presentation: health financing in central and west asia: country studies of pakistan, uzbekistan and...

1

Yeonhee Yang

CWRD/CWPF Intern

MPH-MBA student at Johns Hopkins University

Intern Presentation

Health Financing in Central and West Asia:

Country Studies of Pakistan, Uzbekistan and Kyrgyz Republic

Final Version (Presentation)

September 09, 2015

Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the

governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibil ity for any consequence of their use. Terminology used may not necessarily be consistent

with ADB official terms.

Outline

2

Background

Comparative Review of Health Financing in CW Asia

Country Studies

Recommendations

Conclusion

Outline

3

Background


Country Studies

Recommendations

Conclusion

Ultimate

health

system goal

Health

financing

policy goal

Health

financing

objectives

4

Health financing policy focuses on

how to move closer to UHC

• “Health financing is much more than a matter of raising money for health.

It is also a matter of who is asked to pay, when they pay, and how the money raised is spent.”

(WHO, 2011)

Revenue collection Pooling Purchasing/provision

The way money is raised to pay

health system costs

The accumulation and management

of financial resources to re-distribute

the financial risk

The process of paying for health

services

Sufficient and sustainable

resource generation Financial accessibility Optimal use of resource

Universal Health Coverage

Improved and equitable health outcome

Health

financing

functions

How to raise? How to allocate? How to use?

Source: Adapted from WHO

Ultimate

health

system goal

Health

financing

policy goal

Health

financing

objectives

5

Analytical framework to undertake

a systemic review of health financing system

Revenue collection Purchasing/provision

Sufficient and sustainable

resource generation Financial accessibility Optimal use of resource

Universal Health Coverage

Improved and equitable health outcome

How to raise? How to allocate? How to use?

Source: WHO-OASIS; Note: OASIS=Organizational ASsessment for Improving and Strengthening Health Financing; BP=Benefit package

Level of

population

coverage

Level of

equity

financing

Degree of

financial risk

protection

Level

of

pooling

Level of

administrative

efficiency

Equity

in BP

delivery

Efficiency

in BP

delivery

Cost-

effectiveness

& equity in

BP definition

Pooling

Health

financing performance

Indicators

Health

financing

functions

Level

of

funding

6

There are huge gaps moving toward UHC

in Central and West Asia

…and burden on the direct payment

by households is high

Source: World Bank, WHO; Note: OOP=Out-of-pocket

*Abuja Declaration (WHO): a pledge of allocating ‘at least’ 15% of

annual government budget to improve the health sector.

In the region, fiscal space for health is low...

General govt. health expenditure as % of total govt. expenditure, 2013 OOP expenditure on health as % of total expenditure on health, 2013

*Result Framework for the OPH (ADB): OOP expenditure kept under 30% by 2030.

7

In spite of growth over the decade,

the spending on health in the region is low…

Source: World Bank, WHO; PPP=Purchasing power parity

Total health expenditure in US$ PPP per capita from private and public sources, 1995-2013

Low and middle income countries, 2013

0

200

400

600

800

1000

1200

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

199

5

200

0

200

5

201

0

201

3

Kazakhstan Azerbaijan Georgia Armenia Uzbekistan Turkmenistan KyrgyzRepublic

Tajikistan Afghanistan Pakistan

US

$ P

PP

pe

r c

ap

ita

Public Private Low and middle income countries

8

… and most of expenditures are financed by

private funds, especially out-of-pocket

Source: World Bank, WHO; Note: VHI=Voluntary health insurance; OOP=Out-of-pocket

Proportion of total health expenditure by financing agent, 2012

Public funds Private funds

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Turkmenistan Kyrgystan Kazakhstan Uzbekistan Armenia Pakistan Tajikistan Azerbaijan Afganistan Georgia

Pe

rce

nta

ge

State budget Social security funds VHI Other OOP

Outline

9

Background


Country Studies

Recommendations

• Pakistan: Leaky bucket

• Uzbekistan

• Kyrgyz Republic

Conclusion

10

In PAK, poverty gains are fragile

and health outcomes lag behind

• GDP per capita: US$ 1,275

• Sixth most populous country in the world, reaching 182.1 million people

• 62.1% of population lives in rural area

• 60.1% of population is considered as the vulnerable

• Administrative unit:

