Theoretical insights into the development of health insurance in low-income countries

This Discussion Paper is concerned with the development of risk-sharing systems for health, in low- and middle-income countries. It questions whether insurance theory developed in wealthier economies, in particular the central ideas of adverse selection and moral hazard, has relevance in the context of poorer countries with high levels of unmet health needs, and low utilisation of health services. Empirical evidence on these two issues is reviewed, as is the debate around social capital and collective action, and its relevance to extending risk sharing in poorer countries. Drawing on thinking and evidence from development economics, it is argued that informal risksharing may crowd-out formal risk-sharing schemes, the reverse of arguments found in much of the literature. Rooted in a holistic framework of household risk-reducing strategies, the paper considers the dynamic of demand for insurance in poorer countries, influenced by factors such as social cohesion, perceived corruption, and duty to the state. A central argument in the paper is that much of the literature on health insurance in low-income countries fails to consider well-developed and highly relevant bodies of literature in development economics and sociology.health insurance

Cost-effective safe motherhood interventions in low-income countries: a review

This paper reviews studies providing evidence of the cost-effectiveness of safe motherhood interventions in low-income countries. The economic case for investing in safe motherhood interventions is also examined. It is estimated that 1,600 women die globally each day as a result of problems during pregnancy or childbirth. A large proportion of these deaths is preventable. According to the World Bank, antenatal and maternal services comprise two of the six most cost-effective sets of health nterventions in low-income countries. Due to the problem of linking programme interventions with outcomes however, few cost-effectiveness studies currently exist. Despite this certain interventions are more cost-effective than others, such as substituting manual vacuum aspiration for dilatation and curettage when dealing with incomplete abortion. It is estimated that 26% of maternal deaths are avoidable through antenatal/community-based interventions, costing around 30% of the World Health Organisation’s Mother Baby Package. Ensuring access to high quality essential obstetric care can prevent a further 58% of maternal deaths, consuming 24% of total Mother Baby Package costs. Current evidence suggests that targeting investments on essential obstetric services would reap the greatest efficiency gains.safe motherhood; maternal mortality; cost-effectiveness

Paying for health care in Vietnam: extending voluntary health insurance coverage

This discussion paper aims to synthesise a variety of reports and research projects conducted by the International Programme at the Centre for Health Economics, concerning the Vietnamese health system, over the past 4 years. In particular it focuses on the development of the state voluntary health insurance scheme which is the subject of a current DFID-funded research project. Previous work conducted by the members of the International Programme includes an investigation into the impact of economic reforms on the health system, an evaluation of the impact of user charges on access to health services amongst the poor, and a report providing an analysis of the state health insurance programme. The aim of the current research project is to analyse the experience of voluntary health insurance to date, making recommendations to policy-makers on its future development. A large household survey will form part of the investigations. The paper presents the situation to date, highlighting major developments, successes and failures, and the main challenges facing the scheme. The research project started in July 1998 and is due to be completed in March 2000.GDP, health insurance

Financing options for the provision of assistive products

Having predictable, stable and adequate financial resources is essential for achieving universal coverage of essential health products and services, including assistive products. Access to such resources would enable governments and participating organizations to initiate and maintain a system for providing assistive products and associated services, as well as to grow the scope and scale of their operations over time. While limited funding is not the only reason to explain the shortfall in the provision of assistive products globally, unpredictable and inadequate public funding has been cited as the primary cause of poor access to these products in many countries. Several financing options have been presented in this paper that could be considered by decision-makers to initiate or supplement the financing of assistive products

Assessing the efficiency of countries in making progress towards universal health coverage: a data envelopment analysis of 172 countries.

INTRODUCTION: Maximising efficiency of resources is critical to progressing towards universal health coverage (UHC) and the sustainable development goal (SDG) for health. This study estimates the technical efficiency of national health spending in progressing towards UHC, and the environmental factors associated with efficient UHC service provision. METHODS: A two-stage efficiency analysis using Simar and Wilson's double bootstrap data envelopment analysis investigates how efficiently countries convert health spending into UHC outputs (measured by service coverage and financial risk protection) for 172 countries. We use World Bank and WHO data from 2015. Thereafter, the environmental factors associated with efficient progress towards UHC goals are identified. RESULTS: The mean bias-corrected technical efficiency score across 172 countries is 85.7% (68.9% for low-income and 95.5% for high-income countries). High-achieving middle-income and low-income countries such as El Salvador, Colombia, Rwanda and Malawi demonstrate that peer-relative efficiency can be attained at all incomes. Governance capacity, income and education are significantly associated with efficiency. Sensitivity analysis suggests that results are robust to changes. CONCLUSION: We provide a 2015 baseline for cross-country UHC technical efficiency scores. If countries wish to improve their UHC outputs within existing budgets, they should identify their current efficiency and try to emulate more efficient peers. Policy-makers should focus on strengthening institutions and implementing known best practices to replicate efficient systems. Using resources more efficiently is likely to positively impact UHC coverage goals and health outcomes, and without addressing gaps in efficiency progress towards achieving the SDGs will be impeded

