Health, Nutrition and Population (HNP) Discussion Papers
391 items available
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This series is produced by the Health, Nutrition, and Population (HNP) Family of the World
Bank's Human Development Network (HDN). The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate.
Items in this collection
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Publication
From Scheme to System: Understanding the Concept and Measurement of Hospitalizations for Ambulatory-Care-Sensitive Conditions
(Washington, DC: World Bank, 2023-09-18)Ambulatory Care Sensitive Conditions (ACSCs) - conditions for which hospitalization could be prevented or reduced with timely access to effective preventive and early disease management services in primary health care outpatient settings—has emerged as a valuable concept for assessing disparities in healthcare access and utilization among vulnerable populations. This paper provides an overview of the concept of ACSCs and explores its potential for measurement in low-and middle-income countries, using India as a case study. Hospitalization or claims data for ACSCs are increasingly used globally to assess the access to and quality of primary health care services. Analyzing trends in hospital admissions for ACSCs can provide critical policy-relevant information as effective management of ACSCs can lead to reduced hospitalizations, lower morbidity, and mortality, and reduced cost pressures on health systems. The paper highlights the relevance of ACSC analysis in the context of India's flagship health sector reforms—Ayushman Bharat—which aims to achieve universal health coverage. Monitoring and analyzing hospitalizations for ACSCs under Pradhan Mantri Jan Arogya Yojana (PM-JAY)- the world's largest health insurance scheme and one of the four pillars of Ayushman Bharat- will allow decision-makers to assess the magnitude of preventable hospital admissions from an economic efficiency and patient well-being perspective and enable them to make informed policy decisions on strengthening the quality of primary healthcare services. . -
Publication
Forgone Health Care During the COVID-19 Pandemic: 2020 and 2021 Survey Trends from 25 Developing Countries
(Washington, DC: World Bank, 2023-08-10)During the first year of the COVID-19 pandemic, health system disruptions, fear of becoming infected with COVID-19, mobility restrictions and lockdowns, and reduced household incomes likely contributed to households forgoing needed health care. Using repeated measures collected with a standardized instrument over two time periods in 25 countries and roughly 63,000 households, this analysis documents how the prevalence of forgone health care and its drivers changed between the early period of the pandemic in 2020 and the first half of 2021. In 2020, in the pooled sample, 17.9 percent of households reported not being able to obtain needed health care. Reported prevalence of forgone care was 15.6 percent in low-income countries (LICs), 17.0 percent in lower-middle income countries (LMICs), and 20.5 percent in upper-middle-income countries (UMICs) included in the sample. In early 2021, the prevalence of forgone care was lower: 10.3 percent of the households in the pooled sample that reported needing care were not able to obtain it. The prevalence of forgone care was 7.9 percent in LICs, 15.1 percent in LMICs, and 5.3 percent in UMICs. Financial barriers were the main reason households reported for not obtaining needed health care; and among households forgoing care, the share that did so for financial reasons remained similar between the two time periods: 42 percent in 2020 and 45 percent in 2021 (a statistically insignificant change). This study is a comprehensive analysis of the changes in forgone care in low- and middle-income countries. It documents the predominance of financial barriers among those who could not obtain needed health care, especially in low- and lower-middle-income countries as compared to upper-middle-income countries. Given the uneven recovery from the COVID19 pandemic and the deepening economic crisis due to the Russian invasion of Ukraine, it is likely that financial barriers to obtaining health care will persist and perhaps increase, potentially jeopardizing progress toward achieving universal health coverage. -
Publication
Multisectoral Nutrition Programming in Action: Impact Evaluation of Uganda Multisectoral Food Security and Nutrition Project