Four provinces: Punjab, Sindh, Baluchistan, KP

One federal capital territory: Islamabad Capital Territory

A group of federally administered tribal areas (FATA)

• Life expectancy: 66 years

• Infant mortality rate per 1,000 live births: 69.0 (LIMC: 44.0)

• Under-five mortality rate per 1,000 live births: 112.6 (LMIC: 93.4)

• Maternal mortality rate per 100,000 live births: 170 (LMIC: 240)

• Births attended by skilled health personnel: 52% (LMIC: 34%)

• Measles immunization among 1-year-old: 61% (LMIC: 76%)

• Density of health workforce per 10,000 population;

Physician: 8.3 (LMIC: 7.9)

Nursing/midwifery personnel: 5.7 (LMIC: 18.0)

16,641

20,789

13,554

11,796

4,611

4,893

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

LMIC

Pakistan

DALYs per 100,000 population

Group I: Communicable, maternal, perinatal and nutritional conditions

Group II: Noncommunicable diseases

Group III: Injuries

Burden of disease by cause group, 2012

Economic indicators

Health indicators

Source: World Bank, WHO; Note: LMIC=Lower-middle-income countries; DALY=Disability-adjusted life year

The 18th Constitutional Amendment (30 June 2011)

• Granted provinces long-promised autonomy and

empowerment in many parts of health system

• The Ministry of Health was devolved to the

provinces

• Health service delivery is primarily a provincial

matter while the federal government plays a

supportive and coordinating role

(created Ministry of Inter Provincial Coordination)

11

Selected health financing index 2000 2012

Total health expenditure as % of GDP 3.0% 2.8%

Total health expenditure, per capita (US$ PPP) $80.6 $122.4

General govt. health expenditure as % of total govt. expenditure 3.5% 4.7%

General govt. health expenditure as % of total health expenditure 21.7% 36.9%

OOP expenditure as % of total health expenditure 63.4% 54.8%

OOP expenditure as % of private expenditure on health 81.0% 86.8%

Private prepaid plans as % private expenditure on health 9.6% 12.2%

External resources for health as % total expenditure on health 0.8% 4.9%

2000 2012

4.0% 4.1%

$99.5 $217.5

6.1% 6.2%

21.7% 36.9%

58.6% 54.8%

81.0% 87.2%

0.3% 0.6%

2.7% 3.2%

Lower-middle-

income countries

Source: World Bank, WHO

Total health spending in PAK is

extremely low, compared to other LMICs

Pakistan

The 18th

amendment

in 2011

12

Source/

collection

Pooling

Purchasing

Provision

Federal budget Province / district

administrations

MoD

MoD

Military

Health

Care

system

PDoH

PDoH

3-tier public

providers

(BHU, MCHC,

RHC, THQ,

DHQ, provincial

tertiary care)

Each

autonomous

body

Each

autonomous

bodies

Contracted

networks of

health

providers

Employers’

contributions

Each

institution

ESSI

(province level)

Contracted

networks of

health

providers

Households

OOP

Private

providers

(Fee-for-

service)

Several vertical

programs

through MoIPC

Tax-financed Social security Private funds

(9.7%) (Gov employee: 4.9%) (2.0%) (4.4%)

Each

province Military

ESSI-

registered

employers

Autonomous

bodies’

employers

Population

Coverage Coverage Coverage Coverage

Public financing system is highly fragmented,

and the use of private services has increased

Source: Author’s compilation; Note: MoD=Ministry of Defense; MoIPC=Ministry of Inter Provincial Coordination; PDoM=Provincial department of Health; ESSI=Employee’s Social Security

Institute; BHU=Basic Health Unit; RHC=Rural Health Center; MCHC=Maternal and Child Health Center; THQ=Tehsil Headquarters Hospital; DHQ=Districts Headquarter Hospital

Uninsured*: 78.1%

(Coverage)

*except from private employers

(0.6%) and safety nets (0.2%)

