Abdo S. Yazbeck

Better Health Systems for India's Poor: Findings, Analysis, and Options

This report focuses on four areas of the health system in which reforms, and innovations would make the most difference to the future of the Indian health system: oversight, public health service delivery, ambulatory curative care, and inpatient care (together with health insurance). Part 1 of the report contains four chapters that discuss current conditions, and policy options. Part 2 presents the theory, and evidence to support the policy choices. The general reader may be most interested in the overview chapter, and in the highlights found at the beginning of each of the chapters in part 2. These highlights outline the empirical findings, and the main policy challenges discussed in the chapter. The report does not set out to prescribe detailed answers for Indias future health system. It does however, have a goal: to support informed debate, and consensus building, and to help shape a health system that continually strives to be more effective, equitable, efficient, and accountable to the Indian people, and particularly to the poor.

Reaching the poor with health, nutrition, and population services: what works, what doesn't and why.

Health services can make an important contribution to improved health conditions among disadvantaged groups. Yet as the contents of this volume make clear, the health services supported by governments, and by agencies like ours too often fail to reach these people who need them most. This is not acceptable. Nor need it be accepted. The studies presented here point to numerous strategies that can help health programs reach the poor much more effectively than at present. In doing so, they strongly reinforce the messages of the 2004 World Development Report and other recent publications about the importance and possibility of making services work better for poor people. Different views will be formed about which of the strategies are most promising for a particular setting-whether, for example, one would be best advised to follow Brazils approach of seeking universal coverage for basic health services, Cambodias strategy of contracting with non-governmental organizations, Nepals use of participatory program development, or some other approach. The report provides a discussion on issues like these, in order to build upon the important basic findings presented herewith, i.e., that better performance is possible. In brief, better performance in reaching the poor is both needed and feasible. These are the two messages from this report that will be discussed further.

What's in a country average? Wealth, gender, and regional inequalities in immunization in India

Recent attention to Millennium Development Goals by the international development community has led to the formation of targets to measure country-level achievements, including achievements on health status indicators such as childhood immunization. Using the example of immunization in India, this paper demonstrates the importance of disaggregating national averages for a better understanding of social disparities in health. Specifically, the paper uses data from the India National Family Health Survey 1992-93 to analyze socioeconomic, gender, urban-rural and regional inequalities in immunization in India for each of the 17 largest states. Results show that, on average, southern states have better immunization levels and lower immunization inequalities than many northern states. Wealth and regional inequalities are correlated with overall levels of immunization in a non-linear fashion. Gender inequalities persist in most states, including in the south, and seem unrelated to overall immunization or the levels of other inequalities measured here. This suggests that the gender differentials reflect deep-seated societal factors rather than health system issues per se. The disaggregated information and analysis used in this paper allows for setting more meaningful targets than country averages. Additionally, it helps policy makers and planners to understand programmatic constraints and needs by identifying disparities between sub-groups of the population, including strong and weak performers at the state and regional levels.

Attacking inequality in the health sector : a synthesis of evidence and tools

The overwhelming evidence of inequalities in health outcomes and in the use of health services calculated and disseminated by the World Bank and other development agencies in the last 10 years has energized global efforts to address the needs of the poor and socially vulnerable. These efforts have led to a renewed interest at the global and national levels in both understanding the causes of health sector inequalities and developing policies to tackle them. It is time to synthesize the new knowledge being generated from research and experimentation on addressing inequality. The main purpose of this book is to make available the accumulated knowledge of successful policy and analytical tools in this fight to reverse the vicious circle of income-poverty and ill health. The book presents both a practical set of analytical tools for understanding the causes of inequality in the use of health services and a menu of proven pro-poor policy actions. It is based on the evaluation of 14 successful policy changes in low- and middle-income countries in Africa, Asia, and Latin America, and a review of the published literature on inequality in the health sector.

Health policy research in South Asia : building capacity for reform

The richness of the research papers in this volume makes it difficult to quickly capture the main themes and implications of their research. But three repeated themes can be highlighted: equality of public spending, the role of the private sector, and the role of consumers. On the theme of equality in public expenditures, research in Bangladesh, India, Nepal, and Sri Lanka shows that in some parts of South Asia-such as south India and Sri Lanka-governments do a much better job of distributing subsidies in the health sector than other regions. The research overwhelmingly documents the dominance of the private sector in Bangladesh and India and finds a very strong private sector in Sri Lanka. The research also highlights different policy instruments available to the government for working with the private sector to achieve health sector outcomes. A third general theme is the role of consumers and the mechanisms available to them to influence health services delivery. The authors in this volume have supported the belief that individuals and households can make a difference in how health services are delivered. While the three themes summarized above cut across several of the chapters in this volume, a more basic theme underlies all the chapters and is the main motivation for conducting health policy research. That theme is that empirical research can and should challenge basic assumptions about the health sector and will provide policymakers some of the tools needed to improve and monitor the performance of the sector.

