UNICO Studies Series
40 items available
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The World Bank supports the efforts of countries to share prosperity by transitioning toward universal health coverage (UHC) with the objectives of improving health outcomes, reducing the financial risks associated with ill health, and increasing equity. The Bank recognizes that there are many paths toward UHC and does not endorse a particular path or set of organizational or financial arrangements to reach it. Regardless of the path chosen, successful implementation requires that many instruments and institutions be in place. While different paths can be taken to expand coverage, all paths involve implementation challenges. With that in mind, the World Bank launched the Universal Health Coverage Studies Series (UNICO Study Series) to develop knowledge and operational tools designed to help countries tackle these implementation challenges in ways that are fiscally sustainable and that enhance equity and efficiency. The UNICO Studies Series consists of technical papers and country case studies that analyze different issues related to the challenges of UHC policy implementation.
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Publication
Bangladesh: Unravelling the 'Good Health at Low Cost' Story
(World Bank, Washington, DC, 2019-07)This case study describes Bangladesh’s success story using the standardized approach used by the Universal Health Coverage Studies Series (UNICO Studies Series) to provide a balanced account of the key pillars that lay behind the success of pluralism in the health system of Bangladesh. The aim is to recognize the contributions of the different actors (including the Government and the informal sector, which in the past have not been sufficiently recognized) and the strengths and weaknesses of these pillars as the needs and opportunities evolve due to emerging health issues. This lack of knowledge is an impediment to policy formulation and implementation aimed at maintaining the success of Bangladesh in the health sector. The case study suggests that there were four pillars to the successful pluralism that characterized Bangladesh: (a) effective prioritization of public financing on highly cost-effective interventions, (b) effective alignment of government and DP financing based on the mechanism of the SWAp, (c) extensive use of female CHWs and innovative NGOs, and (d) a large informal private sector that functions as a retailer of an unusually large and competitive domestic pharmaceutical industry. It should be acknowledged that determinants such as significant poverty reduction, education of girls, female labor force participation, and water and sanitation interventions outside the health sector also played a significant role in achieving better health outcomes. -
Publication
Malaysia: A New Public Clinic Built Every Four Days
(World Bank, Washington, DC, 2019-01-01)This case study on Malaysia is part of phase two of the multicountry Universal Health Coverage study series (UNICO), which explores propoor universal health coverage (UHC) programs, which expanded one or more of the three dimensions of the UHC cube, breadth of population coverage, depth of service coverage, and height of financial coverage, in a manner that is propoor. Malaysia is one of only a handful of global examples of low-income or middle-income healthcare systems which had been able to deliver equitable and effective health outcomes at low cost and with strong financial protection, through public sector supply-side investments. The experiences and lessons learnt from Malaysia’s Public Healthcare System (PHS) are hence relevant for low, and low-middle-income countries considering such a pathway to UHC. Sections two to four of this case study describes the political, economic, and population context in which PHS exists, and covers two important aspects of PHS, service delivery and health financing, which are instrumental to its success. PHS coexists with a large parallel private sector, which is described together in these sections. Additional topics on PHS, its institutional architecture, management of its benefits package, and information environment, are covered in sections five to seven. Two major focus areas are then discussed: the first focus area (section eight) discusses how PHS achieved propoor coverage through implicit targeting, while the second focus area explores the interrelationship between PHS and the private sector. Section 10 concludes with a proposed reform agenda for Malaysia. -
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Universal Health Coverage in Russia: Extending Coverage for the Poor in the Post-Soviet Era
(World Bank, Washington, DC, 2018-06)Over the past two decades Russia experienced a significant increase in state-financed entitlements for health care through the Program of State Guarantees for Medical Care (PSG). The PSG, which is underpinned by the Constitution was an important element of the social contract implemented by the State on the back of rapid economic growth during the 2000s. The PSG is a universal program with uniform benefits paid for through a single national pool. The PSG was accompanied by significant supply side investments to develop a multi-level service delivery system, substantially increase tertiary care provision, strengthen the diagnostic capacity of medical facilities and reduce geographic variations in funding and services. This case study examines what the increase in state financed entitlements for health meant for coverage of the poor in Russia, using the health sector in Russia in the early 1990s as the starting point. The economic and political transformations of the early 1990s resulted in a significant deterioration in health outcomes and financial protection. Although health outcomes have improved, they continue to lag behind that of comparator countries. Large PSG related investments and reforms during the 2000s supported the achievement of health gains and moderated the reversal of trends during the fiscal crisis. Fiscal redistribution has been used to increase resource allocation to less well-off areas. Increased public spending on hospital care helped improve access to inpatient care for the poor, particularly the elderly. Increased