13

In all aspects, PAK’s health financing

performance is low

Level of

funding

Level of

population

coverage

Level of

financial risk

protection

Level of

equity in

financing

Level of

pooling across

the financing

system

Level of

efficiency and

equity in the

delivery of BP

Degree of

cost-

effectiveness

and equity

consideration

in BP scheme

Level of

administrative

efficiency

---

Low High

Health shocks 54%

Natural calamities

7%

Agricultural shocks

4%

Economic shocks

28%

Law and order 3%

Family matters 4%

Share of OOP medical spending in household

budgets by income quintiles, 2005-2006

Shocks faced by

the poor/vulnerable, 2005

- 54.8% of external resources were not allocated to any

provinces or to any programs in 2012

- 11% of the government health expenditures are used in

administrative work in 2012

Source: Author’s analysis based on PSLSMS, PSNS, HIES, NHA, etc; Note: OOP=Out-of-pocket

Trends of proportion of external resources

for health, 2000-2013

14

PAK: Problem tree for health financing

Protection through

pre-paid mechanism

is limited

Predominant play of

private sectors w/o curb

on high cost expansion

Capacity of risk

distribution is weak and

less effective

Inequity to access

appropriate health service

Increased poverty gap due to

catastrophic health expenditure

Poor and inequitable

health outcome

Constrained economic

growth

Core Problem

Effects

Causes

Scarcity of

public

health

facilities

Poor quality of

services and

distrust for public

health providers

No

established

referral

patterns

No regulation

of payment

for private

sector

No effective control

of multi-channel

payment system

Highly frequent

pooling system

(institutional /

provincial level)

No VHI

mechanism

No earmarked tax

for health

Public services

are de facto

paid

Extremely low public funding

Weak integrated

health sector policy

and planning

VHI-unfriendly

environment

(lack of regular capacity

and affordability) Low

revenue

collection

Various investment

level on health

across provinces

Public sectors are

“choked pipes”

No government

purchasing

power

Lack of incentives to

improve efficiency in

service delivery

No statutory

explicit BP

scheme

No monitoring and

evaluation

High inefficiency

of public resource

management

Source: Author’s analysis; Note: BP=Benefit package; VHI=Voluntary health insurance

Financial hardship for the poor/vulnerable

Outline

15

Background


Country Studies

Recommendations

• Pakistan

• Uzbekistan: Rocky road from the Semashko model

• Kyrgyz Republic

Conclusion

16

• GDP per capita: US$ 1,878

• Population is 30.2 million, accounting for about 40% of Central

Asia’s total

• 63.8% of population lives in rural area

• Ranked 102 out of 169 countries on the UNDP’s Human

Development Index

• Administrative unit:

12 regions (viloyats)

One autonomous republic: Karakalpakstan

One administrative capital: Tashkent

• Life expectancy: 69 years

• Infant mortality rate per 1,000 live births: 36.7 (LIMC: 44.0)

• Under-five mortality rate per 1,000 live births: 63.9 (LMIC: 93.4)

• Maternal mortality rate per 100,000 live births: 36 (LMIC: 240)

• Measles immunization among 1-year-old: 97% (LMIC: 76%)

• Density of health workforce per 10,000 population;

Physician: 25.3 (LMIC: 7.9)

Nursing/midwifery personnel: 119.4 (LMIC: 18.0)

Pharmaceutical personnel: 0.4 (LMIC: 4.2)

Economic indicators

Health indicators

16,641

6,840

13,554

14,571

4,611

2,713

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

LMIC

Uzbekistan

DALYs per 100,000 population



Group III: Injuries


Overall health outcomes in UZB are commensurate

with those in LMICs, facing double burden of disease

Semashko model in the Soviet period

• Highly centralized planning with minimum

discretion allowed to local managers and a strong

emphasis on curative services

• Characterized by a large network of providers, a

high degree of specialization, and input-based

financing

• Made tangible progress, including financial

protection through universal access to basic health

services and success in fighting infectious

diseases

Source: World Bank, WHO; Note: LMIC=Lower-middle-income countries; DALY=Disability-adjusted life year

