare reform*)) OR (Health reform*)) OR (Reforming health financing)) OR (Reforming health system* financing)) OR (Reforming health care financing)) OR (Reforming healthcare financing)) OR (Reforming health)) OR (Reforming healthcare)) OR (Reforming health care)) OR (Reforming health system*)) OR (Reforming healthcare system*)) OR (Reforming health care system*)) OR (Health financing)) AND (((((((((((((sustainable development goal*) OR (SDG*)) OR (Sustainable development goal*3)) OR (SDG 3)) OR (UN development blueprint)) OR (United Nations development blueprint)) OR (global development agenda)) OR (2030 development agenda)) OR (2030 agenda)) OR (post millennium development goal*)) OR (Post-MDG*)) OR (Post MDG agenda)) Filters: in the last 5 years, Humans
The search yielded 692 potential articles and from initial screening of titles and abstracts 69 articles were considered potentially eligible. Of the 69 titles and abstracts, 1 was in Chinese and 1 in Spanish, the rest were in English. Of the 69 articles potentially eligible, we were able to retrieve 68 articles, the exception being the one published in Chinese. The article in Spanish was translated using google scholar. After review of full length articles of the 68 articles, 2 articles were found to meet our eligibility criteria (Table 1).
Table 1: Eligible articles for review
Author
|
Year
|
Country/setting
|
Agustina et al(34)
|
2019
|
Indonesia
|
Wang YP and Zhou XN(35)
|
2020
|
China
|
This pilot search process has indicated the potential availability of relevant literature for review.
Study selection
All retrieved articles will initially be exported to EndNote software X9 (36), where duplicates shall be removed. After removing duplicates, the EndNote library will be shared between two reviewers where the selection process will be conducted in two phases. Firstly, the two reviewers will screen the titles and abstracts of identified articles independently for potential eligibility and retrieve the full text of articles judged as potentially eligible. Secondly, full text retrieved will be screened by the two reviewers for eligibility using a standardized screening form (attachment 1). Disagreements will be resolved by discussion or with the help of a third reviewer.
Reviewers have undertaken a calibration exercise and refined the eligibility screening tool using results from a pilot search conducted on PubMed aforementioned. This calibration exercise has been undertaken to facilitate uniform application of eligibility criteria across reviewers. This will enhance the validity of our process and minimize bias in identification and selection documents for review. In order to improve transparency of the review process we will depict the overall selection process of documents and reasons for inclusion and exclusion in a flow chart in line with the PRISMA statement (37). The full texts of all relevant studies found to meet the inclusion criteria will be retained for the final synthesis (38). For articles that will fail to meet the inclusion criteria at the full-text screening phase, reasons for their exclusion from analysis will be documented.
Data extraction
Two reviewers will abstract data from eligible articles independently using standardized data abstraction form adapted from the Joanna Briggs Institute (JBI) data abstraction format (Attachment 2) (39). A calibration exercise will be conducted on a randomly chosen sample to ensure adequate agreement, and disagreement will be resolved by consensus or with the help of a third reviewer if consensus is not reached. Study characteristics to be extracted will include: the bibliographic details of study (study title, author, year of publication), objectives (purpose of the study), study design, setting (country); influence of SDGs declaration on health financing reforms; the dimension or aspect of health financing system reformed; and how Ministries of Health and other stakeholders have used SDGs declaration to drive health financing reforms for UHC.
Appraisal of studies
We shall not carry out assessment of risk of bias for the included articles for this review. This is because, existing tools for critically appraising of studies for reviews is still contested and have strong limitations, especially for qualitative studies (40). However, we shall assess the quality of the included studies.
Retrieved articles eligible for inclusion will undergo a quality assessment process during the synthesis of results. The quality appraisals will be conducted using the Joanna Briggs Institute’s Critical Appraisal Checklists (see attachment 3, an example of the JBI checklist for qualitative studies). Two reviewers will conduct the quality appraisals, where there are disagreements, a third reviewer will be engaged and discussions among the three reviewers will be used to resolve the differences. The results will help us to determine if studies included are consistent with the standard quality appraisal for articles reporting on the type of study. Quality assessment will also be used for judging the relative contribution of each study to the development of explanations and relationships between SDGs declaration and health financing reforms. It has been noted that poorer quality studies tend to contribute less to the synthesis and therefore, the synthesis becomes ‘‘weighted’’ towards better-quality studies (40).
Synthesis and Interpretation of results
We shall use NVIVo and a thematic framework (Attachment 4) to facilitate analysis. Thematic framework synthesis is a qualitative approach that involves selecting, recording and categorizing key issues and themes (41). For each article, the process will involve familiarization with information, identification, recording, categorization and interpretation of the influence of SDGs on health financing reforms, and how Ministries of Health and other stakeholders have used the SDGs to advance health financing reforms towards UHC. On the effects of the reform occasioned by SDGs declaration on health financing system, we will use Kutzin’s conceptual framework for analyzing health financing systems (8). In using Kutzin’s framework we shall focus on changes in the organization and/or management of functions of revenue collection, pooling, purchasing and policy on benefits. The results on the three review questions will be presented narratively.