Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Acknowledgements Contents

This report was prepared as a collaboration between the World Bank, UNICEF, and Introduction 4 the Japan International Cooperation Agency (JICA), with financial support from the Country Progress on UHC: Identifying Positive Outliers 10 Government of Japan. Investigating UHC Gains in Outlier Countries 30 The report was produced under the direction of Tim Evans, Senior Director, Health, Nutrition and Population Global Practice (HNP), World Bank Group. The editorial team Shaping the Future 56 was composed of Alexander Irwin (Principal Editor/Writer), Magnus Lindelow (Practice Manager, HNP East and Southern Africa Region, World Bank), Mickey Chopra (Service Conclusions 76 Delivery Global Lead, HNP, World Bank), and Christoph Kurowski (Health Financing Global Lead, HNP, World Bank). References 79 Technical Annex 1 86 Technical contributions and comments were provided by the following World Bank Group staff: Federica Secci, Adam Wagstaff, David Wilson, Patrick Hoang-Vu Eozenou, Ajay Technical Annex 2 102 Tandon, Owen Smith, Son Nam Nguyen, Reem Hafez, Laurence Lannes, Jewelwayne Salcedo Cain, David Evans, David B. Evans, Ellen Van De Poel, Jeremy Veillard, Pia Endnotes 103 Schneider, Mukesh Chawla, Netsanet Walelign Workie, Shunsuke Mabuchi, Katelyn Jison Yoo, Annie Liying Liang, Annie Haakenstad, Moritz Piatti, Alessia Thiebaud, Aparnaa Somanthan, Marelize Gorgens, Mayo Hirabayashi, Aditi Nigam, Sulzhan Bali, Andreas Seiter, Irina Nikolic, Michele Gragnolati, Sarah Alkenbrack, Elyssa Finkel, Jedediah Fix, and Maria Eugenia Bonilla-Chacin.

Valuable comments and technical input was also provided by Minoru Matsunoshita (Ministry of Finance, Government of Japan), Takizawa Ikuo (JICA), Yoshii Yumiko (JICA), Ito Kenichi (JICA), David Hipgrave (UNICEF), Stefan Peterson (UNICEF), Kumanan Rasanathan (UNICEF), and Agnes Soucat (WHO).

Anugraha Palan and Sheryl Silverman oversaw media and communications for the report. Kurt Niedermeier was the principal graphic designer. Administrative support was provided by Juliet Teodosio, Gertrude Mulenga Banda, and Panida Srithong.

Responsibility for any remaining errors and omissions rests with the editorial team.

2 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 3 Since 2000, the world has advanced towards Universal Health Coverage (UHC) at an unprecedented pace.

But not fast enough. At present rates, the 2030 global UHC targets under the United Nations Sustainable Development Goals (SDGs) will not be met. Urgent action is needed to speed up gains in the two dimensions of UHC, health service coverage and financial protection, and to ensure that no one is left behind.

At a decisive time for the global UHC movement, this report addresses policy makers in countries that are striving to accelerate UHC gains, along with their national and global partners. The report argues that the way forward for UHC may involve action on two fronts. On the one hand, countries can get additional mileage from proven strategies, including by drawing on lessons from countries that have seen rapid UHC progress in the past. On the other hand, opportunities may exist for countries to surpass previous achievements by embracing a culture of “business unusual” in health systems based on continuous innovation, shared learning, and emerging models of collaborative leadership.

Accelerating Progress Towards Universal Health Coverage / 5 Definition and Monitoring

Universal Health Coverage (UHC) is Financial protection is captured by achieved when all people who need tracking the incidence of household health services (promotion, health spending that it is either prevention, treatment, rehabilitation, “impoverishing” (it pushes and palliation) receive them, without households below the poverty line undue financial hardship. or deeper into poverty) or “catastrophic” (it absorbs a defined Based on the WHO and World high percentage of a household’s Bank monitoring framework (WHO annual income or consumption). and World Bank 2014), service coverage is measured using tracer interventions in preventive and treatment services.

6 / Business Unusual The Global Learn from the Past Limitations Roadmap of the Report State of UHC to Shape the Future

Where does the global movement stand today? The first part of this report is retrospective. This report focuses on a few key UHC issues. The remainder of the report is structured as follows.

The latest Global Monitoring Report (GMR) highlights It aims to clarify lessons countries can learn from past Of necessity, it leaves many other important topics SECTION 2 progress on financial protection and service coverage, UHC experiences. To that end, it identifies a set of factors unaddressed. Data constraints and methodological Here we seek to identify low- and middle-income but it has been slower than hoped for. Reviewing country common among countries that made exceptional progress limitations of the retrospective portion of the report are countries (LMICs) that can be considered as UHC positive experiences since the start of the new millennium, on selected service coverage and financial protection discussed in detail in the technical appendix. In order outliers. To do so, we compare countries’ performance however, shows that some countries at different levels indicators between 2000 and 2015. It suggests that, by to construct an objective, reproducible method for on selected service coverage and financial protection of economic development have managed to make adapting proven approaches to their own settings, and by identifying UHC “high achievers” given limited data, we indicators over the period 2000-2015, highlighting a group outstanding progress on one or more dimensions of addressing stubborn implementation bottlenecks, more have compared countries’ performances on a narrow of countries that achieved exceptional gains. The analysis UHC during this period. countries can accelerate progress towards UHC. set of indicators. While this approach has the merit of also sheds light on equity, identifying countries that allowing consistent comparisons across countries, it achieved substantial advances in service coverage among >> What made these achievements possible? The second part of the report looks forward. underplays the complexity of country UHC experiences the poorest households. and neglects forms of health progress that the selected >> What lessons can be learned from these experiences It argues that, even as countries benefit from models of indicators do not capture. It is thus important to SECTION 3 that may inspire and inform progress elsewhere? success, they must prepare to manage deeper health emphasize that the positive outlier countries identified Next, we ask what may explain outliers’ success. Progress >> Equally important, how are determinants of health system transformations now on the horizon. Spurred by in the first part of this report are not the only ones that towards UHC is shaped by a complex interplay of factors systems progress likely to change in the coming political, economic, social, technological, demographic, have recently achieved impressive UHC gains and within and outside the health sector, and success or decades, and what new challenges and opportunities and epidemiologic forces, these transformations will whose experiences may carry important lessons for failure can never be explained with certitude. However, for UHC may result? reshape the landscape in which countries pursue others. Similarly, although the featured outlier countries the analysis draws on existing frameworks and identifies their 2030 UHC goals, creating new risks but also have made progress on the indicators that are the focus several health policy approaches adopted by many outlier This report seeks to open paths of reflection on these opportunities. This report does not attempt to provide of the report, this does not necessarily mean that there countries during the period, and which appear as potential issues. It encourages policy makers to anticipate coming specific policy prescriptions for negotiating the coming has been commensurate progress in other areas. common success factors. changes and suggests conceptual compass points that changes. Instead, it identifies broad principles that may may facilitate UHC innovations. help countries seize opportunities and manage risks in The forward-looking portion of the report suffers from SECTION 4 the new era, opening pathways for accelerated progress the limitations common to all efforts to project future We conclude by turning towards the future. This towards UHC. realities based on current conditions and trends. section presents evidence that policies associated with The best way to detect flaws and omissions in our earlier UHC success, while vital to apply, are unlikely treatment of the future of health systems and UHC will to lift countries to their 2030 UHC goals. The section be to triangulate our arguments with those of others then explores economic, demographic, technological, asking similar questions. This type of debate, mutual and other forces likely to shape health systems in the questioning, and shared learning is exactly what our decades ahead, posing new challenges while opening report seeks to advance. unprecedented opportunities. The concluding portion of the section proposes broad principles country health Accordingly, this report is open-ended and interrogative. leaders may consider as they seek to harness these forces Its aim is to stimulate and expand shared inquiry, to accelerate UHC gains. The picture has implications for making a modest contribution to a larger collective models of health leadership in countries. It also points to process. Only a many-sided conversation can point the the need for global UHC leadership to more effectively way forward for Universal Health Coverage. support UHC innovation, learning, and knowledge sharing within and across countries. A future systems science for UHC implementation and innovation may inform this work and increase its impact. Global UHC partners have an opportunity now to invest in building that science and ensuring wide dissemination of its benefits.

8 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 9 Excellence may be contagious. If we can identify countries that have made rapid progress towards UHC and highlight some of their distinctive features, this provides one starting point for identifying policies and innovations that may help other countries accelerate gains in their turn.

In an attempt to do so, we looked at results for selected service coverage and financial protection indicators in LMICs over the period 2000-2015. The review consisted of three steps. First, we identified countries that achieved rapid progress in the first key dimension of UHC, service coverage. We took special note of countries that made rapid gains in service coverage specifically among the poor. Next, we identified countries that made progress in the second key dimension of UHC, financial protection. Finally, we combined the results from the first two stages to assess how countries fared in advancing UHC agendas overall.

The lack of systematic, standardized, and internationally comparable household data for several components of UHC limited the scope of this analysis. Firstly, service coverage is represented here by a limited set of interventions (See the section on progress in service coverage, below, for more details). Moreover, data to assess progress among the poor is only available for roughly two-thirds of LMICs included in the analysis. Similarly, the sample for financial protection is limited to 46 countries for which data are available to review progress over time. In addition to these data limitations, we do not account for factors outside the control of health policy makers that may have substantially influenced progress toward UHC. These include factors such as economic growth and political and governance context, as well as disaster and conflict. As future analyses refine this work, such variables can be incorporated to provide a more comprehensive and nuanced picture.

We have chosen to develop an analysis that spans the period 2000-2015, from the adoption of the UN Millennium Development Goals (MDGs) to their target year. This period makes sense for several reasons. First, it is long enough to register substantive evolution in countries’ health systems. Second, the MDG era coincides with a time in which the global UHC movement gained momentum. During this period, a substantial number of countries introduced health system reforms aligned with UHC principles. Third, this was a watershed era during which global health investments increased dramatically; many countries showed new levels of leadership in health; ambitious global initiatives (e.g., GFATM, GAVI, PEPFAR) were launched; and new institutional players including influential private philanthropies (e.g., the Bill and Melinda Gates Foundation) entered the arena, contributing to health advances in many settings.

Accelerating Progress Towards Universal Health Coverage / 11 COUNTRY PROGRESS ON UHC Outliers in progress on service coverage ______and financial protection, 2000-2015 FIG. 2.1 ______

The positive outliers identified below are countries where there is a good chance of finding health policy innovations that may have contributed to strong progress towards UHC. Section 3 of this report will pursue that lead. For now, let’s look in more detail at the analytic process that brought us A Fresh Perspective—And Encouraging Results to this set of outlier countries.* Despite its limitations, this initial analysis provides a lens to help bring some remarkable country achievements into view. Although UHC gains in the aggregate need to accelerate further, many countries have made impressive progress on aspects of UHC since 2000. Based on the analysis, several country experiences during the MDG years give cause for optimism about what can be achieved. They include a group of countries that registered a rapid reduction of service coverage gaps across a set of core interventions while also making progress on financial protection (Figure 2.1, and Technical Annex 2). Countries scoring remarkable successes included low- and middle- Countries with SC Data income countries.

