COUNTRY CASE STUDIES
The Japan-World Bank Partnership Program for Universal Health Coverage also supported in-depth studies on key topics of interest and relevance to the participating countries in the context of their Universal Health Coverage strategy.
Contracting for Primary Health Care in Brazil : The Cases of Bahia and Rio de Janeiro
Abstract: This study presents two case studies, each on a current initiative of contracting for primary health services in Brazil, one for the state of Bahia, the other for the city of Rio de Janeiro. The two initiatives are not linked and their implementation has independently sprung from a search for more effective ways of delivering public primary health care. The two models differ considerably in context, needs, modalities, and outcomes. This paper does not attempt to evaluate the initiatives, but to identify their strengths and weaknesses, initially by providing a background to universal primary health care in Brazil, paying particular attention to the Family Health Strategy, the driver of the basic health care model. It then outlines the history of contracting for health care within Brazil, before analyzing the two studies.
The state of Bahia sought to expand coverage of the Family Health Strategy and increase the quality of services, but had difficulty in attracting and retaining qualified health professionals. Rigidities in the process of public hiring led to a number of isolated contracting initiatives at the municipal level and diverse, often unstable employment contracts. The state and municipalities decided to centralize the hiring of health professionals in order to offer stable positions with career plans and mobility within the state, and chose to create a State Foundation, acting under private law to manage and oversee this process. Results have been mixed as lower than expected municipal involvement resulted in relatively high administrative costs and consequent default on municipal financial contributions. The State Foundation is undergoing a governance reform and has now diversified beyond hiring for primary care.
The municipality of Rio de Janeiro, which until recently relied on an expansive hospital network for health care delivery, sought in particular to expand primary health services. The public health networks suffered from inefficiency and poor quality, and it was therefore decided to contract privately owned and managed, not-for-profit, Social Organizations to provide primary care services. The move has succeeded in attracting considerable increases in funding for primary health and coverage has increased significantly. Performance initiatives, however, still need fine-tuning and reliable information systems must be implanted in order to evaluate the system.
The Path to Universal Health Coverage in Bangladesh: Bridging the Gap in Human Resources for Health
Abstract
Bangladesh is committed to achieving universal health coverage (UHC) by 2032. To this end, the government of Bangladesh is exploring policy options to increase fiscal space for health and expand coverage while improving service quality and availability. Despite Bangladesh’s impressive strides in improving its economic and social development outcomes, the government still confronts health financing and service delivery challenges. The country faces limited fiscal space for implementing UHC, and the crisis in the country’s human resources for health (HRH) compounds public health service delivery inefficiencies. The Path to Universal Health Coverage in Bangladesh assesses the current status of HRH in terms of production, recruitment, and deployment as well as related policy-making processes. It then explores policy options based on evidence from international experience that will help Bangladesh improve the availability and skill-mix of its health workforce. To reach its goal of UHC by 2032, the government will have to commit itself to policies to expand health financing options and, at the same time, tackle HRH challenges head on.
The study presents an economic analysis model of different scenarios that accelerate closing the HRH gap for nurses and community midwives by 2020 within the government’s fi scal space, thus improving the skill-mix of its health workforce. The study also presents detailed policy options to address HRH shortages, improve the skill mix, address geographic imbalances, retain health workers in rural areas, and adopt strategic payments and purchasing mechanisms. In presenting these options, the study provides evidence from literature as well as cogent cases from low- and middle-income countries, such as Afghanistan, Chile, Indonesia, Malawi, Nepal, Tanzania, and Thailand, to demonstrate the effect of these policies.
Ethiopia Health Extension Program : An Institutionalized Community Approach for Universal Health Coverage
Abstract: As a low-income country, Ethiopia has made impressive progress in improving health outcomes. This report examines how Ethiopia’s Health Extension Program (HEP) has contributed to the country’s move toward Univeral Health Coverage (UHC), and to shed light on how other countries may learn from Ethiopia’s experiences of HEP when designing their own path to UHC.
The HEP in Ethiopia has demonstrated that an institutionalized community approach is effective in helping a country make progress toward UHC. The elements of success in the HEP include the emphasis on community mobilization which identifies community priorities, engages and empowers community members, and supports their ability to solve local problems. The other aspect of HEP is the emphasis on institutionalization of the activities, which addresses the sustainability of community programs through high level of political commitment, and effective coordination of national policies and leveraging of support from partners. These findings may offer useful lessons for other low income countries facing similar challenges in developing and implementing a sustainable UHC strategy.
Sustaining Universal Health Coverage in France : A Perpetual Challenge
Abstract: While Universal Health Coverage (UHC) offers a powerful goal for a nation, all countries-irrespective of income- are struggling with achieving or sustaining UHC. France is a high-income country where health coverage is in effect universal. Health-related costs are covered by a mix of mandatory Social Health Insurance (SHI) and private complementary schemes, while benefit packages are comprehensive, uniform and of good quality. France provides some of the highest financial protection among countries in the OECD. Still, under pressure to sustain UHC without compromising equity of access, the system has been fine-tuned continually since inception. Much can be learned from France’s experience in its reforms toward better fiscal sustainability, equity and efficiency. The main purpose of the study is to assess major challenges that France has faced for sustaining UHC, and to share its experiences and lessons in addressing system bottlenecks to benefit less developed countries as they embark on the path to UHC.
