Person: Neelsen, Sven
Health, Nutrition, and Population Global Practice
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Health financing, Impact evaluation
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Health, Nutrition, and Population Global Practice
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Last updated: January 31, 2023
Biography
Sven Neelsen, PhD, is an economist in the World Bank’s Health, Nutrition, and Population Global Practice where he focuses on the measurement and tracking of Sustainable Development Goal 3.8 – Universal Health Coverage – and is involved in evaluating and implementing health financing reforms in low- and middle-income countries. Among other things, he has extensively studied the impacts of health coverage extensions and health shocks on out-of-pocket medical payments, health service coverage, and household consumption among the poor in Thailand and Peru.
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Publication Improving Effective Coverage in Health: Do Financial Incentives Work?(Washington, DC: World Bank, 2022-05-11) de Walque, Damien; Kandpal, Eeshani; Wagstaff, Adam; Friedman, Jed; Neelsen, Sven; Piatti-Fünfkirchen, Moritz; Sautmann, Anja; Shapira, Gil; Van de Poel, EllenIn many low- and middle-income countries, health coverage has improved dramatically in the last two decades, but health outcomes have not. As such, effective coverage -- a measure of service delivery that meets a minimum standard of quality -- remains unacceptably low. This Policy Research Report examines one specific policy approach to improving effective coverage: financial incentives in the form of performance-based financing (PBF) or financial incentives to health workers on the front lines. The report draws on a rich set of rigorous studies and new analysis. When compared to business-as-usual, in low-income settings with centralized health systems PBF can result in substantial gains in effective coverage. However, the relative benefits of PBF are less clear when it is compared to two alternative approaches, decentralized facility financing which provides operating budget to frontline health services with facility autonomy on allocation, and demand-side financial support for health services (i.e., conditional cash transfers and vouchers). While PBF often results in improvements on the margins, closing the substantial gaps in effective health coverage is not yet within reach for many countries. Nonetheless, there are important lessons learned and experiences from the roll-out of PBF over the last decade which can guide health policies into the future.Publication The 2022 Update of the Health Equity and Financial Protection Indicators Database: An Overview(Washington, DC: World Bank, 2022-12) Eozenou, Patrick Hoang-Vu; Neelsen, Sven; Smitz, Marc-Francois; Wang, RuobingThis 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 Financial Incentives to Increase Utilization of Reproductive, Maternal, and Child Health Services in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis(World Bank, Washington, DC, 2021-10) Neelsen, Sven; de Walque, Damien; Friedman, Jed; Wagstaff, AdamFinancial incentives for health providers and households are increasingly used to improve reproductive, maternal, and child health service coverage in low- and middle-income countries. This study provides a quantitative synthesis of their effectiveness. A systematic review was conducted of the effects of performance-based financing, voucher, and conditional cash transfer programs on six reproductive, maternal, and child health service indicators, with eligible evidence coming from randomized controlled trials and studies using double-difference, instrumental variables, and regression discontinuity designs. Four literature searches were conducted between September 2016 and March 2021 using seven academic databases, Google Scholar, development agency and think tank websites, and previous systematic reviews. Random effects meta-analysis was used to obtain mean effect sizes. From 58 eligible references 212 impact estimates were extracted, which were synthesized into 130 program-specific effect sizes. Financial incentives increase coverage of all considered reproductive, maternal, and child health indicators, but mean effects sizes are of modest magnitude. Effect size heterogeneity is typically low to moderate, and there is no indication that study bias risk, baseline indicator levels, or a combination of provider- and household-level incentives impact effect sizes. There is, however, weak evidence that mean effect sizes are somewhat smaller for performance-based financing than for voucher and conditional cash transfer programs, and that the increase in income, rather than the incentive itself, drives coverage improvements. Financial incentives improve reproductive, maternal, and child health service coverage. If future research confirms the preliminary finding that performance-based financing has smaller effects, voucher and conditional cash transfer programs are the preferred policy option among incentive interventions to achieve higher reproductive, maternal, and child health service coverage. The relative effectiveness and efficiency of incentives compared with unconditional increases of provider and household incomes, however, need to be studied further.Publication Review of Public Health Expenditure in the Republic of Tajikistan: Discussion Paper(World Bank, Washington, DC, 