Rapid SC Progress Progress on Service Coverage

Angola Honduras* Burkina Faso FP Progress To start, we focus on service coverage. We consider four tracer indicators: Azerbaijan Liberia Kazakhstan* 1 completion of four antenatal care visits (ANC4) Botswana* Myanmar* Lao PDR Albania* Guinea 2 in-facility delivery Brazil* Namibia* Peru* Bangladesh Mozambique 3 met need for contraceptives Cambodia Sierra Leone Rwanda Bosnia* Pakistan 4 DTP3 vaccination coverage (a detailed discussion of data and methodological Colombia* Thailand* Turkey* Congo Rep.* Zambia* issues can be found in Technical Annex 1) Egypt* Vietnam* Guatemala* Although multiple UHC-relevant service indicators and indices exist, we chose these China* Nicaragua* indicators for three main reasons. First, we want to rely on output data, such as service India Nepal Countries with FP Data coverage, as opposed to input data, such as service delivery capacity indicators (e.g., health worker density). The latter represent the availability of services, but do not reflect the share of people in need that receive services. Second, we limit the analysis to *High-baseline countries indicators with household data available for all developing countries. Third, among this group, we prioritized a set of indicators without strong interdependencies that reflect different types of service delivery capacities. For example, countries’ levels of institutional delivery provide an important indication of how well systems operate across levels of care. ANC4 provides an indication of system abilities to overcome demand- and supply- side constraints and ensure regular contacts with the system. Finally, contraception uptake suggests how systems shape and respond to the evolving demand for health services. We recognize that this approach provides only a limited view of the full notion of universality, and further analysis is needed as better data become available. *The seven countries at the center of the figure made progress in both service coverage and financial protection during this period. The group of high-baseline countries includes countries that started out with high service coverage levels (>50 percent) for four selected interventions in 2000. Low-baseline countries are those whose average service coverage levels for the four interventions were <50 percent in 2000. See the discussion below and the Technical Annexes for a more complete account of how these countries were identified, and for an explanation of data constraints. For our variables of interest, we found: 62 countries with sufficient service coverage (SC) data but insufficient financial protection (FP) data; two countries with insufficient SC data but sufficient FP data; 25 countries with both insufficient SC and insufficient FP data; and 10 countries that were excluded due to having population less than 1.5 million in 2015. These relationships are presented graphically in Technical Annex 2.

12 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 13 COUNTRY PROGRESS ON UHC Coverage gap reduction, low-baseline countries, ______

2000-2015 FIG. 2.2 ______

Baseline (2000) and endline (2015) coverage is shown in ranges above the bars. “Coverage gap reduction” in this study represents the relative, not absolute, reduction between 2000 and 2015 in the gap separating a country’s coverage level from 100 percent. It is calculated as (C2015-C2000)/(100- While interested in capturing health system capacities, we recognize the wide variation C2000) where C2000 represents the coverage in in system status at the outset of the MDG era. We therefore grouped countries based on their starting level of achievement against the four indicators (specifically, their arithmetic 2000 and C2015 is the endline coverage in 2015. average result across all four). We established a cut-off at 50 percent coverage at baseline The coverage gap at a given time is the difference in 2000. Countries with averages below 50 percent are defined as low coverage baseline countries (LBCs). Countries starting out above 50 percent are defined as higher coverage in percentage points between a country’s coverage baseline countries (HBCs). A given country will be compared only with others in its group. level and 100 percent. The outcome that interests us is how countries fared in reducing health service coverage gaps: that is, in extending coverage of four key services to people previously excluded. We define a country’s “coverage gap” as the number of percentage points that separated its initial coverage level from 100 percent. For example, a country with 44 percent coverage in 2000 started with a coverage gap of 56 percent. To assess countries’ performance, we compare their relative gap reductions: the portion of their respective coverage gaps that they eliminated between 2000 and 2015.1 80% 80% 27 - 78% Results for Low-Baseline Countries 70% 70% In 2000, coverage across the four indicators was less than 50 percent in 37 out of 108 2

31 - 71% LMICs, home to 2.5 billion people. Countries in this group started with an average service 60% 60% coverage of 34 percent and registered an average coverage increase of 20 percentage

42 - 72% points from 2000 to 2015. By 2015, the list of countries with less than 50 percent 33 - 66% coverage had been reduced to 13, or in population terms from 2.5 billion to 473 million 34 - 64% 47 - 71% 50% 50% people.3 This is impressive progress. 32 - 61% 37 - 64% 40 - 66% 29 - 57% Individual countries achieved even more remarkable performances. In the graph on page 14 40% 40% (Figure 2.2), the green bars indicate the coverage gap reduction for the ten countries that achieved the largest coverage gap reductions among LBCs (top 25 percent of countries). Combined, they are home to more than 1.4 billion people. They include Cambodia, 30% 30%

COVERAGE GAP REDUCTION (% ) Rwanda, Azerbaijan, Sierra Leone, Burkina Faso, India, Lao PDR, Nepal, Liberia, and

33 - 46 % Angola. Like their peer LBCs, they started with an average service coverage of around 35 percent, but these top-performing countries registered an average coverage increase of 20% 30 - 39 % 20% 32 percentage points (coverage gap reduction of almost 50 percent), in contrast to a 9 percentage-point increase among the low performers (bottom 25 percent of countries).

10% 10%

0% 0% India iberia Nepa l L Angola ao PD R Rwand a L Cambodia Azerbaijan Bottom 19 Bottom 10 Sierra Leon e Burkina Faso

14 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 15 Absolute Service Coverage Gap Reduction

1990-2015 FIG. 2.3 ______Business Unusual: This figure compares countries with slower Shifting UHC Gains into Higher Gear (dark line) versus more rapid (white line) progress.

In figure 2.3 on page 16, we show how LBCs narrowed their coverage gaps over the period 1990-2015. The dark line represents the countries that progressed slowly (the — Low baseline, slow gap reduction (< 50th percentile) — Low baseline, rapid gap reduction ( > 75th percentile) 19 poorest-performing countries out of the 37—i.e., the countries below the 50th percentile). Even these countries 80% registered substantial reductions in their coverage gaps over the period, but their line follows a steady, gradual 70% slope with no acceleration.

60% The white line, though, shows the progress achieved by the well-performing countries (the top nine countries in 50% terms of coverage improvements—i.e., above percentile 75). We see a marked acceleration of these countries’

40% progress in the time period that corresponds to the early

COVERAGE GAP (% ) 2000s. The curves for individual high-performing countries

30% show the same pattern of accelerated progress in the pursuit of UHC.

20%

10%

0% 1990 1995 200020052010 2015

16 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 17 Coverage gap reduction, high-baseline countries,

2000-2015 FIG. 2.4 ______Results for High-Baseline Countries

Baseline and end line coverage is shown in ranges Many LMICs started the millennium with higher average baseline coverage levels above the bars. ( > 50 percent). These are countries that would tend to have higher income and more developed health systems. They represented 3.6 billion people in 2015. On average, countries in this group started with a coverage of 75 percent and registered a 9 percentage-point increase, reducing the coverage gap by roughly one-third (33 percent).

Figure 2.4 shows results among countries with rapid progress in the high baseline coverage group, highlighting the 14 countries with the largest reductions in the coverage gap (countries in the 20th performance percentile or above). Together, rapid-progress high-baseline countries are home to more than two billion people. These countries include China, Egypt, Colombia, Nicaragua, Namibia, Turkey, Botswana, Brazil, Honduras, Thailand, Peru, Myanmar, Turkey, Kazakhstan, and Vietnam. Like their HBC 80% 80% peers, on average, they started with a coverage level of approximately 75 percent, but attained a coverage increase of roughly 14 percentage points, compared to virtually no progress in the low-performing HBCs (bottom 25 percent). Top-performing HBCs thus 78 - 94% reduced their coverage gap by 50 percent. 70% 70% 69 - 88%

FIG. 2.5 82 - 92% Change in Service Coverage for the Poor ______60% 60%

77 - 89% Skilled birth attendance, lowest income quintile, 72 - 86% 60 - 79% 77 - 88% 92 - 96% 75 - 87% baseline coverage versus annual rate of change, 73 - 86% 50% 85 - 92% 50% 53 - 75% 85 - 92% 64 - 80% 65 LMICs.

40% 40% Burundi 6

Rwanda

COVERAGE GAP REDUCTION (% ) Cambodia 30% 30% Honduras 4 Egypt Peru 77 - 82% Sierra Leone Malawi Pakistan Liberia Burkina Faso 20% 20% Zambia Bangladesh Colombia 78 - 81% 2 Ghana Indonesia Namibia Nepal Philippines Congo Laos Cote dIvoire

10% 10%

0 nnual change in coverage (2000-2015), lowest income quintile

0% 0% A Peru Brazil Chin a Turke y Vietnam Namibia

Thailan d 2 Myanmar Colombia Hondura s Botswan a Nicaragu a Bottom 35 Bottom 18 0102030405060708090 100 Kazakhstan

Egypt, Arab Rep. Baseline (2000) coverage, poorest income quintile

18 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 19 COUNTRY PROGRESS ON UHC ______

Inequality in Service Coverage

An earlier landmark study demonstrated that countries with the greatest service coverage For these three indicators, Figures 2.5 to 2.7 compare coverage increases among the poor increases among the poor also achieve the greatest overall increases in coverage (Victora (bottom income quintile), measured as the annual rate of change, with the coverage in the et al. 2012). The study also reported that coverage improvements among the lowest baseline year for the same group. A finding common for all three indicators is that some income quintile are not the result of a capping effect, that is, the consequence of limited countries achieved substantial coverage gains among the poor not only from low, but also scope for improvements among rich households. from high baseline coverage rates among the lowest income quintile. There is, however, some variation across the different types of interventions. For DTP3, many countries have Complementing the picture of service coverage dynamics among the poor, we looked managed to attain large coverage increases from a baseline above 50 percent. However, for additional trends using three coverage indicators. These do not fully overlap with the for the two other indicators, large increases are observed primarily at lower levels of indicators for coverage used in the earlier analysis due to data constraints.4 We used baseline coverage. For SBA, the overall coverage gains have been slower than for the skilled birth attendance (SBA), for which coverage, as in the case of institutional deliveries, other two indicators, yet, many countries have managed significant progress even for depends on functional facility-based health services that ideally are available all the time. such a relatively complex intervention. Noteworthy for family planning is the fact that SBA Previous analysis has found SBA to be one of the most inequitable coverage indicators coverage has decreased in several countries. (Victora et al. 2016). Coverage with DTP3, as indicated earlier, is the result of service delivery not just from fixed sites but also through outreach services and campaigns. Family planning is also used as an example of an intervention that is more sensitive to demand- side factors.

Change in Service Coverage for the Poor FIG. 2.6 Change in Service Coverage for the Poor FIG. 2.7 ______

DTP3, lowest income quintile, baseline coverage Family planning, lowest income quintile, baseline versus annual rate of change, 64 LMICs. coverage versus annual rate of change, 71 LMICs.