investment in diagnostic equipment at outpatient care facilities is associated with increased access to tests and services, albeit only in major cities. A push to reallocate spending towards primary care increased access to both physicians and services in rural areas. Limited PSG coverage for outpatient drug purchases means that OOP drug payments remain one of the biggest threats to financial risk protection. To further deepen and expand coverage for the poor, there is a critical need to narrow the divergence between PSG’s de jure and actual coverage. In principle, the PSG provides a uniform benefits package that all Russians are entitled to under the Constitution. In practice, underfunding and a lack of clarity over the benefits package lead to implicit health care rationing through inadequate access to good quality health care services and affordable drugs and supplies. Additional fiscal space for health is needed and health policy must make more effective use of available resources. Expanding coverage for outpatient drugs and strengthening primary care are immediate priorities. -
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Morocco’s Subsidized Health Insurance Regime for the Poor and Vulnerable Population: Achievements and Challenges
(World Bank, Washington, DC, 2018-01)In Morocco, a reform process to establish universal health coverage (UHC) through nonsubsidized and subsidized social health insurance (SHI) was launched in 2002. This case study focuses on the subsidized SHI scheme, régime d’assistance médicale (RAMED). This program, which is Morocco’s flagship social protection and health program and which had the support of the King Mohamed VI, was piloted in 2008 and scaled up to the national level in 2012. As of November 2016, 6.35 million people - 19 percent of the population - had valid RAMED identification cards. RAMED relies on a sophisticated methodology to target poor and vulnerable households, combining proxy means testing and community targeting methods. This case study reviews RAMED’s achievements and identifies potential reforms to address the challenges RAMED is facing. After presenting details of the health financing and delivery systems and an overview of public health care, the case study reviews RAMED’s institutional arrangements, poverty targeting, enrolment and identification mechanisms, benefits package, and information environment system. The study concludes with a discussion of potential areas of improvements. -
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Dominican Republic: Implementing a Health Protection System that Leaves No One Behind
(World Bank, Washington, DC, 2018-01)During the last 50 years, the Dominican Republic has experienced important economic growth, with rates higher than most Latin American countries. However, despite the substantial reduction in poverty and indigence in recent years, average wages within the formal sector remain extremely low, and a large proportion of the working-age population is outside the formal sector. The country introduced a structural health reform in 2001, which has been successful in affiliating 70 percent of the population to the Family Health Insurance, with a complete package of services with the same content for all, although with different forms of financing and provision of services. However, the public service network, which is legally in charge of providing care to the lower-income population, lagged in its restructuring process, with serious problems of quality, efficiency, and governance. Thus, although many of the coverage goals have been achieved, population health outcome indicators remain well behind most countries in the Latin America region. Another key aspect of the pending agenda to achieve greater health and financial protection within social insurance is the in-depth revision of the Basic Health Plan (Plan Básico de Salud). This revision’s objective would be built on guaranteed coverage of certain health conditions considered to be priorities, including the restructuring of the health care model to introduce rationality, control costs, reduce or eliminate funding differences between the Contributory Regime (Regimen Contributivo) and Subsidized Regime (Régimen Subsidiado), and increase public funding for the Subsidized Regime. It is necessary to ensure that the benefits provided in the Basic Health Plan are delivered; that is, that the services required by the population are effectively covered, which will also reduce out-of-pocket spending. It is necessary to monitor the financial situation of all entities of the health system and to continue strengthening institutional capacity to carry out the financial and technical audits of health providers. The permanent monitoring of the financial sustainability of the Family Health Insurance Subsidized Regime and the Basic Health Plan is fundamental, while a systematic analysis of the fiscal space is carried out. -
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Universal Health Coverage in Croatia: Reforms to Revitalize Primary Health Care
(World Bank, Washington, DC, 2018-01)This chapter describes and seeks to take stock of a cluster of supply-side reforms that aimed to revitalize what was described by the Croatian Public Health Institute as a passive and low-impact primary care system. The cluster of reforms, which include a mix of organizational, primary care provider payment and pharmaceutical pricing and reimbursement reforms, and enabling information technology investments, were implemented starting in 2008. The chapter is organized as follows. Section two provides an overview of Croatia’s health system; section three provides an overview of Croatia’s Social Health Insurance System; section four discusses the financial sustainability challenges facing the Social Health Insurance System; section five presents the evolution and challenges of primary care in Croatia before 2008; section six discusses the primary care reforms implemented from 2008 onward and reviews the available evidence on its impact, including on how poorer regions and individuals may have benefited; and section seven concludes and outlines the way forward. -
Publication
Advancing Universal Health Coverage: What Developing Countries Can Learn from the English Experience?