Assessing the efficiency of sub-national units in making progress towards universal health coverage: Evidence from Pakistan

The World Health Report 2010 encourages countries to reduce wastage and increase efficiency to achieve Universal Health Coverage (UHC). This research examines the efficiency of divisions (sub-provincial geographic units) in Pakistan in moving towards UHC using Data Envelop Analysis. We have used data from the Pakistan National Accounts 2011-12 and the Pakistan Social Living and Measurement Survey 2012-13 to measure per capita pooled public health spending in the divisions as inputs, and a set of UHC indicators (health service coverage and financial protection) as outputs. Sensitivity analysis for factors outside the health sector influencing health outcomes was conducted to refine the main model specification. Spider radar graphs were generated to illustrate differences between divisions with similar public spending but different performances for UHC. Pearson product-moment correlation was used to explore the strength and direction of the associations between proxy health systems organization variables and efficiency scores.The results showed a large variation in performance of divisions for selected UHC outputs. The results of the sensitivity analysis were also similar. Overall, divisions in Sindh province were better performing and divisions in Balochistan province were the least performing. Access to health care, the responsiveness of health systems, and patients\u27 satisfaction were found to be correlated with efficiency scores.This research suggests that progress towards UHC is possible even at relatively low levels of public spending. Given the devolution of health system responsibilities to the provinces, this analysis will be a timely reference for provinces to gauge the performance of their divisions and plan the ongoing reforms to achieve UHC

Health financing in fragile and conflict-affected situations: A review of the evidence

Witter, Sophie - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Bertone, Maria Paola - ORCID 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XReplaced with final published version 2020-04-16WHO has well-developed guidance for health financing policy, which supports progress towards universal health coverage (UHC) and overall health system goals. Central to this is the importance of public finances, and the role of government in using those finances in the best way, to strengthen their health system to maximize progress towards UHC. Fragile and conflict affected settings (FCAS) present a growing challenge for countries trying to make progress towards UHC and improve health. This paper examines the core features of FCAS, including deficits in capacity, legitimacy, and security, and considers their implications for efforts to build resilient health systems. Health financing interventions pursued in FCAS in response to both the challenges and opportunities arising from the different deficits are summarized using the WHO health financing functional approach as the organizing framework. Data analysis shows that FCAS countries have significantly higher out of pocket expenditures, greater external dependency and health-related impoverishment, as well as lower mean government expenditure on health. There are substantial challenges for health financing in FCAS settings but considerable ingenuity has also been shown in addressing them, often driven by external stakeholders. Certain approaches, such as performance-based contracting and funding emerged in FCAS settings out of the need to innovate but leave a longer legacy which is given close consideration. This paper forms provides the background to and informs a second paper which revises and adapts WHO’s health financing guidance in the context of FCAS.Financial support was provided by the United Kingdom’s Department for International Development (Making Country Health Systems Stronger programme).https://www.who.int/publications-detail/health-financing-policy-in-fragile-conflict-affected-situations/pubpu

Health financing in fragile and conflict-affected settings: What do we know, seven years on?

Maria Paola Bertone - ORCID: 0000-0001-8890-583XSophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.The authors acknowledge funding from DfID UK under the Making Health Systems Stronger grant to WHO.232pubpu

Health financing policy & implementation in fragile & conflict-affected settings: A synthesis of evidence and policy recommendations

Witter, Sophie - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Replaced Final Draft with published version 2020-04-16This paper provides tailored guidance for policy makers tasked with developing and implementing health financing policy in fragile and conflict affected situations, as well as those who advise such policy. The document takes the perspective of public policy given its central importance for the long-term development of health systems, and as such is highly relevant to the humanitarian development nexus agenda, which aims to ensure connectivity between humanitarian and development efforts, an issue highlighted during the World Humanitarian Summit 2016. The intention is to not to prescribe specific processes or health financing arrangement, but to guide policy makes to develop and implement policies in a way which increases resilience in the health system in both the short, medium and long-term. The recommendations are based on a review of evidence from a wide range of fragile and conflict-affected settings, as well as an extensive process of consultation with stakeholders. The overarching recommendations are: safeguarding the financing of critical health system functions, include population-based interventions such as disease surveillance, ensuring safe medication, water and sanitation systems, and other common goods for health. ensuring policy is consistent with a set of principles which underpin health financing in support of UHC, to avoid the development of multiple uncoordinated and incoherent schemes or sub-systems which undermines resilience in health systems. Use cash and voucher assistance (CVA) to protect human welfare to meet both health and non-health needs, but as a complement to supply-side support for the delivery of essential health services.https://www.who.int/publications-detail/health-financing-policy-and-implementation-in-fragile-and-conflict-affected-settingspubpu