Sierra Leone Kyrgyzstan 8 4 Rwanda Lesotho Burundi Cambodia Liberia Guatemala Uganda

Honduras Senegal Pakistan Malawi 6 2 Ethiopia

Liberia

Burkina Faso

4 Togo 0 Niger DRC Sierra Leone Uganda Viet Nam Cambodia Bosnia and Herzegovina Haiti Dominican Republic Bangladesh Colombia Mali Macedonia 2 Congo Nepal Tanzania -2 MozambiqueGhana Bottom 20%, Annual Change (%pts) Bottom 20%, Annual Change (%pts)

0 -4

2 -6 0102030405060708090 100 0102030405060708090100

Bottom 20%, Baseline Coverage (%) Bottom 20%, Baseline Coverage (%)

20 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 21 COUNTRY PROGRESS ON UHC ______Financial Protection Results: Low-Baseline Countries

Progress on Financial Protection The figures on pages 24-25 show how 15 LBCs The second pillar of UHC is financial protection. We use two Global Monitoring Report performed in increasing financial protection by (GMR) indicators to assess countries’ progress: reducing catastrophic health expenditures and Indicator 1 Indicator 2 ______cutting the number of families pushed into poverty The reduction in incidence of financial The reduction in the proportion of catastrophe linked to large out-of-pocket households pushed below the by health spending. The countries represented by (OOP) health payments, defined as the international poverty line of $1.90 per day green triangles are those that saw rapid gains in number of households spending more (in 2011 PPPs) by OOP health spending.6 than 10 percent of their total consumption service coverage. In each of the charts, left is bad 5 on OOP health payments. and right is good. The further to the right countries are on the graph, the larger the annual reduction The two indicators measure slightly different effects of the lack of financial protection in health. The second indicator only quantifies the proportion of households who would not they achieved in the incidence of catastrophic be living in poverty had they not incurred OOP health spending. However, catastrophic health spending (captured by the first indicator) can occur to people at all income health expenditures or impoverishment due to levels, sometimes pushing them under the poverty line, but sometimes not. Even when health spending. not pushed below the poverty line, people must still often adjust their spending and consumption patterns to compensate for high health spending—e.g., by drawing on savings, selling assets, borrowing, or foregoing consumption of necessities such as For example, looking at annual change in the incidence of catastrophic health housing, food, and clothing. expenditures (Figure 2.8a), Guinea and Burkina Faso achieved the best results—strongly reducing the proportion of households that experienced catastrophic health spending— Data constraints limited our sample to 46 of the 108 countries (15 LBCs and 31 HBCs) while Nigeria and Nepal saw large increases in the proportion of people suffering for which service coverage data were considered in the last section. We continue to look catastrophic expenditures. separately at low service coverage baseline countries (LBCs) and higher service coverage baseline countries (HBCs). This is because we still want to compare countries only with Guinea, Burkina Faso, Pakistan, Mozambique, and Bangladesh show progress in both others that had similar health system starting conditions. indicators. This means the financial protection situation was improving in these countries for the period covered by the expenditure surveys. We also consider Rwanda and Lao Findings on financial protection indicators must be interpreted with caution to understand PDR as countries with gains in financial protection. Rwanda showed a largely stable rate country progress toward UHC. Most importantly, they must be read against progress of impoverishment using a poverty line of $1.90, with a fall in catastrophic health on service coverage. For example, any deterioration in financial protection indicators, spending (CATA). However, using the higher poverty cut point of $3.10, impoverishment especially in the incidence of large OOP payments, may result from people gaining access from OOP spending in Rwanda fell. Lao PDR showed substantial drops in impoverishment to more services that entail some direct household payments, in other words, from due to OOP health payments, along with stable levels of catastrophic spending, so it improvements in service coverage. In turn, apparent improvements in financial protection certainly did better in protecting people from becoming poor due to OOP expenditures. may result from more people foregoing care when they need it. In Section 3, we therefore focus on countries that made progress in both service coverage and financial protection indicators. But before getting to that, let’s look at the findings concerning country progress on financial protection.

22 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 23 COUNTRY PROGRESS ON UHC Annual percentage point reductions from 2000- ______2015 in the incidence of large and impoverishing OOP expenditures, low-baseline countries

Catastrophic Spending on Health FIG. 2.8a Impoverishing Spending on Health FIG. 2.8b ______

LOW BASELINE COUNTRIES LOW BASELINE COUNTRIES

Guinea (2002-2012) Nepal (2003-2010)

Burkina Faso (2003-2009) Pakistan (2001-2010)

Pakistan (2001-2010) Guinea (2002-2012)

Cote d'Ivoire (2002-2008) Lao PDR (2002-2007)

Rwanda (2000-2010) Burkina Faso( 2003-2009)

Mozambique (2002-2008) Bangladesh (2000-2010)

Bangladesh (2000-2010) Mozambique (2002-2008)

Mali (2001-2006) Senegal (2001-2011)

Lao PDR (2002-2007) Cameroon (2001-2014)

Cameroon (2001-2014) India (2004-2011)

Niger (2005-2011) Rwanda (2000-2010)

Senegal (2001-2011) Cote d'Ivoire (2002-2008)

India (2004-2011) Niger (2005-2011) SC Breakthrough countries SC Breakthrough countries Other countries Other countries Nigeria (2003-2009) Mali (2001-2006)

Nepal (2003-2010) Nigeria (2003-2009)

-2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 -0.25 -0.20 -0.15 -0.10 -0.05 0.0 0.05 0.01 0.15 0.20 0.25 0.30

Annual (%pts) change in protection from catastrophic payments (10%) Annual (%pts) change population protected from impoverishment ($1.90)

Note: For catastropic spending, we report annual percentage point changes in the share of the population protected from Note: For impoversihing spending, we report annual percentage point changes in the share of the population protected catastrophic payments at 10% threshold. from impoverishment at $1.90 poverty line. Financial Protection Results: Annual percentage reductions from 2000-2015 in the incidence of large and impoverishing OOP High-Baseline Countries expenditures, high-baseline countries

Catastrophic Spending on Health FIG. 2.9a ______

CATASTROPHIC SPENDING ON HEALTH

Figure 2.9a-b shows progress for the 32 HBCs Congo, Rep.: 2005-2011 Guatemala: 2000-2014

during the periods covered by the household Albania: 2002-2012 expenditure surveys. The following 10 countries Bosnia/Herzegovina: 2001-2011 showed progress in extending financial protection Ukraine: 2002-2013 Zambia: 2004-2010 in terms of both indicators: Albania, Bosnia and Turkey: 2002-2012 Herzegovina, Cape Verde, Guatemala, South Africa: 2000-2010 Vietnam: 2002-2014

Kazakhstan, Peru, Republic of Congo, Turkey, Peru: 2000-2015 Vietnam, Zambia. Mexico: 2000-2012 Kyrgyz Republic: 2005-2011

Kazakhstan: 2001-2013

Among these countries, we have seen that four Lithuania: 2000-2010 also achieved strong gains on our service Sri Lanka: 2002-2009 coverage indicators in the period 2000-2015. Indonesia: 2001-2015 Mongolia: 2002-2012 These countries were Kazakhstan, Peru, Turkey, Serbia: 2003-2010 and Vietnam. Accordingly, these four countries are Belarus: 2000-2012 Kosovo: 2003-2011

included in the group of overall UHC positive Philippines: 2000-2015 outliers (Figure 2.1). Bulgaria: 2000-2010 Romania: 2000-2012

Macedonia, FYR: 2000-2008

Iran, Islamic Rep.: 2005-2015

Moldova: 2000-2013

Costa Rica: 2004-2012 SC Breakthrough countries China: 2000-2007 Other countries Nicaragua: 2001-2014

Georgia: 2000-2013

Morocco: 2000-2006

-2.0 -1.0 0.0 1.0 2.0 3.0

Annual (%pts) change in protection from catastrophic payments (10%)

Note: For catastropic spending, we report annual percentage point changes in the share of the population protected from catastrophic payments at 10% threshold.

26 / Business Unusual COUNTRY PROGRESS ON UHC ______Conclusion

Impoverishing Spending on Health FIG. 2.9b ______This section has used quantitative measures and a reproducible process to identify a group of countries that can be considered as UHC positive outliers for the period 2000- 2015. The procedure used is exploratory and has clear limitations, not least the lack IMPOVERISHING SPENDING ON HEALTH of data on important dimensions of UHC for many countries. However, this approach provides one means of objectively identifying some countries whose UHC progress Congo, Rep.: 2005-2011 during these years was unusually strong. Clearly, these are not the only countries that Vietnam: 2002-2014 have made remarkable advances against criteria of UHC achievement since the turn Kyrgyz Republic: 2005-2011 of the millennium, nor the only ones whose experience may carry valuable lessons for

Macedonia, FYR: 2000-2008 others trying to accelerate UHC gains. Yet, the country experiences highlighted in this analysis are noteworthy and merit careful investigation to identify policies and practices Moldova: 2000-2013 that may have contributed to success. Indonesia: 2001-2015 Zambia: 2004-2010 The next section will therefore explore some of the health policies and delivery China: 2000-2007 strategies used by these outlier countries and others where rapid UHC progress has been documented. The goal is not to assert causal connections, but to open paths for Peru: 2000-2015 further learning. Albania: 2002-2012

Mexico: 2000-2012

Ukraine: 2002-2013

Romania: 2000-2012

Kazakhstan: 2001-2013

Iran, Islamic Rep.: 2005-2015

Sri Lanka: 2002-2009

Mongolia: 2002-2012

Bosnia/Herzegovina: 2001-2011

Turkey: 2002-2012

Belarus: 2000-2012

Guatemala: 2000-2014

Lithuania: 2000-2010

Kosovo: 2003-2011

Bulgaria: 2000-2010

Morocco: 2000-2006

Costa Rica: 2004-2012

Serbia: 2003-2010 SC Breakthrough countries South Africa: 2000-2010 Other countries Philippines: 2000-2015

Georgia: 2000-2013

Nicaragua: 2001-2014

-0.20 -0.10 0.0 0.10 0.20 0.30 0.40 0.50

Annual (%pts) change population protected from impoverishment ($1.90)

Note: For impoversihing spending, we report annual percentage point changes in the share of the population protected from impoverishment at $1.90 poverty line.

28 / Business Unusual The last section identified a group of countries that made unusually rapid progress on key UHC indicators during the period 2000-2015.

What factors may have contributed to their success? This section will not provide definitive answers, but it offers some preliminary insights and may help us ask better questions. Studying the policies and approaches implemented by UHC outliers suggests patterns that can guide further research. This is our goal.

Progress from Diverse Starting Points: Two Country Examples

An important finding from the analysis in Section 2 is that countries with very different health system starting points and economic conditions achieved substantial UHC gains during the MDG era. Let’s consider what this looked like in two specific cases.

Sierra Leone and Vietnam differ sharply in geographic, demographic, economic, and epidemiologic terms. Both countries still have far to go to reach UHC goals. Yet each was able to make impressive advances on the service coverage and financial protection indicators included in our analysis. An intuitive first step is to ask what salient health policies such countries were implementing during their periods of rapid progress. The associations observed will help us take the investigation further.

Sierra Leone began the new millennium with low levels of health service coverage, high poverty, and scant domestic revenues to finance public services. Just coming out of a devastating civil war, the country was heavily reliant on development assistance for health. Nevertheless, Sierra Leone achieved some notable gains before the setbacks brought on by the Ebola virus outbreak. Between 2008 and 2013, the proportion of children fully vaccinated by 12 months of age increased from 31 to 58 percent, and the proportion of children under five with fever who received anti-malarial drugs increased from 30 to 48 percent. Nutritional outcomes improved as well—the under-5 stunting rate decreased from 37 to 29 percent, and the wasting rate from 10 to 5 percent.

Accelerating Progress Towards Universal Health Coverage / 31 INVESTIGATING UHC GAINS Sustained economic growth, albeit from a very ______low base, allowed the government to put more resources towards health during these years.