2021-07) Egamov, Farrukh; Neelsen, Sven; Dorgabekova, Husniya; Madeville, KateThis Public Expenditure Review updates previous assessments of the levels and efficiency of health financing in Tajikistan and its consequences for healthcare access and health of the Tajik population. Funding for the public healthcare system which provides almost all healthcare remains far short of levels required to provide a universal basic benefit package. As a result, household out-of-pocket payments account for most healthcare spending in the country, and Tajiks frequently forgo needed care for financial reasons. The underfunding of public healthcare in part results from an overall lack of public revenues. It is, however, exacerbated by the health sector enjoying limited priority, with a health share in total government spending far below internationally recognized targets. Inefficiencies in the spending of the limited public funds further undermine the system’s ability to provide the population with basic healthcare of appropriate quality. Despite efforts in the past two decades to introduce elements of strategic purchasing and direct a higher share of funding towards primary care, public health financing in Tajikistan still largely follows the centrally planned, hospital-focused, and mainly input-financed Semashko model. The result are substantial regional inequalities in per capita government health spending which reflect differences in health facility and health worker densities rather than healthcare need, a continued overemphasis on hospital and specialist care, and an inability of facility managers to take efficiency-oriented staffing decisions. Key recommendation to address these shortcoming are that a substantially higher share of public revenues be allocated to the health sector, that an independent, single payer organization, a fully-fledged capitation mechanism for primary care and elements of strategic purchasing for inpatient care be gradually introduced, and that current benefit packages are revised and extended to achieve more rational and equitable healthcare utilization. Broad consensus building among stakeholders will be essential for the success of such reforms.Publication The 2019 Update of the Health Equity and Financial Protection Indicators Database: An Overview(World Bank, Washington, DC, 2019-06) Eozenou, Patrick; Wagstaff, Adam; Smitz, Marc; Neelsen, SvenThis paper outlines changes that have been made in the 2019 version of the Health Equity and Financial Protection Indicators database. On the financial protection side, the changes include an increase in the number of indicators from five to 14; revisions to several previous data points, reflecting the analysis of new surveys (or adaptations thereof); and refinements to the estimation of out-of-pocket expenditures. On the health equity side, the 2019 database includes 198 more data points than the 9,733 in the 2018 database, reflecting the addition of 535 new datapoints, and the dropping of 337 previously included data points now considered to be substandard.Publication The 2018 Health Equity and Financial Protection Indicators Database: Overview and Insights(World Bank, Washington, DC, 2018-10) Eozenou, Patrick; Wagstaff, Adam; Smitz, Marc; Neelsen, SvenThe 2018 database on Health Equity and Financial Protection indicators provides data on equity in the delivery of health service interventions and health outcomes, and on financial protection in health. This paper provides a brief history of the database, gives an overview of the contents of the 2018 version of the database, and then gets into the details of the construction of its two sides -- the health equity side and the financial protection side. The paper also provides illustrative uses of the database, including the extent of and trends in inequity in maternal and child health intervention coverage, the extent of inequities in women's cancer screening and inpatient care utilization, and trends and inequalities in the incidence of catastrophic health expenditures.Publication Introducing the World Bank’s 2018 Health Equity and Financial Protection Indicators Database(Elsevier, 2018-10-22) Eozenou, Patrick; Wagstaff, Adam; Smitz, Marc-Francois; Neelsen, SvenAmong the many shifts of emphasis that have been evident in global health over the past twenty-five years or so, two stand out: a concern over the poor lagging behind the better off in progress towards global goals; and a concern to look beyond whether people get the services they need to the affordability of the out-of-pocket expenditures associated with these services. The World Bank's 2018 Health equity and financial protection indicators (HEFPI) database is a new global resource for tracking progress on both fronts. It is, in effect, the fourth in the series of such databases. The 2018 database includes eighteen indicators of service use (twelve preventative, six curative) and twenty-eight health outcome indicators. The data are calculated from household surveys, identified mostly through searches of data catalogues and websites of multicountry survey initiatives. The 2018 HEFPI dataset is freely downloadable, and a data visualisation tool is also available. To ensure the data are reproducible, and in line with the guidelines for accurate and transparent health estimates reporting, the authors document their methods thoroughly in a working paper and highlight the differences between their definitions and others; They also provide the essential computer code used to produce the estimates.