17



Total health expenditure, per capita (US$ PPP) $103.5 $305.6







2000 2012

4.0% 4.1%

$99.5 $217.5

6.1% 6.2%

21.7% 36.9%

58.6% 54.8%

81.0% 87.2%

0.3% 0.6%

2.7% 3.2%

Uzbekistan Lower-middle-

income countries

Government health expenditure in UZB are

higher than peer groups, but can’t lower costs

to households

Source: World Bank, WHO; Note: PPP=Purchasing power parity

18

Source/

collection

Pooling

Purchasing

Provision

Population

Inefficiency inherited from the former

Soviet system…

Viloyat health department,

Viloyat finance department

Viloyat health department,

Viloyat finance department

Republican budget

Ministry of Health

Republican

health facilities

Households

OOP

Tax-financed Private funds

General population

Viloyat and tumans/city administrations Republican budget

Purchasing-provider spilt

capitation rate

Viloyat/city

hospital

SVPs Poly-

clinics

SRBs

(rural) (city)

Partially

Integration

line-item budgeting

& Self-financing

Coverage

Prevalent

Informal payments

Source: Author’s compilation; Note: OOP=Out-of-pocket; SVP=Rural physician point; SRB=Outpatient clinics of central rayon hospital

(Region)

19

…results in households having financial

impediments in seeking healthcare

Level of

funding

Level of

population

coverage

Level of

financial risk

protection

Level of

equity in

financing

Level of

pooling across

the financing

system

Level of

efficiency and

equity in the

delivery of BP

Degree of

cost-

effectiveness

and equity

consideration

in BP scheme

Level of

administrative

efficiency

---

Low High

Share of OOP medical spending in household

budgets by income quintiles, 2003

Incidence of informal payment

in rural areas, 2005

Financial barriers to health care

in Ferghana, 2001

Source: Author’s analysis based on Living Standards Assessment, Cashin et al. etc; Note: OOP=Out-of-pocket

3.8

2.3 2.5

3.0

3.4

0.0

1.0

2.0

3.0

4.0

Poorest Q2 Q3 Q4 Richest

% o

f to

tal

exp

en

dit

ure

0.49

0.26

0.45

0.19

0.24

0.44

0.18

0.00

0.10

0.20

0.30

0.40

0.50

0.60

Poorest Q2 Q3 Q4 Richest Statedoctor

Privatedoctor

Info

rmal-

to-f

orm

al p

aym

en

ts

0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0

Richest

Q3

Q2

Poorest

% of those seeking health care in the past 30 days

Did not seek health care because not enough money

Finding the money to pay for health care was difficult

Needed to borrow money to pay for health care

UZB: Problem tree for health financing


Informal payment is

prevalent

Protection through

pre-paid mechanism

is limited

Primary care is under-

utilized

Capacity of risk


less effective

Lack of

medical

supplies

“Shallow”

BP scheme

Frequent

pooling system

(vlioyat level)

Low salary

of health

workers

Lack of quality

in primary care

No VHI

mechanism

No established

referral

procedure

Various investment

level on health

across oblast

No government

purchasing

power

Rigid input-based

financing in hospital

(line-item budgeting)

Insufficient public funding

Inequity to access





health outcome


growth

Low level of

external aids

No monitoring

and evaluation

(data scarcity)

Core Problem

Effects

Causes

20 Source: Author’s analysis; Note: BP=Benefit package; VHI=Voluntary health insurance

Inefficient

resource

management

Inefficient

government

revenue

VHI-unfriendly

environment

(lack of regular

capacity and demand)

Outline

21

Background


Country Studies

Recommendations

• Pakistan

• Uzbekistan

• Kyrgyz Republic: Regional leader in health system reform

Conclusion

Source: Author’s compilation

• State program for NCD

prevention (2013-2020)

• National program for TB

(2012-2016)

• Perinatal program (2008-

2017)

• State program for HIV

prevention (2012-2016)

• Introduction of the Mandatory

Health Insurance Fund

(MHIF) and purchaser-

provider spilt

• Replacement of line-item

health financing with new

provider payment methods

for the use of MHIF

Hospital: case-based

payment

PHC: capitation

• Introduction of State

Guarantee Benefit

Package (SGBP) and

official co-payments

• Pooling of funds at

oblast level

• Launch of Additional

Drug Package (ADP)

providing drug benefits

to citizens enrolled in

the MHI

22

1996 2000 1998 2002 2004 2008 2006 2010 2012 2014 2016

Manas (1996-2006) Manas Taalimi (2006-2010)

