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India's health sector continues to be challenged by overall low levels of public financing, entrenched accountability issues in the public delivery system, and the persistent dominance of out-of-pocket spending. In this context, this case study describes three recent initiatives introduced by the central and state governments in India, aimed at addressing some of these challenges and improving the availability of and access to health services, particularly for the poor and vulnerable groups in the country. This includes two federal schemes introduced by the Government of India-the National Rural Health Mission (NRHM) of the Ministry of Health and Family Welfare and the Rashtriya Swasthya Bima Yojana (RSBY) of the Ministry of Labor and Employment-and the Rajiv Aarogyasri scheme launched by the state government of Andhra Pradesh. The three schemes discussed in this case study were designed and implemented by different agencies almost in parallel, over the same time period, and used different financing and delivery approaches. A discussion of the mechanics and operational features of these programs has been undertaken to unravel the underlying complexities, interactions, and interdependencies of these programs within the country's health system. The remainder of this case study on India's march toward universal health coverage focuses on three recent, prominent programs, and includes a discussion on the institutional structure of these programs and their interactions within the country's health system, their mechanisms for beneficiary targeting and enrolment, the benefits packages covered by them, accompanying innovations in public financial management, and their information environment. Annex one presents an overview of the health system and health financing in India, and annex two discusses the evolutionary context of India's Government sponsored health insurance schemes. The discussion of the mechanics and operational features of these programs has been undertaken to unravel the underlying complexities, ...

This book presents research findings on India's major central and state government-sponsored health insurance schemes (GSHISs). The analysis centers on the GSHISs launched since 2007. These schemes targeted poor populations, aiming to provide financial protection against catastrophic health shocks, defined in terms of inpatient care. Focus is on two lines of inquiry. The first involves institutional and "operational" opportunities and challenges regarding schemes' design features, governance arrangements, financial flows, cost-containment mechanisms, underlying stakeholder incentives, information asymmetries, and potential for impact on financial protection and on access to care and use by targeted beneficiaries. The second entails "big picture" questions on the future configuration of India's health financing and delivery systems that have surfaced, due in part to the appearance of a new wave of GSHISs.In addition to gains in population coverage, reaching about 185 million low-income beneficiaries by 2010, the new crop of schemes introduced a demand-side approach to public financing while embracing several innovation features, at least for the Indian context. These include: defined entitlements, separation of purchasing from financing, patient choice of providers, impressive use of information and communication technology and engagement with the private sector in the areas of insurance, administration and provision. Strong political interest in the schemes is also evident, especially at the state level and is a driver of increased public expenditures for health.The schemes face a number of operational challenges that have emerged during implementation and are examined in the book. They will need to strengthen institutional and governance arrangements, purchasing and contracting capacities, monitoring systems, and cost containment mechanisms.

Bhutan is situated between the Tibetan Plateau in the North and Indian plains in the south. The development philosophy in Bhutan is embedded in the concept of Gross National Happiness (GNH) that, as a public policy strategy, seeks to address a more meaningful purpose of development that goes beyond the fulfillment of material satisfaction. The concept is grounded in the four pillars of development; socio-economic, environment, culture, and good governance. Bhutan s record on growth and development has made it a top performer in the South Asian region. The average annual growth rate of GDP over 1980-2010 in country was more than 7.6 percent, one of the highest in the South Asian sub-continent (SAS). Bhutan, with a Gross Domestic Product (GDP) per capita of about US$2,000, is now classified as a lower-middle income country. However, one of the most notable features about Bhutan s macro economy is its lack of diversification, dependence on and exposure to external developments, and the high levels of year-to-year volatility in its economic growth. Public Expenditure Review (PER) begins with an overview of the macro-economic context (chapter two) and public sector management (chapter three) in Bhutan. This is followed by an analytical summary of achievements to date in the health and education sectors (chapters four and five). The PER concludes (chapter six) with policy options and recommendations which are intended to spur discussion and analysis among policy-makers in Bhutan as they look into different possibilities to increase fiscal space in domestic resources while enhancing the quality of expenditures and improving outcomes in the health and education systems.