Government leadership on health encouraged donors to follow (Donnelly 2011). This No Simple Answers, but Some Emerging Patterns allowed an increase in the number of health workers through expansion of training facilities and increased public-sector deployment (Bertone et al. 2014; Witter, Haja, The stories of Sierra Leone and Vietnam confirm that no two UHC outlier countries had and Bertone 2015). New cadres of health workers were also introduced. In 2010, identical approaches. However, these countries’ experiences also suggest that progress the government moved decisively to address demand-side barriers by providing over the last 15 years has been underpinned by complementary reforms and innovations free preventive and curative health services for pregnant women, lactating mothers, across the service delivery, financing, and governance domains. and children under five years in any public health facility, while creating financial incentives for service productivity (Bertone et al. 2014; Witter, Haja, and Bertone 2015). Outlier countries have differed in when reforms were initiated (some preceded 2000), Decentralization has been another prominent feature of Sierra Leone’s health agenda, their mix, and scale of implementation, making it hard to draw a straight line from a set with most primary care financing and management now conducted through local of reforms and innovations to improvement in outcomes. Moreover, many factors outside government and district teams. the health sector, such as trends in economic growth, infrastructure, poverty, and education, probably also played a role in health and coverage gains. Although progress has been made in increasing coverage, a recent review identified ongoing challenges such as stock-outs of essential drugs and other medical supplies, It is widely acknowledged that there is no single recipe or one-size-fits-all approach a still-inadequate health workforce, and under-the-table payments. In addition to their to make progress towards UHC. Country contexts, including economic conditions, chronic negative impacts, these flaws also contributed to Sierra Leone’s difficulties in health system characteristics, social values, and political processes, matter. Yet, it is controlling the Ebola virus outbreak. Ebola’s destruction, in turn, has exacerbated pre- also recognized that rapid progress will require strengthening critical aspects of health existing health-system flaws and reversed some earlier advances (Bertone et al. 2014). systems. Looking at health policies common across outlier countries can show us the kinds of system-strengthening measures countries were using during a time in which In contrast to Sierra Leone, by 2000, Vietnam had already reached relatively high they registered major gains relevant to UHC. Identifying such patterns is an important baseline coverage levels for many essential health services. In the following years, the step towards better understanding how to accelerate UHC progress across countries, country was able to go further. Vietnam made major strides in expanding access to even though case analysis falls short of causal proof. services, in many cases outperforming peer countries. At the same time, it reduced the incidence of large and impoverishing out-of-pocket payments. Part of the success can be ascribed to health-financing reforms targeting the poor and vulnerable. In 2005, Identifying Policy Entry Points health care was guaranteed free-of-charge for children under six through Vietnam’s social health insurance scheme (Lieberman and Wagstaff 2009). In 2009, free and Outlier countries generally implemented many different health policies and delivery subsidized social health insurance coverage was expanded to include the poor, strategies during the period 2000-2015. Which ones do we focus on? elderly, and students. These reforms have been successful thanks to strong political commitment, including the willingness to invest in service coverage expansion and Recent UHC policy frameworks provide guidance. The joint vision document of the financial protection. Between 2005 and 2014, Vietnam more than doubled health UHC2030 alliance, for example, identifies key policy entry points across the three spending as a share of total government expenditures, from 6 percent to 14 percent domains of service delivery, financing, and governance (UHC2030 2017). Similarly, (WHO 2015). For Vietnam, as for Sierra Leone and other UHC outliers, a long road in the 2016 UHC in Africa framework, a set of priority policy actions to accelerate still lies ahead. But these countries’ achievements in the study period confirm that UHC progress across the continent were proposed (World Bank et al. 2016). Table remarkable gains are possible. 1 compiles a synthesis of UHC policy entry points from these two key normative documents. We have drawn on these sources to structure our investigation of policy measures in outlier countries.

32 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 33 Table 3.1 Complementing the UHC2030 joint vision and Synthesis of Policy Entry Points to the UHC in Africa framework, the following discussion focuses on how countries have been Accelerate Universal Health Coverage able to transform their health systems in ways that resonate with the principles and policy entry points identified in those consensus documents.

We focus primarily on the positive outlier countries identified by the analysis in Section 1 / 2 / 3 / 2, although in some cases we also cite examples from other countries that have scored substantial UHC gains. All these countries’ experiences are significant in that they illustrate how clarity of vision, a willingness to look for new solutions, and a focus on results can drive significant change in how the health system is organized and in the Service Delivery Financing Governance outcomes achieved.

______Aspects of governance such as leadership and strengthening institutional capacity are essential to UHC progress (UHC2030 2017), and there are some indications that outlier countries innovated productively in this area. However, the challenges of adequately >> Strengthen primary health care >> Reduce financial barriers to >> Establish platforms for societal capturing these features and limited published evidence mean that these topics will not and community services access, with focus on the poor dialogue and multi-sectoral action be examined in this report – it remains an important task for future research. >> Improve quality and patient safety and the informal sector >> Strengthen monitoring and >> Target services for poor and >> Scale up pro-poor interventions reporting on UHC and promote Instead, our discussion focuses on the more proximate factors influencing service marginalized populations such as demand-side incentives access to information coverage and financial protection in the UHC consensus frameworks. In some cases, for >> Invest in the workforce and >> Enhance efficiency in spending, >> Adopt legal frameworks the sake of brevity and clarity, we will link multiple entry points from the frameworks under supply chains including through strengthened supporting access to services a single heading. For example, in our discussion of financing for UHC, the topic labeled >> Engage with non-state actors purchasing >> Strengthen institutional capacity “Reducing financial barriers” encompasses two entry points from Table 3.1: (1) reducing >> Increase prepaid and pooled to implement UHC financial barriers to access, with a focus on the poor and the informal sector, and (2) financing for health and improve >> Improve preparedness plans and scaling up pro-poor interventions, such as demand-side incentives. effectiveness of development capacity to implement and assistance for health monitor IHR >> Strengthen research and development, including technology transfer mechanisms

Note: Authors’ compilation based on UHC2030 2017 and World Bank et al. 2016. The wording and sequence of policy entry points have been altered from those in the source publications, with the aim of creating a single table that captures the key points from both documents. IHR = International Health Regulations. Accelerating Progress Towards Universal Health Coverage / 35 INVESTIGATING UHC GAINS 1 / ______

Service Delivery

Strengthen Primary Health Care and community services Improve quality

Health facilities and human resources are a critical foundation for progress towards Expanding frontline services has required new and creative approaches to capacity UHC. Outlier countries focused major efforts in these areas. For example, Burkina Faso building and health systems management. Examples include the simplification and expanded its network of primary care facilities between 2003 and 2010, substantially integration of clinical protocols, for instance with the Integrated Management of reducing the average distance people had to travel to reach a primary care facility. This Childhood Illness (IMCI). Development of inter-disciplinary and problem-based learning effort was complemented by reinforcement of frontline referral networks, for example, by has facilitated more effective frontline teams. increasing the number of rural district hospitals with surgical capacity. Cambodia also increased its number of health centers and referral hospitals, with a focus on remote and Achieving and sustaining quality of care has been a challenge. A systematic review of 80 inaccessible areas. studies, largely from Africa and Asia, showed that suboptimal clinical practice is common in both private and public ambulatory health sectors of several LMICs (Berendes et al. These efforts have often involved substantial expansion of both the numbers and types 2011). The Service Delivery Indicators (SDIs) Initiative systematically evaluated quality of of health workers, along with incentives to deploy them in previously underserved care in nine Sub-Saharan African countries and found that there was significant variation areas. Most outlier countries increased the number of publicly and privately funded in provider absenteeism (14.3‒44.3 percent); productivity per day (5.2‒17.4 patients); training institutions for health professionals, while expanding the government-paid health diagnostic accuracy (34‒72.2 percent); and adherence to clinical guidelines (22‒43.8 workforce. Countries such as Rwanda, Nepal, Malawi, and Ethiopia complemented percent) (SDI 2017). Researchers observed frequent misdiagnosis of common medical this with national deployment of community or health extension workers. Initiatives to conditions such as pneumonia, tuberculosis, diarrhea with severe dehydration, malaria encourage wider deployment of health workers, such as compulsory service, affirmative with anemia, and type 2 diabetes. selection of rural student health workers, financial incentives, and improved living infrastructure have achieved mixed results. Some countries have been able to demonstrate tangible progress in boosting quality. Turkey, for example, introduced the Health Transformation Program in 2002, which led In the case of countries starting with higher baseline coverage in 2000, including to significant improvements in coverage (insurance coverage increased from 64 to 98 Vietnam (Minh et al. 2015), Turkey (Atun et al. 2013), and Thailand (Towse and percent between 2002 and 2012), while powerfully raising key indicators of quality of Tangcharoensathien 2004), investment in service delivery capacity, especially at the care. The share of pregnant women having four antenatal care visits rose from 54 to 82 primary health care level and in under-serviced areas, remained an important part of the percent between 2003 and 2010, and citizen satisfaction with health services increased strategy to expand coverage. Strategies have varied from using compulsory service, from 39.5 to 75.9 percent between 2003 and 2011 (Akdağ 2015; Atun, et al. 2013). as in Turkey (Atun et al. 2013), through to extra payments in Thailand (Lindelow et al. Thailand implemented its Universal Coverage Scheme (UCS), which extended health 2012), and to the widespread introduction of telemedicine to allow a greater variety of insurance to the entire population, in 2002. In the following years, effective coverage conditions to be managed by family practitioners in China and Kazakhstan (Karanikolos of non-communicable disease (NCD) screening and treatment has steadily increased. et al. 2012; Meng et al. 2015). In countries such as Brazil, this was taken even further, Between 2004 and 2009, the proportion of persons with hypertension whose condition with the development of primary health care teams consisting not just of medical doctors was well controlled increased from 6 percent to 14 percent for men, and from 12 but also specialist nurses and para-health workers (Gragnolati et al. 2013). percent to 27 percent for women (Tangcharoensathien et al. 2015). During these same years, diagnosis of diabetes improved from 34 percent to 57 percent for men and from 51 percent to 78 percent for women. The rate of effective diabetes treatment more than doubled among both genders. Using a variety of metrics, quality of care in hospitals also improved. Among patients admitted with acute myocardial infarction, 30-day mortality, death at hospital discharge, and death on arrival all consistently declined between 2005 and 2011 (Tangcharoensathien et al. 2014).