(Washington, DC: World Bank, 2023-06-15)There has been renewed interest and effort in recent years to adopt a multisectoral approach to address malnutrition in many countries. The government of Uganda, with technical support from the World Bank and financial support from the Global Agriculture and Food Security Program (GAFSP), has been implementing a multisectoral nutrition project with strongcoordination in activities by several line ministries including Agriculture, Education, Health, and Local Government, to improve child and maternal nutrition. This quasi-experimental evaluation has been conducted to measure the impact of this project. The study finds impact on households’ increased adoption of micronutrient-rich crops, improvement in household dietary diversity, reduced food insecurity, as well as improvement in caregivers’ knowledge of better nutrition practices. These have resulted in improved child-feeding practices and reduced childhood stunting, wasting, and anemia among the households that directly participated in project activities. The study also finds evidence of some spillover effects on households from the intervention communities that were not direct participants. In terms of maternal health, fewer women in intervention districts are found to be anemic although there is no impact on their dietary diversity. The results indicate that multiple pathways—foodproduction, food habit, micronutrient supplementation, and health care services—have contributed simultaneously to the impact on nutritional outcomes of children and mothers. Since multiplicity of impact pathways is critical in arguing for a multisectoral approach, the project is found to be a case where this approach has been effective. -
Publication
Purchasing in a Pandemic: Lessons from the Health Systems Response in Armenia and Romania
(World Bank, Washington, DC, 2023-04-07)Purchasing for health, which includes what, how, and from whom services are purchased, was one of the policy levers available to countries as part of their health systems’ response to the COVID-19 pandemic. Ideally, the purchasing function should align with the broader health financing functions. Empirical evidence indicates that purchasing arrangements transformed during the pandemic across the world. A systematic examination of these changes can inform ongoing efforts to leverage purchasing to strengthen health system performance. The Collectivity Project is a global community of practitioners, decision makers, and re-searchers contributing to collaborative health system projects. The thematic group convened experts from eight countries to systematically assess the changes in purchasing arrangements as part of the COVID-19 health response and their implications for health system objectives. This report examines adjustments made in purchasing arrangements that occurred during the Armenia and Romanian response to the COVID-19 pandemic. The research adopted mixed methods and a deductive approach. Data were obtained from a scoping literature review, key informant interviews, and an exploratory analysis of quantitative health system indicators. The study was informed by a framework for understanding purchasing changes that adapted existing frameworks to explore the implications of purchasing adjustments on critical outcomes. The research describes critical changes in purchasing, provider and user responses to these changes, and health system outcomes that accompanied the COVID-19 response in Armenia and Romania. For example, it was essential to have a governance environment that defined shared objectives and facilitated coordination across stakeholders. During this time benefits expanded, and contracts changed, including payment mechanisms to offset the decline in essential service use and incentivize care delivery for COVID-19. Furthermore, the pandemic saw the accelerated adoption of innovation, particularly telemedicine, within service delivery. The lessons from purchasing during the pandemic have implications for improving coverage, quality, and adaptability to a crisis, including beyond the contexts studied. -
Publication
The 2022 Update of the Health Equity and Financial Protection Indicators Database: An Overview
(Washington, DC: World Bank, 2022-12)This paper outlines changes that have been made for the third version of the World Bank’s Health Equity and Financial Protection Indicators (HEFPI) database launched in 2022. Across all indicators, subpopulation breakdowns by urban and rural place of residence and subnational region were added. On the financial protection side, the number of indicators further expanded to 31, reflecting a broadening of the definition of medical impoverishment from being limited to those pushed below the poverty line by medical spending to also include those already under the poverty line who incur any medical spending, that is, those ‘further impoverished’ by medical spending. The additional financial protection indicators also include indicators that show the intersection of catastrophic and impoverishing health spending, that is, identify the populations exposed to both types of financial hardship simultaneously. The health equity side of the database now includes 19,820 country-level data points from 1,318 surveys across 35 service coverage and 38 health outcome indicators. An upgraded data visualization portal was launched alongside the new dataset. -
Publication
Performance-based Financing in the Health Sector of the Democratic Republic of Congo: Impact Evaluation Report