“Lessons from Manas”

Den Sooluk (2012-2016)

• Reforming the health care delivery system with the aim of

strengthening primary health care, developing family

medicine and restructuring the hospital sector

• Reforming health financing, including introduction of

outcome-based payment methods

• Improving medical education and developing human

resources

• Improving the provision with pharmaceuticals

• Improving quality of care

• Strengthening public health

• Introducing new health management methods in the

context of greater autonomy of health facilities

• Improving equity and

accessibility of health services

• Reducing the financial burden

on the population

• Increasing effectiveness of the

health system


• Increasing responsiveness and

transparency of the health

system


• Creating a strong link between

program activities and their

impact on health gains in four

priority areas;

Cardiovascular disease

Maternal and child health

TB

HIV infection

• Maintaining hard-fought gains in

financial protection, access and

efficiency of health services

• Pooling of funds at

national/republican level

(single payer system)

• Improvement of

purchasing

arrangements of the

MHIF and the Ministry of

Health

• Expansion of co-

payment exemptions

enrolled in the MHI

• Salary

increase

for health

workers

1991

Integrated the Health Policy Analysis and

Monitoring Unit under MoH’s structure (2006)

Established the Health Policy Analysis Center,

in close collaboration with MHIF (2009)

Ma

jor

ch

an

ge

s in

he

alt

h

fin

an

cin

g f

un

cti

on

s

Hea

lth

Refo

rm P

rog

ram

s

Kyrgyz Republic’s

independence

KGZ was quicker to embrace change and

develop comprehensive reform programs

23



Total health expenditure, per capita (US$ PPP) 76.1 $208.6







2000 2012

4.0% 4.1%

$99.5 $217.5

6.1% 6.2%

21.7% 36.9%

58.6% 54.8%

81.0% 87.2%

0.3% 0.6%

2.7% 3.2%

Lower-middle-

income countries

Source: World Bank, WHO; Note: PPP=Purchasing power parity

15.2

8.7 6.7 6.7

3.3 3.9 0.0

5.0

10.0

15.0

20.0

2006 2007 2008 2009 2010 2011 2012 2013

Perc

en

tag

e (

%)

External resources for health (% of total expenditure on health)

Health expenditure, total (% of GDP)

Health expenditure, public (% of GDP)

Sector-wide approach to coordinate the external funds…

Annually

↑ 0.6%

…has been gradually decreasing the donor dependency

Most of health financing indicators in KGZ

are ahead those in other LMICs…

Kyrgyz Republic

24

Source/

collection

Pooling

Purchasing

Provision

Population

…by squeezing efficiency gains out of the system

and using the savings to improve the coverage

Local budget (rayon/city

and ayilokmottu (rural)) Republican budget

Social Fund (earmarked

2% payroll tax)

Households

Republican MHIF

(nation-level pool)

SGBP administered by republican MHIF (single-payer)

General population

Co

-pa

ym

en

t

Co

ve

rag

e C

ove

rag

e

FGPs, oblast and rayon hospitals,

private pharmacies, etc.

Tax-financed Social security Private funds

Contract (PHC: capitation, hospital: case-based payment)

Health services not

included in the SGBP

SGBP:

Type, scope and

conditions for providing

health services free and

based on benefits

Serv

ice c

overa

ge

“Complimentary”

Source: Author’s compilation;

Note: MHIF=Mandatory Health Insurance Fund; SGBP=State-guaranteed benefit package; PHC=Primary health care; FGP=family group practices

25

7.1%

5.5% 5.0% 5.2%

4.5% 4.9%

4.2% 3.6%

5.3%

3.9% 4.4%

2.9%

3.9% 3.6%

4.0%

0.0%

2.0%

4.0%

6.0%

8.0%

Poorest 2 3 4 Richest

2003 2006 2009

11.2%

6.3%

3.1%

4.4%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2000 2003 2006 2009

The KGZ health reform is successful,

but more efforts will be required

Total OOP payments share of total household expenditure, 2003-2009

% who needed but did not seek care due to distance or

affordability, 2000-2009

Source: World Bank, KIHS, WHO; Note: OOP=Out-of-pocket; DALY=Disability-adjusted life year