36 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 37 INVESTIGATING UHC GAINS INVESTIGATING UHC GAINS ______

Target services for the poor and marginalized

High-performing countries have complemented building primary care service The AIDS epidemic also spurred greater investment in home-based care, often delivered infrastructure with various “last mile” delivery strategies to push services outward from by new cadres of CHWs. Early CHW programs in the Health For All era (1975-2000) facilities and bring them directly to communities. Models included outreach, campaigns, generated mixed results. Reviews highlighted recurrent structural flaws and argued for and home-based care, often relying on community health workers (CHWs). more systems-oriented approaches. Recently, “next-generation” CHW programs have built upon these lessons. Successful recent programs have incorporated: more formal The most common approach was mobile outreach from fixed sites. Frontline facilities policy frameworks to clarify CHW roles; measures to integrate CHWs into national became launch platforms to expand services into neglected areas. This was a critical human resources and financing strategies (including payments); more systematic element of the strategy to expand coverage in Lao PDR, where outreach services to training, career paths, and supervision; and development of simplified clinical algorithms, provide immunization began as early as 1982. Outreach for provision of general maternal decision support tools, and rapid diagnostics to allow a wider range of providers to offer and child health (MCH) services was introduced in 2009, and there is an ongoing effort lifesaving interventions (Perry et al. 2014). to move towards integrated MCH, EPI, and family planning outreach. There is widespread evidence of the positive impact of well-designed and run home- Another approach has been the implementation of integrated campaigns. Polio based and CHW programs for many different health outcomes (Lewin et al. 2015). campaigns started co-delivering vitamin A in 1999, and the use of bundled campaigns However, financial sustainability and maintaining high performance as programs go to to deliver key child survival interventions expanded rapidly. Seventy-three countries now scale remain outstanding challenges. carry out such campaigns globally, with an average of 100 campaigns conducted per year. Studies have shown consistently high coverage for vitamin A and measles vaccines regardless of the numbers of interventions delivered throughout integrated campaigns. Engage with non-state actors

There is evidence that campaigns can disrupt routine health service delivery and Both outlier and other countries have contracted with non-state actors for the delivery ultimately compromise the sustainability of comprehensive, continuous health services of health services (e.g. Afghanistan, Burkina Faso, Cambodia) and/or the execution of for the population. Moreover, integrated campaigns are usually largely reliant on financial other system functions (e.g., medicines procurement and supply chain in Kenya). In and technical support from donors. However, the salient advantage of integrated Afghanistan, for example, health leaders took over a system devastated by conflict. The campaigns is that they can achieve rapid, equitable coverage at low cost, providing government chose a strategy based on performance-based contracting (PBC) to rapidly basic packages of child survival interventions for as little as US$0.60 per child, while the expand delivery capacity while ensuring quality of care. Cambodia has also obtained potential disruption can be minimized with stronger planning and management (Doherty promising results with PBC schemes (McDowell 2010; Morgan 2011; World Bank 2008). et al. 2010). Reviews of progress with the contracting model suggest that effectiveness is linked closely with the amount of autonomy given to the provider, including control over management and human resources (Arur et al. 2010; Bennett and Mills 1998; Heard et al. 2011). However, autonomy of private providers in the context of contracting-out needs to be built on a foundation of robust government stewardship. Success depends on building an environment of trust but also objective measurement and fair processes. (Guinness 2011; Lonnroth et al. 2006; Ullah et al. 2006).

38 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 39 2 / In general, programs to reduce and eliminate user fees show mixed results. Health Financing

Reducing financial barriers

In parallel to improvements in the availability of services, outlier countries reduced Lessons from outlier and other countries suggest that programs can register substantial financial barriers that either prevented people from using health services when they increases in service utilization, particularly when accompanied by improvements in needed them, or caused households to incur high out-of-pocket payments. Financial the availability of services, reimbursement of providers for the loss of revenue, and the barriers included user fees at facilities - both formal and informal payments - as well as replacement of fees with other provider performance incentives. Evidence about the other costs to households from seeking care. effects on financial protection are scarce and less promising. The removal of financial barriers may see out-of-pocket spending rise, not fall, as it allows people access to Several low coverage baseline outlier countries reduced or removed user fees at public more services, potentially associated with fees or co-payments, as well as with other facilities for select, highly cost-effective priority interventions, with MCH interventions costs people may incur when they seek medical care, such as transportation expenses being the common denominator. For example, Burkina Faso’s 2006 reform reduced (Mathauer and Kutzin 2017). user fees for deliveries, caesarean sections, and neonatal care (Ganaba et al. 2016). In 2010, Lao PDR rolled out a Free Maternal, Neonatal, and Child Health program, covering In high-baseline outlier countries, programs emerged that went from subsidizing user fees deliveries and other related outpatient and inpatient services for children under the age to financing large shares of the costs of services with general tax revenue. Rwanda, a low- of five (Boudreaux et al. 2014). In the same year, Sierra Leone launched its nationwide baseline outlier country, is one of the few global exceptions that succeeded in expanding Free Health Care Initiative (FHCI), providing free services to pregnant women, lactating community-based health insurance drawing on subsidies and contributions to rapidly scale mothers, and children under five years old (Bertone et al. 2014). up population coverage for a basic package of health services. More recently though, the country has faced challenges to maintaining high levels of coverage. Concerns have Countries have also provided more comprehensive coverage – offering more services at emerged about financial management capacities and the long-term financial sustainability reduced or waived fees to more people. For example, under its reduced user fee policy, of the model, to which the government has tried to respond (Kalisa et al. 2016). Burkina Faso started out covering only MCH services but then expanded coverage to include treatment for malaria, tuberculosis, and HIV/AIDS (Ganaba et al. 2016). Health A key feature of the programs in high-baseline outlier countries was to guarantee not equity funds in Laos and Cambodia exempted the poor from user fees for a broad package only free care, but sufficient availability of services. In most of these countries, programs of outpatient and inpatient services (Ensor et al. 2017; Tangcharoensathien et al. 2011). were initially targeted to the poor and only later expanded to fill population coverage gaps. Today, these countries are all in the later stages of the expansion process. Turkey’s Even when coverage was limited to a few interventions, fiscal realities forced some Green Card Program initially targeted the poor and other vulnerable groups, but was countries to limit benefits to the poor and vulnerable, at least temporarily. Burkina later expanded and merged with social health insurance schemes for formal-sector Faso’s 2006 reform provided full exemptions only for the extremely poor, while coverage employees, giving rise to a single Universal Health Insurance (UHI) scheme (Menon et al. for other beneficiaries was limited to 80 percent of fees (60 percent in tertiary care 2013; Reich et al. 2016). Vietnam and Peru have also moved toward a unified risk pool hospitals). Lao PDR’s Free Maternal, Neonatal and Child Health program was initially across programs and insurance schemes, but both countries struggle to cover gaps in rolled out to the most deprived districts, and the benefits of the country’s Health Equity the informal sector. Fund remained targeted to the poor. To increase the likelihood that benefits reach their intended beneficiaries, countries used identification mechanisms including a mix of geographical targeting (e.g., the poorest districts), proxy means testing, and community- led identification of people in greatest need.

40 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 41 INVESTIGATING UHC GAINS In parallel to expanding population coverage, ______programs in high-baseline outlier countries continued increasing the depth of coverage, that is, the services included in the benefits package.

In countries with social health insurance for formal-sector employees, this resulted in Creating provider incentives for efficiency the equalization of benefits with social health insurance entitlements and facilitated the consolidation of programs and schemes. For example, Turkey’s Green Card program Irrespective of country income or baseline coverage, outlier countries have increasingly originally covered only inpatient treatment costs, but in 2004, it expanded to cover both made strategic use of financing arrangements to drive more efficient service delivery. outpatient and inpatient services at public hospitals and, as of 2005, began to cover Countries reformed payment and contracting systems while establishing arm’s-length outpatient prescription drugs. Now that the program is part of the Universal Health arrangements between payers and service providers. Insurance (UHI) scheme, the benefits package has expanded again to align with the social health insurance benefits (Menon et al. 2013). LBC outlier countries, like Sierra Leone and Rwanda, started to transfer some funds to facilities linked to outputs and outcomes. In Sierra Leone, where management The expansion of the benefits package has been typically governed by prioritization capacity was generally weak, these changes were modest: supplemental fee-for-service exercises facilitated through health technology assessments (HTAs) or other prioritization payments for a few maternal and child health services (Bertone et al. 2014; Witter et approaches, all of which typically consider medical, ethical, social, economic, and al. 2015). In Rwanda, these changes were more ambitious. Provider payments were political factors. Thailand has been a pioneer among middle-income countries in the use tied to targets for coverage and improvements in health outcomes among the patient of HTAs to inform decision-making along the pathway to UHC, and has set standards population. Payments also included rewards for facility readiness and service quality for other countries in the region to follow (Teerawattonen and Luz 2016). While few other (Bucagu et al. 2012). Though extensively researched, the effectiveness and cost- outlier countries have adopted HTAs, Turkey formalized HTAs for hospital services in effectiveness of these results-based finance programs and success factors remains a 2012-2013 to ensure affordability and efficiency (Sampietro-Colom and Martin 2017). matter of debate (World Bank and WHO 2017). Similarly, Kazakhstan recently introduced an HTA process using both inclusion and exclusion criteria to define a state-guaranteed benefits package (Jones et al. 2017; High-baseline outlier countries, like Peru and Turkey, have increasingly adopted blended Muratov et al. 2014). payment using output-based and performance elements. Peru introduced a capitation payment for primary and secondary care levels, with a risk-adjustment for population Regardless of the level of system development, countries recognized that not only fees need and 20 percent of the payment linked to performance indicators (Seinfeld and and charges, but other costs to households from seeking care constitute significant Besich 2014). In Turkey, capitation payments are blended with fee-for-service payments barriers to access. Thus, Health Equity Funds in Lao PDR and Cambodia reimbursed and a performance element to encourage the delivery of antenatal and post-natal patients for transportation and food, while other countries make cash transfers to services in primary care facilities (OECD 2014). At the hospital level, global budgets and the poor conditional on the utilization of various health services. Turkey introduced case-based payments remain the dominant form of payment, but supplemented with conditional cash transfers in 2003 to pregnant women and children from the most performance-based bonuses for medical staff (Cotlear et al. 2015; Menon et al. 2013). disadvantaged households, and Peru’s conditional cash transfer program (JUNTOS), which was part of a broader poverty-reduction strategy, made payments contingent on the use of prenatal and postnatal check-ups, as well as regular health and nutrition visits (Atun et al. 2013; Perova and Vakis 2012).

42 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 43 INVESTIGATING UHC GAINS The shift away from paying for inputs, such as ______salaries, and the introduction of performance contracting commonly took place with a separation in the organizational arrangements for financing and service provision to establish an arm’s-length relationship.

However, the payer and contractor arrangements vary substantially, depending on Increase prepaid and pooled financing for health and improve effectiveness of the program and context. Key models include internal contracting: for example, development assistance for health between the central level and districts in Burkina Faso (Perrot 2006), or hospitals paying sub-contracted primary health centers in Thailand (Hanvoranvongchai 2013). To improve the availability of services and remove financial barriers to access, countries The introduction of third-party payers offers another option. These third parties may must raise additional prepaid and pooled resources for health, most importantly, be non-profits (for example, NGO-administered health equity funds in Lao PDR and government financing. Increases in government financing are often facilitated by rapid Cambodia) (Ensor et al 2017; World Bank and WHO 2017) or social health insurance economic growth and improvements in the ability of governments to raise revenues, yet, agencies (for example, the Social Security Institution in Turkey) (Menon et al. 2013). in outlier countries, leaders also succeeded in moving health high on the political agenda These models have often included giving providers some authority and control over the and generating political will to invest in health. In Sierra Leone, health was central to the use of resources, not limited to financing but also including human resources to respond post-conflict poverty reduction strategy. Lao PDR anchored increases in government to changed incentives. Reforms in Turkey, for example, increased the financial autonomy spending on health into national laws, also setting a national target for allocations to of health facilities. health (World Bank and WHO 2017).