(World Bank, Washington, DC, 2022-10)The Democratic Republic of Congo (DRC) is the largest country in sub-Saharan Africa, by area. The country has a long history of conflict, political upheaval, and instability and has a very high poverty rate despite its abundance of natural resources. Mortality and fertility rates in DRC are among the highest in the world. The Health System Strengthening for Better Maternal and Child Health Result Project (PDSS – Le Projet de Développement du Système de Santé) was launched in 2015 with the objective of improving utilization and quality of maternal and child health services in eleven provinces of out of the provinces in the Democratic Republic of Congo (DRC). The main component of the project is the implementation of a provider payment system reform through Performance-Based Financing (PBF), launched in the end of 2016. Contracted health facilities receive quarterly payments conditional on the volumes of targeted services provided and on quality of care. The objective of this impact evaluation is to assess whether the PBF approach impacts utilization and quality of primary health services, in comparison to equivalent amounts of unconditional financing. The rational for comparing outcomes produced by facilities implementing PBF to those produced by facilities who receive equivalent amounts of unconditional financing is to isolate the impact of the PBF incentive mechanisms from the direct impact of the additional resources received through the program. -
Publication
Impact of Health Sector Support Project on Essential Nutrition Services: Evidence from Bangladesh
(World Bank, Washington, DC, 2022-09)Despite progress over the past two decades, poor nutrition remains a significant public health challenge in Bangladesh. Stunting among children under five years declined from 43 to 31 percent between 2007 and 2018, while 42 percent of women between 15 to 49 years are anemic. The Ministry of Health and Family Welfare is implementing the Health Sector Support Project (HSSP) with financing and technical assistance from the World Bank in the Sylhet and Chattogram divisions of the country. The project considers improving nutrition outcomes as a core priority. Leveraging administrative data from 13,855 community clinics (CCs) from 2018 to 2020 and a difference-in-difference approach, the analysis finds that HSSP led to improvements in the delivery of both maternal and child nutrition services. The proportion of eligible pregnant women who received requisite antenatal services (receipt of at least 30 iron and folic acid tablets, nutrition counseling, and weight measurement) increased by 2.7 percent over the duration. Similarly, the proportion of children between 0 and 23 months, who received age-appropriate nutrition counseling, increased by 8.9 percent over the same period. The paper identifies several factors that led to these improvements and notes the impediments. The HSSP renewed focus on the importance of delivering quality nutrition services, and the technical assistance provided through the HSSP has strengthened capacity, not only around the delivery of services but also in improving the data ecosystem and quality of project monitoring and results verification. There are, however, issues impeding service delivery of nutrition services. The community health care providers (CHCPs) are often faced with competing priorities, as nutrition is one of the many services they provide. Similarly, the CHCPs have been found to lack the required capacity and skills in delivering services and are also burdened with poor information technology (IT) equipment. -
Publication
Private Sector Engagement in Public Health Systems
(World Bank, Washington, DC, 2022-09)The aim of the literature review was to provide evidence on private health sector engagement globally, with a specific focus on the South Caucasus. The analysis focused on private sector engagement through the lens of policy dialogue, information sharing, regulation, financing, and private sector provision, including performance and private sector engagement modalities. Results showed that the private sector in Armenia, Azerbaijan, and Georgia is heterogenous. Regulation aimed to increase health coverage with quality services and increase the institutional capacity of the Ministries of Health to collect and analyze data to know better how the private health sector operates and promote private-public partnership to respond to public health challenges. The creation of an autonomous health superintendence would help improve the performance of the private sector: overseeing and supervising the service delivery of private providers and ensuring a strong regulatory environment within countries with high levels of out-of-pocket payments. This entity should enforce transparent behaviors of doctor practices, licensing of physicians, and accreditation of private providers. In addition, the South Caucasus countries can adopt a mix of