Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations

Bismarck meets Beveridge on the Silk Road: coordinating funding sources to create a universal health financing system in Kyrgyzstan

Options for health financing reform are often portrayed as a choice between general taxation (known as the Beveridge model) and social health insurance (known as the Bismarck model). Ten years of health financing reform in Kyrgyzstan, since the introduction of its compulsory health insurance fund in 1997, provide an excellent example of why it is wrong to reduce health financing policy to a choice between the Beveridge and Bismarck models. Rather than fragment the system according to the insurance status of the population, as many other low- and middle-income countries have done, the Kyrgyz reforms were guided by the objective of having a single system for the entire population. Key features include the role and gradual development of the compulsory health insurance fund as the single purchaser of health-care services for the entire population using output-based payment methods, the complete restructuring of pooling arrangements from the former decentralized budgetary structure to a single national pool, and the establishment of an explicit benefit package. Central to the process was the transformation of the role of general budget revenues – the main source of public funding for health – from directly subsidizing the supply of services to subsidizing the purchase of services on behalf of the entire population by redirecting them into the health insurance fund. Through their approach to health financing policy, and pooling in particular, the Kyrgyz health reformers demonstrated that different sources of funds can be used in an explicitly complementary manner to enable the creation of a unified, universal system

Kyrgyzstan: Health system review.

Kyrgyzstan has undertaken wide-ranging reforms of its health system in a challenging socioeconomic and political context. The country has developed two major health reform programmes after becoming independent: Manas (1996 to 2006) and Manas Taalimi (2006 to 2010). These reforms introduced comprehensive structural changes to the health care delivery system with the aim of strengthening primary health care, developing family medicine and restructuring the hospital sector.Major service delivery improvements have included the introduction of new clinical practice guidelines, improvements in the provision and use of pharmaceuticals, quality improvements in the priority programmes for mother and child health, cardiovascular diseases, tuberculosis and HIV/AIDS, strengthening of public health and improvements in medical education. A Community Action for Health programme was introduced through new village health committees, enhancing health promotion and allowing individuals and communities to take more responsibility for their own health. Health financing reform consisted of the introduction of a purchaser provider split and the establishment of a single payer for health services under the state-guaranteed benefit package (SGBP). Responsibility for purchasing health services has been consolidated under the Mandatory Health Insurance Fund (MHIF), which pools general revenue and health insurance funding. Funds have been pooled at national level since 2006, replacing the previous pooling at oblast level. The transition from oblast-based pooling of funds to pooling at the national level allowed the MHIF to distribute funds more equitably for the SGBP and the Additional Drug Package. Although utilization of both primary care and hospital services declined during the 1990s and early 2000s, it is increasing again. There is increasing equality of access across regions, improved financial protection and a decline in informal payments, but more efforts will be required in these areas in the future