These arm’s-length arrangements are dependent on timely and reliable information on In several countries, a clearer recognition of the link between out-of-pocket health service delivery. Concurrent investments in data systems enabled purchasers of health expenditures and household impoverishment helped prompt higher general government care to hold providers accountable for services rendered and health outcomes. Better health spending. Meanwhile, leaders in many LMICs found that economic growth was information from improved data systems also has positive spill-over effects that extend not leading to formalization of the labor force and an accompanying extension of social beyond accountability. It enables process improvement, systems research, and better health insurance, as had been predicted based on historical experiences in high-income decision-making. countries. Therefore, the extension of health insurance to the poor and informal-sector workers required delinking coverage from employment status and drawing on broad- Many countries opted not only to empower providers but also consumers. In Turkey and based fiscal instruments. In Thailand and Turkey, leaders capitalized on these insights and Thailand, complaints systems were introduced to ensure that providers do not under- garnered support during elections to place both health and financial protection high on deliver services in response to payment methods that encourage cost containment. political agendas (Bump and Sparkes 2014; Ghislandi and Muttarak 2016; Kuhonta 2017). In Thailand and Kazakhstan, telephone hotlines were set up to receive questions and complaints from the public (Katsaga et al. 2012; Hanvoranvongchai 2013). In While political commitments to invest in health and financial protection often remain Kazakhstan, the National Committee on Medical and Pharmaceutical Activity Control is rhetorical, leaders in outlier countries translated political will into actual increases in primarily responsible for responding to patient complaints. In Turkey, Patient Rights Units public financing for health. Laos increased the health share of government spending were established in hospitals and primary health care facilities in 2004, with electronic from 4.1 percent in 2005 to 6.3 percent in 2015 (World Bank and WHO 2017). Even systems for patient complaints and suggestions. Turkey also established telephone more impressive, as noted above, Vietnam more than doubled health spending as a hotlines to the communication centers of the Ministry of Health and the Prime Minister’s share of government spending, from 6 percent in 2005 to 14 percent in 2014. During office (Atun et al. 2013). the study period, positive outlier countries experienced, on average, more rapid growth in per capita government health spending than did countries with more modest health service coverage increases (below percentile 50) (See Figures 3.1a-b).

44 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 45 Government Health Spending per Capita FIG. 3.1a Government Health Spending: ______Low- and High-Baseline Countries

For the purpose of comparison, the data have LOW-BASELINE COUNTRIES

been converted into an index set at 100 for the 275 year 2000. The following graphs compare average government health spending per capita in: (1) outlier countries, i.e., countries with rapid 250 progress on service coverage and progress on

financial protection (orange lines), and (2) 225 countries with modest service coverage increases (below percentile 50) (grey lines). Low- and high- 200 baseline countries are considered separately. It is important to note that government expenditures may include development assistance for health. 175 INDEX (2000 = 100 )

The study period was marked by an unprecedented increase in development assistance for health (DAH). Global DAH increased from US$ 11.4 billion in 2000 to US$ 37.6 150 billion in 2015 (IHME 2017). Low-baseline outlier countries saw a more rapid increase in DAH per capita. They also managed to align external financing behind government priority programs to expand access to basic services and reduce financial barriers. In Burkina Faso, for example, resources from development partners have helped subsidize 125 user costs for delivery, emergency obstetric care, and neonatal care, while also providing free access to other interventions such as antiretroviral drugs, artemisinin- based combination therapies, and insecticide-treated bed nets (Ameur et al. 2012; Yaogo 2017). Donor assistance has supported Rwanda’s community-based health 100 insurance scheme and Sierra Leone’s free health care initiative for maternal and child health services (Kalisa et al. 2016). Both Laos and Cambodia have drawn on donor funding to finance health equity funds covering user fees and other costs (e.g., transportation) for the poor (Flores et al. 2013). 75 2000 2002 2004 2006 200820102012 2014

— Countries with rapid SC and FP progress — Countries below 50th percentile in SC progress

Source: World Bank calculations, based on World Health Organization Global Health Expenditures Database and International Monetary Fund World Economic Outlook.

46 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 47 INVESTIGATING UHC GAINS ______Government Health Spending per Capita FIG. 3.1b ______

HIGH-BASELINE COUNTRIES “What Got Us Here Won’t Get Us There” 7

Remarkable UHC successes in the new millennium still leave a vast, unfinished agenda. 275 Despite gains in service coverage and financial protection, most countries are struggling to satisfy population needs. Equity gaps in service delivery and financing persist. Where services are provided, quality failures are rife, such that coverage expansion is often not translating into improved outcomes. Meanwhile, in many countries where incomes and 250 access to information are increasing, citizens’ expectations for health services are rising steeply, and health systems struggle to keep up.

The 2013-2016 Ebola virus outbreak in West Africa provided a stark reminder of the 225 unfinished agenda of health systems strengthening, even in settings where some encouraging gains have been recorded. In the decade before the outbreak, Liberia and Sierra Leone, for example, had achieved significant progress in their coverage of select MCH indicators. Their health systems seemed to be on a path of improvement. Yet these 200 systems were unable to manage the Ebola epidemic, which eluded control, ultimately reversing years of hard-won health gains in these countries.

Such events highlight the importance of making progress across the whole spectrum 175 of UHC. In this case, the relative neglect of health security measures (Kruk et al 2015)

INDEX (2000 = 100 ) (pages 50-51), the chronic lack of adequate human resources (Shoman et al. 2017), and pre-existing perceptions among the population that the health system could provide only a narrow set of services (Svoronos and Mate 2011) contributed to health systems’ 150 inability to cope with the emergency.

The Ebola epidemic was an exceptional event. Yet the systemic weaknesses it revealed are unfortunately not exceptional at all. Ebola symbolizes the many new, persistent, and 125 re-emerging threats that health systems must prepare to manage on the road to UHC. Public health emergencies may become more frequent in many regions in the years ahead: including pandemics, climate-related extreme weather disasters, conflict, and large-scale population displacements. Most health systems remain poorly prepared 100 to manage such emergencies. Health systems destabilized by emergencies may lose ground and fall further behind their UHC aspirations.

75 2000 2002 2004 2006 2008 2010 2012 2014

— Countries with rapid SC and FP progress — Countries below 50th percentile in SC progress

48 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 49 UHC and Health Security

A system displaying these qualities can be described as a “resilient health system” (Kruk Pandemics and other crises can et al. 2015). Resilience in this sense has been recognized as a crucial dimension of devastate health systems and reverse health systems strengthening and UHC agendas (UHC2030 2017). Resilience protects UHC investments for the future in a world of multiple threats. years of hard-won health and economic However, only a minority of countries have scored highly in even a sub-set of core public health functions such as workforce development, laboratory services, and health progress. Preparedness for epidemics surveillance. In the context of competing priorities, policymakers are faced with the challenges of investing to deliver clinical services, but also increasing resilience through should be integrated into UHC. Health stronger public health systems. systems should be able to: The recent International Working Group on Financing Preparedness suggested financing innovations at global, regional, and national level that may help countries reinforce health security (World Bank 2017). Uganda’s ring-fenced budget for surveillance offers one approach. It includes a contingency fund that releases money only during an outbreak, 1 rapidly detect and control infectious combined with distinct funding for routine surveillance and response activities (Osewe disease outbreaks and other acute and Mensah 2017). Potentially transformative surveillance investments include the deployment of a nationwide population health threats electronic reporting system. Technological tools alone cannot produce health system resilience (for example, without people trained to use those tools). However, many problems in infectious disease surveillance cannot be solved without the aid of advanced technologies. For example, in a high-performing country like Armenia, all surveillance data 2 continue to provide quality routine is integrated in a single, interoperable and interconnected national electronic reporting system (the EIDSS) (WHO 2016). Improved quality of clinical care including rational use of health services while responding antibiotics and establishment of efficient laboratory services are examples of investments to crises that serve the dual purpose of increasing effective coverage and health security. Another set of health security challenges and opportunities facing health systems pertains to working more effectively across different sectors. The One Health approach provides a comprehensive framework that lays the basis for more effective collaboration, especially 3 recover quickly and adapt to changing to address the connections between animal and human health. Financing and contexts and new challenges, showing operationalizing such frameworks remains a frontier challenge (Lee and Brumme 2013). a capacity to “bend but not break” under stress.

50 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 51 INVESTIGATING UHC GAINS ______Graying Populations and Non-Communicable Diseases: Health System “Perfect Storm” or Impetus for Innovation? At the same time, health policy makers must manage cost pressures associated with technological innovations, ageing populations, and NCDs (page 53). They must address pervasive inefficiencies, not only in terms of what services to provide in which setting, but also how and by whom services are delivered. Smart trade-offs require technical capacity to assess the costs and benefits of different choices, but also platforms to enable a broad dialogue about health system priorities, with the participation of civil society, as well as technical experts.

To ensure progress toward UHC, countries face the challenge of continuously expanding the resources available for health, while also using current resources more efficiently. The ageing of populations is rapidly accelerating around the world. Several countries Health policy makers must carefully balance the imperative to cover more people with are growing old relatively rapidly and before they get rich. Most of the health challenges the potentially competing demands to expand the range of available services, improve confronted by older people are chronic conditions, especially NCDs. Management of their quality, strengthen health security, and expand financial protection. And they NCDs tends to be complex and life-long, and it requires high volumes of outpatient must ensure progress toward UHC even during economic downturns and declines in drugs, frequent interactions with health systems and providers, as well as intensive development assistance for health. disability management.

Countries are also grappling with the fragmentation of financing systems. Indeed, Other than diseases, reduced functionality is an important factor which tends to affect fragmentation into financing pools is often the result of the gradual extension of coverage older people’s quality of life, with profound consequences for individuals and populations. and financial protection. Fragmentation is commonly followed by inefficiencies due to For individuals, these consequences may include the indignity of increased dependence the loss of economies of scale, duplication of administrative processes, and dilution on others for daily tasks. As problems worsen, seniors may be forced to leave their of provider incentives. Moreover, forms of fragmentation in which one group’s benefits homes and live with family members who must provide round-the-clock care, or in package (e.g., that of formal sector workers) is substantially better than another group’s institutions. At the population level, growing numbers of people with limited functionality (e.g., the poor) can solidify inequalities in health status and economic wellbeing. demand investments in infrastructure and care provision that countries may see as beyond their reach. When public-sector health and social services for elders fall short, With only a handful of notable exceptions among LMICs, such as the outlier countries, older people must rely on privately-funded care arrangements, which may vary widely in progress in expanding financial protection to the poor has been slow. In fact, the removal scope and quality, depending on people’s ability to pay. This threatens to deepen of financial barriers has often seen out-of-pocket payments rise, not fall, because socioeconomic health inequities among elders that in many cases have already it allowed people access to more services which entailed some direct household accumulated through the life course (WHO 2015). payments. Economic growth to provide the necessary resources for UHC will not be enough to accelerate progress in most settings. An active search for ways to increase Many countries are ill-prepared for population ageing and the associated NCD challenges. domestic resource mobilization and boost the amount of money going to health remains A 2017 review shows that only 22 percent of countries in Sub-Saharan Africa have critical. In many settings, it seems clear that these resources cannot come exclusively national integrated NCD policies, strategies, or plans. Only 13 percent have set tobacco from the public sector. The way development assistance for health can support these excise taxes equal to at least 50 percent of retail prices, and just about 4 percent of efforts is an equally important unanswered question for many countries. countries have set up national clinical guidelines, protocols, or standards for NCD managements in primary health care (Nyabaa et al. 2017).

Countries need a health systems transformation to shift away from past hospital-centric, disease-based curative models of health care and towards the provision of integrated care that is centered on the needs of older people. Reducing exposures to risks such as smoking; technological and organizational innovations to expand cost-effective home- based care models; and other financial and procurement innovations are allowing some countries to help older people play a productive role in society for far longer.

52 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 53 INVESTIGATING UHC GAINS ______

Where Do We Go from Here?