Since independence, India has struggled to provide its people with universal health coverage. Whether defined in terms of financial protection or access to and effective use of health care, the majority of Indians remain irregularly and incompletely covered. Finally, and most recently, a new generation of Government-Sponsored Health Insurance Schemes (GSHISs) has emerged to provide the poor with financial coverage. Briefly, the main objective of these new GSHISs was to offer financial protection against catastrophic health shocks, defined in terms of an inpatient stay. Between 2007 and 2010, six major schemes have emerged, including one sponsored by the Government of India (GOI) and five state-sponsored schemes. This new wave of schemes provides fully subsidized coverage for a limited package of secondary or tertiary inpatient care, targeting below poverty populations. Similar to the private voluntary insurance products in the country, ambulatory services including drugs are not covered except as part of an episode of illness requiring an inpatient stay. The schemes have organized hospital networks consisting of public and private facilities, and most care funded by these schemes is provided in private hospitals. Ostensibly, the objective of any health insurance scheme is to increase access, utilization, and financial protection, and ultimately improve health status. Due to lack of evaluations and analyses of household data, the authors of this book do not examine the impact of health insurance in terms of these objectives. This book is not meant to highlight problems of the GSHISs, but rather to raise potential challenges and emerging issues that should be addressed to ensure the long-term viability of these schemes and secure their place within the health finance and delivery system.

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.

Any analysis of health financing issues has to begin with sound estimates of the level and flow of resources in a health system, including total levels of spending, the sources of health expenditures, the uses of funds in terms of services purchased, and in terms of who purchases them. The analysis should also aim at understanding how these resource flows are correlated with health system outcomes, including those of improving health, reducing health inequalities, and reducing the incidence of catastrophic health expenditure. National Health Accounts (NHA) provide a framework to collect, compile, and analyze such data on all types of health spending in a country and so create a robust evidence base for policy making. Although NHA data delineate the key financial metrics of a health system, the collection of these data have not been institutionalized in most developing countries. The root problems are often the same: insufficient resources to collect, collate, analyze and produce information on spending; poor development of health and other information systems; low levels of local capacity to interpret information to meet policy needs; and inadequate demand for data within countries. Furthermore, in many low- and middle-income countries, NHA activities have been conducted as ad hoc, donor-driven initiatives. Since 2008, the World Bank has been coordinating a global initiative to identify bottlenecks to the institutionalization of NHA, and to learn lessons in countries at different stages on the journey towards this institutionalization. The focus has been less on the production of NHA and more on its relevance as a tool to enable policy makers develop and implement evidence-based decisions, and better measure the impact of health reforms, especially those related to health financing. This report has been developed through a consultative process,

The objective of this study is to evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality.

Objectives To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality.

By 2016, Member States of the World Health Organization (WHO) had developed and implemented national action plans on noncommunicable diseases in line with the Global action plan for the prevention and control of noncommunicable diseases (2013-2020). In 2018, we assessed the implementation status of the recommended best-buy noncommunicable diseases interventions in seven Asian countries: Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam. We gathered data from a range of published reports and directly from health ministries. We included interventions that addressed the use of tobacco and alcohol, inadequate physical activity and high salt intake, as well as health-systems responses, and we identified gaps and proposed solutions. In 2018, progress was uneven across countries. Implementation gaps were largely due to inadequate funding; limited institutional capacity (despite designated noncommunicable diseases units); inadequate action across different sectors within and outside the health system; and a lack of standardized monitoring and evaluation mechanisms to inform policies. To address implementation gaps, governments need to invest more in effective interventions such as the WHO-recommended best-buy interventions, improve action across different sectors, and enhance capacity in monitoring and evaluation and in research. Learning from the Framework Convention on Tobacco Control, the WHO and international partners should develop a standardized, comprehensive monitoring tool on alcohol, salt and unhealthy food consumption, physical activity and health-systems response.