The financial protection and access improved significantly…

…but the financing system is not targeted well to diseases or the poor


16,641

5,767

15,300

13,554

3,421

4,611

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

LMIC

KGZ

DALY per 100,000 population



Group III: Injuries

50 47 48

45

39

0

10

20

30

40

50

60

Poorest 20% Q2 Q3 Q4 Richest 20%

% c

ov

era

ge

of

po

pu

lati

on

Current policy (covers 47.6% of population)

Coverage of co-payment exemptions policies, 2010

26

The KGZ reforms can be lessons learned to

countries with overcapacity but limited fiscal space

• Successes are in part due to the comprehensive approach, not a single instruments or “magic” bullet

• Complex reforms require careful sequencing of various reform steps

• Paying attention to institutional aspects was important in order to ensure sustainable benefits

• Phased implementation and careful sequencing were an effective implementation approach and helped

build capacity and stakeholder support as well as learning by doing

• Strong government coordination and collaboration with the development partners facilitated

harmonized support for reform design and implementation

• Well-developed health information system that facilitated effective research-to-policy channels and

central budget planning

Problem

definition

and

Options

development

Political

decision

Piloting

and

Learning

from

evidence

Evaluation

and

Redesign

Scaling

Embedding

in legal,

regulatory

framework

Positive policy cycle in Kyrgyz Republic

Health information system

Source: Author’s analysis, World Bank, the London School of Hygiene & Tropical Medicine

Outline

27

Background


Country Studies

Recommendations

Conclusions

28

Protection through

pre-paid mechanism

is limited

Predominant play of



Capacity of risk


less effective

Inequity to access





health outcome


growth

Core Problem

Effects

Causes

Scarcity of

public

health

facilities

Poor quality of

services and

distrust for public

health providers

No

established

referral

patterns

No regulation

of payment

for private

sector


of multi-channel

payment system

Highly frequent

pooling system

(institutional /

provincial level)

No VHI

mechanism

No earmarked tax

for health

Public services

are de facto

paid


Weak integrated


and planning

VHI-unfriendly

environment



revenue

collection

Various investment

level on health

across provinces

No government

purchasing

power



service delivery

No statutory

explicit BP

scheme

No monitoring and

evaluation

High inefficiency

of public resource

management

Comprehensive and sector-wide approach is

necessary for PAK’s health reforms


In Punjab

29

Protection through

pre-paid mechanism

is limited

Predominant play of



Capacity of risk


less effective

Inequity to access





health outcome


growth

Core Problem

Effects

Causes

Scarcity of

public

health

facilities

Poor quality of

services and

distrust for public

health providers

No

established

referral

patterns

No regulation

of payment

for private

sector


of multi-channel

payment system

Highly frequent

pooling system

(institutional /

provincial level)

No VHI

mechanism

No earmarked tax

for health

Public services

are de facto

paid


Weak integrated


and planning

VHI-unfriendly

environment



revenue

collection

Various investment

level on health

across provinces

No government

purchasing

power



service delivery

No statutory

explicit BP

scheme

No monitoring and

evaluation

High inefficiency

of public resource

management

Comprehensive and sector-wide approach is

necessary for PAK’s health reforms


Financing

institutional design

ICT, hospitals,

health workers

Federal-

provincial

coordination

30

Flagship programs can be identified through

integration of operational focus in PAK

Health

financing

Health

infrastructure

Health

governance

ADB’s

operational

focus

Project loan / result-based financing for national health insurance

Sequencing of various reform steps, beyond health financing

Federal

Provincial

… and long-term pipeline development in line with country partnership strategy “

”

Possible solutions may include…

• Increase provincial funding for health

• Strengthen government purchasing power

• Establish appropriate referral process

• Introduce the research-to-policy channel

• Improve geographical accessibility eg.

building hospitals, training heath workers

• Establish the official co-payment and/or the

user-fee process

…but should be carefully considered

with federal programs and/or directions

31

Reducing inefficiency and re-utilizing its

savings can address the core problem in UZB

Informal payment is

prevalent

Protection through

pre-paid mechanism

is limited

Primary care is under-

utilized

Capacity of risk


less effective

Inequity to access





health outcome


growth

No monitoring

and evaluation

(data scarcity)