The next part of this report is prospective. It will consider facets of possible UHC futures. Clearly, aspects of that future will be in continuity with the past and present. Countries will make incremental reforms by introducing or expanding “tried and tested” approaches to make services more available, reduce financial barriers, and increase stakeholder engagement, for example. Such incremental reforms—expanding proven policies and approaches or adapting them to new settings—will help many countries accelerate UHC progress in the years ahead.

Unfortunately, as explained above, there are good reasons to believe that this will not be sufficient to reach UHC goals. In the next section, we will explore emerging opportunities for countries to introduce deeper changes in how they finance, deliver, and govern health systems. We will ask what is required for countries to seize such opportunities and move beyond incremental change toward more transformative approaches of “business unusual.”

54 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 55 SHAPING THE FUTURE ______

A Different Picture: Transforming Health Systems and Accelerating UHC Progress

While health policies applied in outlier countries suggest promising options, unmet needs and emerging threats pose stark challenges to UHC agendas, particularly considering the scarcity of health system resources. This highlights the need not only to accelerate incremental reforms, but also to step up the search for new, qualitatively different solutions.

Transformative change may come from new attitudes and behaviors among stakeholders; the development of new products and devices; the reconfiguration of how health services are organized, delivered, and financed; or all of these things.

It is important to avoid naïve exuberance about health system innovation and the promise of “silver bullets.” However, there are several interrelated forces that may spur innovation and transform health systems in the years ahead, offering a more hopeful picture than the one described at the end of the previous section.

Accelerating Progress Towards Universal Health Coverage / 57 What might the future look like?

1 2 3 4 5

What would a more People are at the center Digital Health services Pluralistic Globalization hopeful picture look like? of health systems health reimagined health systems of health ______

People increasingly move from The internet, mobile phones, Process innovation is brought to The distinctive capacities of In this new era, approaches being passive recipients of services blockchains and other tools for bear to help reconfigure health non-state actors are leveraged, successfully implemented in one to active producers of their own collecting, storing, analyzing, and systems and improve quality. A with the private sector, civil society, setting can be almost health who make nuanced decisions sharing information increasingly global health care quality and other stakeholders, including instantaneously available for about use of health services. This is penetrate the health sector. In doing movement is building. With a new from outside the health sector, consideration on the other side of a future in which health systems so, technology helps empower quality commitment among playing multiple roles – delivering the world. New collaborative empower and enable people to beneficiaries, improve quality of managers and providers, supported services, resolving bottlenecks in networks are emerging, spanning maintain wellness and prevent care, detect disease outbreaks, by enabling technology, health supply chains and patient transport, countries, regions, and the globe. disease before it happens, and in facilitate payments, and enhance systems become learning systems. training health workers, and filling Horizontal, peer-to-peer connections which patients are active partners in accountability. Successful innovations are rapidly other capacity gaps while holding increasingly circumvent traditional the care process (see page 60). and widely disseminated. Failures each other accountable for results. hierarchies of power and knowledge Health systems also recognize that are analyzed, understood, and This pluralism presents challenges and democratize innovation. New populations are increasingly mobile, corrected, and the lessons shared. for governments, but also new ideas and practices are burgeoning and systems facilitate healthy Innovative experiences in non- opportunities to solve persistent in places once considered mobility and labor market health sectors are adapted to problems. peripheral. Expertise is everywhere. transitions. Supporting reforms are accelerate health progress. implemented across multiple domains – financial (e.g., population- based payment models), behavioral (e.g., sin taxes and “nudges”—see page 61), organizational (e.g., integrated information systems), and governance (e.g., citizens’ charters). Health services acknowledge that disease morbidity and mortality are greater in poorer and otherwise marginalized groups of society, and explicitly prioritize services for those communities. This means that services for children and women, including at the community level, are prioritized.

58 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 59 Out of Facilities Exploiting Behavioral and into Communities Insights for Better Health

Countries at all levels of wealth and UHC Behavioral insights—i.e., insights derived from achievement will increasingly move towards a the behavioral and social sciences, including health services model that is community-based; economics, psychology, cognitive science, and focused more on protecting health than curing neuroscience—are increasingly used to make acute illness; and above all patient-centered public policies work better. and patient-led.

This transformation will affect all dimensions of health systems. Areas of innovation to Recent publications, including the World Development Report 2015, have raised support this paradigm shift include: awareness of this approach. There have been numerous applications to the health sector:

>> New tools and strategies for patient education, empowerment, and autonomy (e.g., Framing of messages. Gain-framed messages in health promotion (e.g., “if you get the flu patient peer support via phone messaging and social networks; increasing capacity vaccine, you will be less likely to get the flu”) consistently improve adoption of preventive for patients to access and manage their own health data 24/7) behaviors relative to loss-framed messages (“if you do not get the flu vaccine, you will be >> New approaches to preserving health and preventing disease before it happens, more likely to get the flu”). through health technologies, community-level action, and patient lifestyle choices (e.g., community-led, participatory programs for healthy physical activity and other Default options. Opt-out (people are automatically enrolled but given the choice to forms of wellness promotion; sensors to detect health-threatening conditions such as withdraw) can be better than opt-in (people can choose to enroll when asked) in air-pollution peaks; mHealth apps and messaging to support people in adopting improving participation in programs, for example HIV testing, organ donation, or healthier lifestyles) insurance schemes. >> “Smart” devices and wearables to facilitate patient self-management at home, linked to the emerging “Internet of Things” (IOT) Information design. For health consumers, simpler enrollment forms and procedures can >> Increasing use of telehealth lead to increases in enrollment in insurance plans. For doctors, a redesigned prescription >> Changes in the health workforce to support new community-based, participatory chart with (i) letter boxes to encourage the use of individual block capitals (ii) dosage units models (e.g., growing use of well-trained, well-paid CHWs in countries at all levels of to be circled rather than written and (iii) a color scheme to draw attention to important income; multidisciplinary care teams to meet a broad range of patient clinical and issues can reduce prescribing errors. social needs; task shifting, including to care team members who can relate to patients as peers, for example HIV-positive mothers who counsel and care for others) Prompts, cues, and reminders. Text-message reminders can improve patients’ APPLICATION OF BEHAVIORAL INSIGHTS OF BEHAVIORAL APPLICATION adherence to treatment regimens such as ART. Reminders can also be effective in As the center of gravity of health action in all countries shifts out of facilities and into changing health care provider behaviors and improving the processes of care. community settings, the need for large cohorts of health workers capable of delivering community-based frontline services will become increasingly acute. The combination of Audit and feedback. Feedback in the form of a letter to high prescribers of antibiotics CHW programs with emerging technology may hold transformative potential, enabling with comparisons to their top-performing peers to can lead to reduction in their antibiotic ambitious LMICs to “leapfrog” in devising and scaling up new solutions. These countries prescription. Encouraging patients to ask their physicians a simple question, “Is my may also avoid overinvestment in certain categories of “hard” infrastructure while rapidly antibiotic prescription absolutely necessary?” can also reduce antibiotic use. building a health workforce adapted to the new care delivery paradigm.

60 / Business Unusual Sources: Loewenstein et al. 2017; Perry et al. 2015; World Bank 2015. What Will It Take? How Technology and Innovative Partnerships Can Help Achieve Gains in the Health Sector

It’s an inspiring picture. Could it become real? A growing number of partnerships are The situation resists simple prescriptions. To create an innovative and learning health bringing new solutions to health systems system is an exceptional challenge, as recent sobering experiences with agendas such as e-health confirm (Lewis et al. 2012). So, what will it take for countries and partners to in low- and middle-income countries. bring this transformational scenario about? This report highlights three critical principles that have important implications for country and global leadership.

1. Look Everywhere, Engage Widely, Share Everything

In the past, health leaders seeking guidance to solve policy and delivery problems had limited options beyond published health-sector norms and guidelines, the academic literature, or the advice of their peers. Today, such limits are rapidly falling away.

Increasingly, solutions to health system problems will emerge from collaboration with a broader set of partners from within and outside the health sector (See page 63). These collaborations with the private sector and other stakeholders can bring fresh ideas, new resources, and innovative delivery practices, along with organizational structures that are Delivering public policy goals with Afghanistan: jumpstarting health Radical collaboration for health often more flexible and responsive than those of the public sector. Public-private private-sector logistics: medical system rebuilding through system resilience in Liberia partnerships and process innovations adapted from other contexts can bring dramatic drones in Africa contracting gains in reach and results for health systems. ______

Solutions will also be found in new technologies and their application to the health sector. Already, new tools and strategies such as drone transport, mHealth applications, and frugal technologies are revolutionizing the delivery of frontline health care in some Some African governments, private Despite ongoing insecurity, In the context of the 2014 Ebola low- and middle-income settings (See page 64). Coming decades are likely to see an firms, and international agencies have Afghanistan has made notable outbreak, open sharing of mobile explosion of advances in telehealth, medical applications of artificial intelligence, and the formed high-profile alliances to solve progress in improving maternal, phone data between the use of internet-connected “smart” devices to support service delivery and patient medical supply-chain problems with newborn, and child survival, nutrition, communications company Orange self-management at home. Such shifts will help relieve pressures on overstretched health drone transport. For example, as of and the coverage of health Telecom, the Swedish nonprofit facilities and health workers, while likely improving patient satisfaction and outcomes. August 2017, drones were interventions. These results were Flowminder, the Liberian government, transporting 20 percent of Rwanda’s achieved through a model of the US CDC, and other partners blood supply outside the capital, contracting with NGOs to provide helped improve modeling of disease Kigali, while the medical drone basic health services at health transmission routes, enabling more system now being scaled up in centers and district hospitals in effective containment. Tanzania is expected to become the defined geographic areas. world’s largest.

62 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 63 “Augmented” Community The potential for innovation and new solutions Health Workers in the health sector is staggering.

Some countries have deployed large cohorts of CHWs as a strategy to expand service However, reaching this potential will depend on an open and proactive approach to find coverage and improve health indicators. Looking ahead, there is potential for the power of new ways of doing things, an inclusive engagement with stakeholders that puts people these models to converge with technological advances to achieve even greater gains. at the center, extensive sharing of lessons and experiences, and the development of a discipline to assess new innovations quickly and reliably. Intensifying the quest Tomorrow’s frontline CHWs will have their operational capacities augmented by new tools for innovation brings risks that leaders must anticipate: for example, the potential and new skills, many based on mobile phone applications and simplified or “frugal” medical proliferation of small, disconnected, inconclusive pilot projects (“pilotitis”). Success also equipment. These transformations may initially be easiest to implement in urban and requires recognizing that, in some areas, new ideas and solutions are not emerging or peri-urban contexts, where they can help meet soaring health care needs. Many of these spreading fast enough, and finding ways to bring water to these “innovation deserts.” tools and strategies will also be increasingly applicable in rural settings.