Reproductive health -- the missing Millennium Development Goal : poverty, health, and development in a changing world

While women in developing countries continue to die in large numbers in child birth, population and reproductive health specialists and advocates around the world are struggling to keep the policy agenda focused on the rights and needs of poor women. The 1994 Cairo Conference and Program of Action changed how we do business, and opened many doors, but the agenda is not complete and has stalled in a number of ways. At the country level, governments and donors are making difficult choices about how and where to allocate scarce human and financial resources. Funding approaches have moved away from the implementation of narrowly directed health programs to a broader approach of health system development and reform. At the same time, countries are also centering their development agenda on the broad goal of poverty reduction. This volume addresses a large knowledge and capacity gap in the Reproductive Health community and provides tools for key actors to empower faster positive change. It is a synopsis of the materials developed for World Banks Institutes learning program on Achieving the Millennium Development Goals: Poverty Reduction, Reproductive Health and Health Sector Reform. The volume brings together knowledge about epidemiology, demography, economics, and trends in global financial assistance. The volume also introduces practical tools such as benefit incidence analysis, costing, and stakeholder analysis to strengthen the evidence base for policy and to address the political economy factors for reform.

Lessons from 20 Years of Capacity Building for Health Systems Thinking

Abstract In 2016, the Flagship Program for improving health systems performance and equity, a partnership for leadership development between the World Bank and the Harvard T.H. Chan School of Public Health and other institutions, celebrates 20 years of achievement. Set up at a time when development assistance for health was growing exponentially, the Flagship Program sought to bring systems thinking to efforts at health sector strengthening and reform. Capacity-building and knowledge transfer mechanisms are relatively easy to begin but hard to sustain, yet the Flagship Program has continued for two decades and remains highly demanded by national governments and development partners. In this article, we describe the process used and the principles employed to create the Flagship Program and highlight some lessons from its two decades of sustained success and effectiveness in leadership development for health systems improvement.

Learning from Economic Downturns : How to Better Assess, Track, and Mitigate the Impact on the Health Sector

Many countries around the world are moving toward universal health coverage, while navigating through periods of economic crisis. The impact of the economic downturn of 2008-09 on the health care sector has renewed efforts to make health systems more resilient during and after economic downturns. Health policy makers and development practitioners are grappling with how to better identify areas that make the health sector vulnerable to economic downturns, and how to track and mitigate the impact of economic downturns. To effectively manage the challenges resulting from economic uncertainty, the health sector must look at recent failures and successes as a learning opportunity for improvement, with the end result being greater health system resilience. This book, financed by the rapid social response program at the World Bank, responds to these challenges facing the health sector. It introduces a framework for assessing, tracking, and mitigating (A.T.M. framework) the impact of economic downturns on the health sector. This framework provides policy makers and practitioners in the health sector with a more systematic way to design and implement policies that can protect people, particularly the poor, from the negative effects of economic downturns. This book illustrates the benefit of implementing rapid surveys to track the impacts of crises in real time as economies shrink, and emphasizes the importance of building effective health information systems that can regularly monitor system changes. Analysis of several country case studies in developing countries sheds light on the importance of linking the health sector with the social protection sector, particularly social safety nets, using the common identification and targeting methods to reach the poor and the vulnerable. The more recent lessons from several European Union (EU) countries emphasize the importance of political economy in implementing policy reforms during economic downturns and again illustrate how the data can help facilitate more evidence-based policy making.

The Newest Three-Letter Fad in Health

What Can We Learn from the National Health Account Story? Other Misused Three-Letter Tools A Way Forward for HTA References Prioritization in health has always fascinated me, so when I saw that the 2016 Prince Mahidol Awards Conference (PMAC) had “Priority Setting” as the theme for the event (http://pmaconference.mahidol.ac.th/), I was really excited. An early draft of the agenda, however, tempered some of the excitement and raised in my mind an issue that the health sector continues to struggle with when it comes to approaches to prioritization: falling in love with technocratic approaches. Global conversations about prioritization always risk being dominated by a highly technocratic agenda that caters more to a donor-focused environment than national needs for lowand middle-income countries. The most recent of these technocratic approaches, on display at PMAC, is health technology assessments (HTAs). Though there is no doubt that HTAs can and should play an important role in prioritization of limited resources for health, there is a long history of overselling technical answers and in some cases causing more harm than good. The January 2016 issue of Health Systems and Reform, “Special Issue: PrinceMahidol AwardConference 2016: Priority Setting for Universal Health Coverage,” offers some hope. The issue included several commentaries and articles that urge a balanced approach to prioritization, and others explore the limitations of empirical tools like cost effectiveness and HTA. The main question for me is the following: Will the zeal for a technical answer win over the more pragmatic commentary presented in these articles ofHealth Systems&Reform?

Keys to Health System Strengthening Success: Lessons from 25 Years of Health System Reforms and External Technical Support in Central Asia

Abstract—Due to their shared history under the Soviet Union and similar health systems, countries in the Central Asia Region offer an important opportunity for the analysis of health system reforms. Building on extensive documentation of health reforms in the region, this article draws on information from a key informant virtual focus group and uses a systematic health systems framework to compare the national health reforms that Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan implemented. This comparison across the five countries captures variations in their approaches to health system reform. In alignment with health needs shared by the five nations, most country reforms and external investments focused on strengthening primary care, benefit packages, and institutional capacity. The comparison shows that of the five countries, the Kyrgyz Republic underwent the broadest, most sustained, and most successful health sector reform in the region. Though the Kyrgyz Republic enacted many reforms that were similar to those in the other countries, it was unique in implementing a comprehensive set of health financing reforms. This article also provides lessons based on external investment made by the donor community in this regions health reforms. Three implementation factors are identified as critical to making the external investment in the Central Asia region effective: sustained and coordinated external support; early and frequent investment in national ownership; and utilization of a sequenced, pragmatic approach. Based on analysis of the shared experiences of these countries and their supporters, the article offers lessons for other countries undertaking health reform.