(World Bank, Washington, DC, 2018-01)The United Kingdom has in many respects the archetypal centrally planned, publicly financed health care system in the form of National Health Service (NHS), established in 1948 in a time of great austerity after Second World War. It is largely funded from general taxation, and provides wide coverage of most mainstream health services, with little recourse to user charges. It offers strong financial protection against the costs of health care and enjoys high public approval ratings. Its principal shortcomings have been weaknesses in service quality, often in the form of long waiting times, and sometimes relating to clinical quality. This paper concentrates on the experience in England, which accounts for 84 percent of the UK population of 64.6 million. The system of health service coverage adopted in the NHS is very simple. There is no explicit requirement to enroll in an insurance plan. Instead, citizens must register with a general practitioner (GP) of their choice. GPs act as a gatekeeper to nonemergency secondary care and prescription medicines and devices. Apart from small fees for some prescription medicines (from which many citizens are exempt), patients are not directly charged for access to NHS care. Throughout most of its history, the NHS model of governance has entailed strong central control by the national ministry, with local administration responsible for detailed local planning and purchasing. The forms of local administration have varied. In the early years of the NHS they were primarily local NHS hospitals, with separate committees for oversight of primary care. Since 1974, local health authorities have assumed the role of oversight of local services, currently covering, on average, populations of 250,000. -
Publication
Expanding Health Care Provision in a Low-Income Country: The Experience of Malawi
(World Bank, Washington, DC, 2018-01)Malawi is a low-income country that is actively working toward achieving universal health coverage (UHC). The government is committed to provide adequate health care, commensurate with the health needs of Malawian society, and international standards of health care as outlined in the Constitution. This UNICO case study explores how Malawi has been able to increase population coverage and financial protection by implementing these two supply-side reforms. The study reviews the situation before the two reforms, what the two reforms envisioned, management arrangements, what the reforms delivered (including positive and negative effects), and the long-term scope for achieving UHC in Malawi. -
Publication
Gabon Indigents Scheme: A Social Health Insurance Program for the Poor
(World Bank, Washington, DC, 2018-01)This paper briefly describes primary health care and accessibility to health care provision in Gabon, and the social health insurance architecture of the GIS. The paper is not intended to provide an analytical and detailed study on health insurance in Gabon. It simply aims to provide a description the GIS in terms of eligibility criteria, targeting, and registration of beneficiaries; special topics related to the management of public funds of the social insurance of the GIS; management of the services offered; and financial sustainability of the GIS. It contributes to the Universal Health Coverage Studies Series on sharing experiences in the field of universal health coverage. -
Publication
Expansion of the Benefits Package: The Experience of Armenia
(World Bank, Washington, DC, 2018-01)The legacy of the Semashko system left Armenia with an oversized and overstaffed health system. Beginning in the 1990s the country focused on re-designing its health system in an attempt to rationalize resources. In order to improve the efficiency, access and quality of health care service provision, the Government undertook supply-side reforms. These reforms included: (a) strengthening Primary Health Care (PHC) provision; (b) downsizing excess hospital capacity; and, (c) changing provider payment mechanisms and introducing a purchaser-provider split.Armenia introduced the Basic Benefit Package (BBP) in 1999 for the socially vulnerable population to target the so-called socially important diseases. The package utilizes public resources to finance, through provider contracts, PHC and emergency services for all Armenian citizens, with co-payment exemptions for the poor and vulnerable. In addition, selected inpatient services are provided for free for the poor, vulnerable and other specific categories.Unfortunately, low public health spending levels and incomplete demand-side health financing reform have resulted in serious shortcomings in financial risk protection outcomes. Armenia’s public health financing is among the lowest in the region. High co-payments for BBP covered services, lack of in-patient care coverage for the non-vulnerable population and outpatient pharmaceuticals for all, have resulted in household out-of-pocket (OOP) spending being the predominant source of financing for health in the country. As Armenia is grappling with an aging society and a health care system struggling to adjust to morbidity and mortality epidemiological changes, its path to Universal Health Coverage (UHC) requires increased funding from prepaid pooled sources in order to sustain and make further progress on improving population health outcomes and financial risk protection.This paper examines the Armenian health system, with a focus on the BBP program. It takes stock of implemented reforms and analyzes the pending agenda. The paper is organized as follows. Section two provides a general overview of Armenia’s health system, focusing on financing and health service delivery. Section three describes the BBP program including its institutional architecture, beneficiary targeting, BBP services and fund management, and related information dissemination. Section four discusses the sustainability of the BBP program amidst economic, epidemiologic, and demographic challenges. The last section focuses on the pending agenda related to targeting, integrated care, and coverage of the non-vulnerable population.