payment systems with private providers and establish arrangements that ensure a strong private-public partnership (PPP) in health through well-defined contracts. Health facilities with management autonomy should also ensure quality-based purchasing. PPPs would be an optimal way for the South Caucasus to engage with the private sector. Political will, legislative environments and regulatory frameworks, transparency, public sector capacity, complete and flexible contracts, and broad stakeholder engagement are essential conditions to expand PPPs. Learning from best practices globally and expanding research on how health systems create and regulate mixed public-private services are also essential to improve quality, equity, and efficiency of these systems, as countries work to achieve universal health coverage. -
Publication
COVID-19 Vaccine Acceptance Among Marginalized Populations in Kosovo: Insight from a Qualitative Study
(World Bank, Washington, DC, 2022-09-01)Kosovo has fully vaccinated 45.5 percent of the population, below what is needed to slow the spread of COVID-19. The Roma, Ashkali, and Egyptian communities, as marginalized ethnic groups, have been identified as high risk for acquiring COVID-19 and for lower acceptance of vaccines. Factors associated with vaccine acceptance are examined in this qualitative study among Roma, Ashkali, and Egyptian community members and representatives from civil society, community leaders, health care providers, and government working directly within these communities. Using a social-ecological model, intrapersonal, interpersonal, community, and structural factors influencing vaccine acceptance were identified. Intrapersonal-level factors centered on fear of side effects and doubt about vaccine safety and effectiveness, and lack of trust of health care providers; at the interpersonal level, male head of households decided for the entire family whether to receive the vaccine; in the social context at the community level, exposure to prolific misinformation on social media, television news, and paper pamphlets distributed in study communities created fear, doubt, and anxiety about vaccines, and stereotypes about the strong immune systems of ethnic minority groups reinforced beliefs about the communities low susceptibility to COVID-19; and structural-level barriers included the requirement for identification documents, and a buildup of doubt about motivations of the vaccinators created by massive vaccine-promotion efforts and police harassment in implementing curfew, and other protective measures targeting ethnic minority communities. Implications of these findings highlight a need for a segmented approach in designing subgroup-specific and multicomponent interventions to promote vaccine acceptance. Strategies include training local opinion leaders in door-to-door awareness raising, directly addressing misinformation, and distributing vouchers to be exchanged for incentives after vaccination; using social media where respected health care providers and community members post videos promoting vaccination; and removing or providing an alternative to identification requirements. -
Publication
Water and Health: Impact of Climate Change in Bangladesh
(Washington, DC: World Bank, 2022-08-31)The government of Bangladesh’s (GoB) Delta Plan 2100 (BDP 2100) disaggregates Bangladesh’s 64 districts into six ecological zones based on hydrological characteristics and climate risks and deems 58 districts to be “extremely vulnerable” to the effects of climate change. The heterogeneity in the water crisis across the different hotspots presents unique health challenges. This paper summarizes the effects of altered quantity and quality of water on human health for each of the ecological zones and provides recommendations based on the findings. Climate change continues to deteriorate the quality and quantity of water in Bangladesh and is one of the leading causes of morbidity and death. The consequences are particularly pronounced for pregnant women and children. There are substantial regional variations in the effects on health, driven by the country’s topological attributes, such as groundwater depletion in the Barind and drought-prone areas and salinity in drinking water in the coastal regions. To address these challenges, it is imperative for agencies such as the Institute of Epidemiology, Disease Control and Research (IEDCR) and the Ministry of Health and Family Welfare (MoHFW) to build research capacity and upscale comprehensive disease surveillance systems to monitor trends in existing and emerging communicable and noncommunicable diseases, and to rigorously evaluate the efficacy of disease prevention and control programs. A set of zone-specific health policies and actions needs to be formulated under the aegis of the MoHFW in collaboration with relevant GoB stakeholders such as the Bangladesh Bureau of Statistics, academics, practitioners, and policy makers, underpinned by credible evidence.