A Study on the Implementation of Jampersal Policy in Indonesia
Abstract: Indonesia launched Jampersal in 2011, a nationwide program to accelerate the reduction of maternal and newborn deaths. The program was financed by central government revenues and provided free and comprehensive maternal and neonatal care with an emphasis on promoting institutional deliveries. Jampersal providers were public and enlisted private facilities at the primary and secondary levels. In 2013, the World Bank and the Center for Family Welfare, University of Indonesia conducted a qualitative and quantitative study to assess the implementation and impact of the program in Garut District and Depok Municipality in West Java Province. The study found that Jampersal utilization was highest among women who were least educated, poor, and resided in rural areas. Utilization was also high among women with delivery complications. The study showed Jampersal only had an impact where institutional delivery coverage was still low such as in Garut District. In this district, women were 2.4 times more likely to have institutional deliveries after Jampersal. The finding suggests implementation of Jampersal policy may have to be adjusted according to the utilization pattern for efficiency and effectiveness. The government discontinued Jampersal with the launching of the National Health Insurance Program (JKN) on January 1, 2014. The study’s findings indicate the merit in reevaluating the policy to terminate the program, given that Jampersal helped increase institutional deliveries while voluntary participation in JKN remains low.
The Production, Distribution, and Performance of Physicians, Nurses, and Midwives in Indonesia : An Update
Abstract: Indonesia launched the national health insurance program - Jaminan Kesehatan National (JKN) - on January 1, 2014, and aims to achieve universal health coverage (UHC) by 2019. Achieving UHC means not only increasing the number of people covered but also expanding the benefits package and ensuring financial protection. Although the JKN benefits package is comprehensive, a key challenge related to the capacity to deliver the promised services is ensuring the availability, distribution, and quality of human resources for health (HRH). Of Indonesia’s 33 provinces, 29 do not have the WHO recommended ratio of 1 physician per 1,000 population, although Indonesia regularly produces 6,000 to 7,000 new physicians annually. The shortage of nurses in hospitals and health centers (puskesmas) is noticeable despite the large number of graduates. The government’s health worker contract policy (PTT [Pegawai Tidak Tetap]) was the main policy lever to improve the distribution of physicians and midwives; it offered a shorter contract and higher monetary benefits for rural and remote postings. Nevertheless, evolution of the policy over more than two decades of implementation indicates that the outcome has not been totally satisfactory and that distribution problems remain. Physician maldistribution has been particularly affected by the number and concentration of hospitals in urban areas, as well as by government’s policy of allowing dual practice. Aside from HRH production and distribution figures, key information on the quality of Indonesian physicians, nurses, and midwives is limited. The latest data from the 2007 Indonesia Family Life Survey (IFLS) vignettes, which measured diagnostic and treatment ability, showed low average scores across these three integral health worker categories. Indonesia is addressing the quality issue by improving the quality assurance system of health professional education through school accreditation and graduate certification and by strengthening health professional registration and recertification systems. With these issues in mind, if Indonesia is to attain UHC by 2019, significant and concerted effort to improve the availability, distribution, and quality of human resources for health is required.
Peru - Analysis of the health care labor market in Peru
Abstract: This report aims to provide an updated analysis of labor market trends for the health workforce in Peru, focusing on the basic health team, physician, nurse, and midwife, and other health professionals related to current priorities. Peru has been labeled as a country with a shortage of health professionals (that is, with less than 25 professionals per 10,000 inhabitants), and although the most recent numbers indicate that the situation has improved, the shortages are bound to become more acute as the country aims to achieve Universal Health Coverage.
The authors found that the country trains both in public and private universities a large number of professionals, but that the majority of trained professionals do not then go on to work for the public sector. This dynamic had not been described before and challenges current assumptions of human resources needs and availability. There is very little reliable data on numbers, type and work conditions for human resources working outside the public sector, including the social security insurance health system (EsSalud), other health insurance providers, and the private sector, and as a result no detailed information can be obtained about the distribution of health professionals outside the public sector. For policy purposes, it is necessary to improve the quality and integration of HRH information across the sector.
Vietnam - Learning From Smart Reforms on the Road to Universal Health Coverage
Abstract: Universal Health Coverage is a powerful framework for a nation aiming to protect their population against health risks. However, countries face multiple challenges in implementing, achieving and sustaining UHC strategies. Sharing and learning from diverse country experiences may enable to foster global and country progress toward that goal. The study seeks to contribute to the global effort of sharing potentially useful lessons to address policy concerns on the design and implementation of UHC strategies in LMICs. Vietnam is one of the LMICs that have taken relatively quick and effective actions to expand health coverage and improve financial protection in the last two decades. The country study, first, takes stock of UHC progress in Vietnam, examining both the breadth and the depth of health coverage and assessing financial protection and equity outputs (Chapter 1). Chapter 2 includes an in-depth analysis of some of the major success strategies and policy actions that the country took to expand health coverage and financial protection for all, including for the poor. Chapter 3 focuses on some of the UHC-related challenges that the country faces in pursuing expansion and sustaining UHC. Vietnam’s experience suggests that, moving toward greater UHC outputs, the system must be constantly adjusted, and that UHC strategies must be adaptive—those used in the past to cover the formal sector and the poor may turn out inadequate to reach the uninsured in the informal sector.