Lack of

medical

supplies

“Shallow”

BP scheme

Frequent

pooling system

(vlioyat level)

Low salary

of health

workers

Lack of quality

in primary care

No VHI

mechanism

No established

referral

procedure

Inefficient

resource

management

Inefficient

government

revenue

Various investment

level on health

across oblast

No government

purchasing

power

Rigid input-based

financing in hospital

(line-item budgeting)

Core Problem

Effects

Causes

VHI-unfriendly

environment

(lack of regular

capacity and demand)

Insufficient public funding


32

PPP can create efficiency incentives for

the private sector by linking payment to

specific performance criteria in UZB and KGZ

Initiator

(defines services

and area)

Selector

(who chooses

provider)

Manager Production

Infrastructure

Source of

Financing

Government service Government Government Government Government Government

Management

contracts Government Government Private sector Government Government

Service delivery

contract

(clinical/non-clinical)

Government Government Private sector Private sector Government

• Greater focus on the achievement of measurable results if contracts define

objectively verifiable outputs and outcomes

• Using the private sector’s greater flexibility, efficiency, and generally

better staff morale to improve services and expand access to needed

services

• Use competition to increase effectiveness and efficiency

• Allow governments to focus more on other roles that they are uniquely

placed to undertake, such as planning, standard setting, financing, regulation

and the various public health functions

Contracting can strengthen the public model… …under UZB and KGZ’s situations

Government has more

stewardship

Empirical evidence to work

well on a larger scale

Tra

dit

ion

al

mo

del

New

PP

P

mo

del

Source: Author’s analysis based on Loevinsohn B, et al.

33

PPP can be introduced not only in service

delivery, but also in medical supply

Sta

ge

2

Sta

ge

1

Janssen GPH

Agreement with PATH, IPM

• Implement clinical trials targeted to the vulnerable

(women)

• Ensure access the treatment through affordable

pricing strategy

NGO/academia

• $30 million of drug

supply

• Treatment protocols

• Trainings for disease

management programs

Agreement with USAID

• Implement the national part clinical targeted to

the vulnerable (women)

• Engage with the global TB community to solicit

support

Collaborate with IDA (International Development Association)

• A procurement agent for the Stop TB

Partnership’s Global Drug Facility (GDF)

• Facilitate access to quality-assured medicines

Bi/multilateral Agencies

• Royalty free license

• R&D expertise HIV

MDR-TB

Target diseases on the company’s pipeline

as well as national disease priority

Building capacity and gains

in regard to clinical outcome,

accessibility to modern technology,

and/or information system

“

”

Building capacity (learning-by-doing) is a main objective

of our work. And partnership with development agencies is

central to all that we do.

Director, Janssen GPH

Source: Interview and news articles from Janssen Global Public Health; Note: IPM=International Partnership for Microbicides; MDR-TB=multi-drug resistant tuberculosis

34

Health Infrastructure

Contribution of ADB on health financing will

support inclusiveness and reduce vulnerabilities,

through UHC achievement

By 2020, ADB will have expanded health operation

to 3-5% of its annual process

CWRD should be processing $XXXX XXXX

health interventions each year

ADB’s Strategy 2020 Mid-term Review

CWRD target: $XX XXXX

processing in 2015

No health intervention

in the pipeline

Health Financing Health Governance

Universal Health Coverage in Asia and Pacific

Inclusive Economic Growth Fighting poverty, improving lives

Central and West Asia

35

Acknowledgement

for the “hottest” EVER summer ;-)

Michiel Van der Auwera (CWPF)

Eduardo Banzon (SDCC)

Betty Wilkinson (CWPF)

Direct supervision of work

Munir Abro (PRM)

Mamatkalil Razaev (KYRM)

Nargiza Talipova (CWUW)

Support and review in the country context

Susann Roth (SDCC)

Andaleeb Alam (YP)

Gerard Anderson (Professor, JHU)

Sachiko Ozawa (Assistant Scientist, JHU)

Hwayoung Lee (Postdoctoral Fellow, SNU)

Hyobum Jang (Fellowship, WHO WPRO)

Hoon Sang Lee (Senior Health Advisor, KOICA)

Enrique Esteban (Director, Janssen GPH)

Advisory / Interview

Willdon Oller (BPMSD)

CWPF IS/NS

ADBK Staffs

…and 2015 ADB Intern Fellows!

Life in ADB

36

Thank You!

…Questions?

[email protected]

[email protected]

https://www.linkedin.com/in/yeonheeyang

Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the

governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibil ity for any consequence of their use. Terminology used may not necessarily be consistent

with ADB official terms.

mailto:[email protected]

mailto:[email protected]



37

Appendix

38

Public financing: Tax-based vs. Payroll tax

• Beveridge model

• Also known as National Health

Services

• Named after William Beveridge who

designed Britain’s National Health

Service in 1942

• Health services almost entirely financed by tax

revenues

• Government collects funds (tax) and also

(generally) is the provides (or contracts them)

health services

• Pooling takes place at Ministry of Health (federal)

level

• Example of single-payer system; one entity (eg.

a government-run organization) collects all health

care funds and pays out all health care costs.

• Bismarck model

• Also known as Social Security

based healthcare systems

• First established by Bismarck in

Germany in late 1800’s

• Compulsory earmarked payroll contributions;

employer-based health insurance because

covers formal sector health workers in many

countries

• Clear link between these contributions and a set

of defined rights for the insured population

• Financing and provision are separated in many

countries

Source: Author’s compilation, based on JHSPH class “Health Financing in LMIC” by Prof. Ozawa

Mo

de

l

Ma

in c

ha

rac

teri

sti

cs

39

Purchasing Mechanisms: Pros/Cons

Payment

mechanism Characteristics Advantages Disadvantages

Fee-for-

service

• Determined prospectively, paid

retrospectively

• Payment based on quantity of

services provided

• Incentive to provide services

• Cost escalation

• Incentives for Supplier-induced demand

• Unpredictable expenses for fund holder

Capitation


prospectively

• Payment based on patient head

count

• Incentive to operate efficiently

• Predictable expenses for fund

holder

• Good if you have a healthy

population

• Eliminates supplier-induced

demand

• Moderate administrative costs

• Disincentive to provide care

• Avoid sick & costly patients (cream-

skimming)

• Possible cost shifting (referral to another

provider)

• Financial risk may put provider in debt

Case-based

(include DRG)


retrospectively

• Payment based on patients’

case/condition

• Incentive to operate efficiently

• High administrative costs (DRG

classification)

• Less suitable for out-patient care (difficult

to define case)

• Incentive to select low risks within case

categories

• Unpredictable expenses for fund holder

Global budget


prospectively

• Payment based on the

organization’s budget

• Low administrative costs


holder

• Permit reallocation of resources

• No direct incentives to be efficient


Line-item

budget


prospectively

• Payment based on each line in

the organization’s budget

• Allow central control

• Desirable when local management

is weak


holder

• Incentive to maintain status quo

• No direct incentives to be efficient


• Resources are fixed & cannot be

reallocated

Source: Author’s compilation, based on JHSPH class “Health Financing in LMIC” by Prof. Ozawa; Note: DRG=Diagnostic-related groups

40

PPP in Health: Wide Range of Options

Design &

construction

Non-clinical

services Primary care

Specialized

clinical

services

Hospital

management

Clinical

support

services

• Detailed

designs

• Building

construction

• Medical

equipment

• Capital

financing

• IT

equipment &

services

• Maintenance

• Food

• Laundry

• Cleaning

• Security

• Lab analysis

• Diagnostic

tests

• Medical

equipment

maintenance

• Ambulance

services

• Primary care

• Public health

• Vaccinations

• Maternal &

child health

• Dialysis

• Radio-therapy

• Day surgery

• Other

specialist

services

• Management

of entire

hospital or

network of

hospitals

and/or clinics

Source: IFC

presentation: health financing in central and west asia: country studies of pakistan, uzbekistan and...

Documents

health expenditure

health financing bp

uhc health financing

health sector

health services sufficient

oop expenditure

total expenditure

west asia