The explosion of current-generation mHealth applications already supports frontline 2. Use Data to (Re-)Shape Health Systems providers including CHWs in a broad array of functions, from patient education to health data collection to monitoring treatment adherence and outcomes (Labrique et al. 2013). With the ever-growing role of digital technologies, new and connected data are The pace and scope of mHealth innovations will further increase, expanding CHWs’ range becoming increasingly abundant. If used judiciously, these data can be a powerful tool to of impact. Higher-performing mobile devices will put next-generation CHWs in real-time understand health needs and re-shape health systems. touch with referral networks and guidance from specialized providers, enabling them to function as the increasingly effective eyes, ears, and hands of the health system at the Maximizing the potential of big data requires greater efforts to address more basic grassroots. Meanwhile, countries may harness e-Learning options to upgrade CHWs’ system and data gaps, such as the need to improve vital statistics on births and deaths, training, both pre- and in-service (WEF 2014). and core surveillance systems. And there are many blind alleys and potential risks related to privacy and misuse of data that need to be managed. Yet, the potential of big While current mHealth tools have enabled frontline workers to gather large amounts of data is clear from initiatives such as India’s ambitious Aadhaar personal identification data, some experts see a coming “tipping point,” where new apps will not only collect program, which through biometric identification of over 1.2 billion of India’s citizens, but rapidly analyze data to guide frontline providers’ action in real time (Michiel 2017). provides the foundation for expanded monitoring of health and social data, electronic “The most successful platforms and programs will weight collection and analysis medical records, improved management of health insurance programs, and empowered equally,” so that collected data is immediately “used to drive decisions” and help patients beneficiaries. In South Africa, linking existing data has helped improve many aspects (Michiel 2017). of health system performance, including the quality of services (See pages 66-67). Data and expanded computing power are also coming together to enhance diagnostic In addition to mobile phones and tablets themselves, simplified and/or mobile-adapted capacity using artificial intelligence (AI) (See page 68). medical equipment will expand frontline health providers’ capacity to assess patient needs and deliver interventions. Already today, mobile-adapted clinical tools include pulse Data has always been instrumental to health system management. However, with the oximeters, ultrasound devices, and EKGs, with the list growing almost daily. These tools advent of “big data,” there is the promise that it may be transformational. reflect what is both the most obvious and most important trend in mHealth and associated technologies: “Nearly every facet … is becoming easier and easier to access for those without formal technical training” (Michiel 2017). Such tools, combined with CHWs’ irreplaceable social capital, cultural knowledge, and community trust, will make “augmented” community-based health auxiliaries the leading edge of UHC progress in the settings that matter most.

64 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 65 Big Data and Health Care in South Africa: Using Data Analytics to Boost HIV Service Coverage and Quality

LEARNING FROM HIGH PERFORMANCE (dark districts) IMPROVING LOW PERFORMANCE  In HIV, viral suppression is an important marker to estimate how well patients are doing and ______their probability of transmitting HIV to others. HIV program managers want to know what proportion of HIV treatment clients actually receive an annual test to determine the amount Proportion of ART (antiretroviral therapy) clients with Number of ART clients with high VL of HIV virus in their bloodstream (viral load), and of those, the proportion who have low HIV known VL (viral load) suppression ( < 400 cp/ml) ( >1,000 cp/ml ) viral load (viral suppression). These are key metrics of the coverage and quality of HIV service delivery.

In South Africa, the World Bank and Boston University supported an effort by the country’s National Health Laboratory Service and National Department of Health to use big data analytics to improve HIV services. South Africa has the world’s largest HIV treatment program and a large national database of viral load tests among clients on HIV treatment (more than 44 million records over two years). However, this dataset could not be linked to individual HIV treatment clients, as unique identifiers were not used by clinics. The team therefore used data science approaches and analytics to bring together different datasets and create a data set of unique patients (using a fuzzy matching algorithm). This was linked to routine HMIS data and HIV client register data.

With all these data, the team could determine the proportion of HIV treatment clients who had viral load tests done at least once a year (as per national clinical guidelines) and, of these patients, the proportion virally suppressed. Data were summarized by province, district, sub-district, and health facility, and used to generate tables and maps.

Researchers found that the results were spatially correlated by district, meaning that facilities in a given district were more likely to have the same performance. This suggests that the district health management team plays an important role in facility-level performance. The analysis has enabled well- and poorly performing facilities and districts to Proportion viral load suppression Number of clients be identified and helped provincial health authorities focus supervision on lagging districts. — < 40% — 0 - 360 — 41% - 50% — 361 - 750 — 51% - 60% — 751 - 1350 — 61% - 70% — 1,351 - 2,350 — ≥ 71% — 2,351 - 28,000

66 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 67 SHAPING THE FUTURE Boosting Health Service Quality ______with African-Made Hi-Tech

3. Learn from Implementation

Perhaps the most critical strand of the health system learning agenda concerns implementation. To reach UHC and other health goals, the question is not just which policies to choose. It is also, and above all, how to implement the chosen policies effectively and sustainably. The answers can only come by doing: through policy and program implementation as iterative learning.

The emerging field of health care delivery science has focused health leaders’ attention Some African tech experts argue that artificial intelligence (AI) may soon help tackle both on this issue and its implications. Testing implementation scientifically provides the quality challenges and workforce shortfalls that slow health progress on the continent. governments and partners with the humbling opportunity to “put our favored notions to AI systems like Google’s Deep Mind and IBM’s Watson have already shown the capability the test.” Rigorous and roadworthy science that is linked to implementation real-time will to reliably diagnose a wide range of medical conditions. Some thought leaders predict ultimately help ensure that efforts to close health gaps are based on facts and deeper that the deployment of such systems is poised to revolutionize health care quality in many understanding of how things work and not simply on blind faith. Efforts are needed, LMICs within a decade (Cornish 2016). however, to increase the credibility, financing, and capacity for delivery science in every country. No health system can afford to pursue ambitious reforms without it (Kruk 2014). AI diagnostic capabilities will relieve skilled health providers of part of their routine workload, making them more productive. In many cases, the diagnoses provided by machines are also likely to be faster, cheaper, and more accurate than those of human New Leadership Challenges specialists. Cervical cancer screening is one area where this is already the case. A team at IBM Africa has developed AI software that, trained with a database of cervix images, Political vision and leadership have always been critical for UHC progress. In recent can detect precancerous tissue color changes far more consistently than trained health decades, policy makers in many countries have made bold decisions to expand health professionals. And what’s true for cervical cancer screening today will soon apply to a service access and remove financial barriers, in many cases knowing this would have host of other health conditions. significant fiscal implications and that gains might only materialize over the longer term. Such leadership remains essential. According to IBM Africa’s David Sengeh: “The objective is not to replace caregivers, but rather to augment their ability to diagnose and screen by automating tasks that are simple However, health leaders at country and global level are also dealing with important but eventually overwhelming for overstretched caregivers…. If we learn to leverage what changes: increasingly informed and empowered populations, new technologies and AI being developed in Africa offers the continent, our young and growing population will service delivery models, health systems that are becoming more complex, expensive, be healthier and wealthier, ready to transform our lives and ultimately lead the world.” and pluralistic, and ever-greater understanding of the co-dependence of what is happening in other countries and sectors. All of this creates exciting opportunities, but also new challenges.

68 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 69 SHAPING THE FUTURE ______The Joint Learning Network (JLN)

______Challenging received wisdom With far-reaching health-systems transformations on the horizon, the received wisdom inherited from the past appears increasingly questionable. In some quarters, this has propelled a new emphasis on “first-principles thinking” on health systems, which sets aside common assumptions in order to look at problems and solutions with fresh eyes. This approach to solve health-system problems is not new. It informed important health- system reforms in recent decades, such as Thailand’s introduction of the Universal Health Coverage Scheme, or the conception of the Health Extension Worker program in Ethiopia. To resolve some of the stickiest challenges, it must be an even more critical part of health leadership in the future. The JLN is an innovative community of practitioners and policymakers from 27 ______Broad and active engagement Strong public-sector leadership does not mean unilateral authority. New leadership models countries who engage in practitioner-to- are based on partnership, collaboration, coalition-building, and stakeholder empowerment. practitioner learning and co-develop tools to They create conditions in which all actors can maximize their added value within a goal- oriented collective process. implement universal health coverage reforms.

______Sharing and exchanging across borders The tools are equipping countries with the how-to’s of designing efficient, equitable, This requires building on participatory peer-learning structures that are already connecting and sustainable healthcare systems, while contributing to global knowledge on countries and global UHC partners, such as the Joint Learning Network for UHC, WHO’s achieving UHC. The JLN embraces a country-led, country-driven model of governance Global Learning Laboratory for Quality, and the Asia eHealth Information Network (page to ensure learning outcomes are aligned with countries’ priorities. It bridges the 71). Such structures can strengthen learning and exchange on the “what” and, more knowledge gap between theory and practice – providing a critical enabler for countries importantly, the “how” of systems reform for UHC. to move toward UHC. All JLN activities are prioritized, shaped, led, and co-facilitated by JLN member countries. Through a unique model for joint problem solving, which includes multilateral workshops, country learning exchanges, and virtual dialogue, JLN members build on real experience to produce and experiment with new ideas and tools for expanding health coverage.

As the global UHC movement advances, health policy makers and practitioners need more cross-learning opportunities to share insights and exchange knowledge on the implementation of policies and programs. By bringing countries together and globally connecting health-system leaders with their peers on shared challenges, the JLN is helping them leverage diverse experiences to develop the tools vital for direct action and reform for UHC.

The JLN is a visible pioneer in the emerging paradigm for global health – strongly country- led, focused on South-South learning emerging from the tacit knowledge of practitioners, implementation-focused, driven by a shared passion across all its stakeholders, and determined in its content and governance by demand from strong country voices.

VISIT: http://www.jointlearningnetwork.org/ http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/; and http://www.aehin.org/

70 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 71 SHAPING THE FUTURE SHAPING THE FUTURE ______

This global agenda may also involve tackling the deeper social roots of innovation gaps. ______Developing critical new governance capacities One way is working with countries to overcome extreme socioeconomic imbalances in Dealing with pluralistic health systems, new technologies, and extensive data are not new young people’s opportunities to contribute to innovation. A recent study in the United challenges for countries. However, the future is likely to make existing capacity constraints States, for example, found that children with parents in the top 1 percent of the income more glaring. Effective engagement with the private sector, civil society, and other distribution are ten times more likely to become inventors than children with below- stakeholders, including from outside the health sector, requires transparency in decision median income parents. Similar inequities were observed for women and racial minorities. making, clear ground rules, continuous dialogue, and robust governance and monitoring This means that there are many “lost Einsteins” – people who would have made highly capacities. These conditions are not a given. They must be created. Similarly, technology’s impactful inventions, had they been exposed to careers in innovation as children, but who infinite promises demand a systems-wide discipline to source, evaluate, prioritize, and never got that chance (Bell et al. 2017). On the global scale, this waste of human talent scale up new tools. For many available technologies and solutions, the evidence base reaches staggering proportions. Ending it and closing innovation opportunity gaps within for scale up is often weak (Iribarren et al. 2017), and the rapid cycle of innovation can be and between countries is a critical task for global innovation leaders. overwhelming for governments with constrained capacity. According to a recent count, more than 100,000 healthcare apps are already available, with 229 apps in dermatology Closer to the health system frontlines, the innovation leadership agenda also includes alone (Mayes and White 2017). One frequent result is inertia, with promising reforms or expanded efforts to source and share health system solutions and evidence, building solutions never being tried; another common result is health-system managers being on the experiences of organizations such as Grand Challenges Canada and PATH, and distracted by a constant flow of new technology fads and pilots that fail to result in, or partnerships such as the Tokyo Joint UHC Initiative that aims to strengthen collaboration are not supported by, required systemic change. Big data also brings important system and alignment of efforts to support UHC at country level (page 75). There are foundations and capacity issues, with the collection and use of individual-level data being fraught for more effective global leadership on these fronts to build on, but much more can and with ethical, regulatory, and procedural challenges. Dealing with these problems requires must be done. systems and capacity that are lacking in most countries today.

______Global efforts to stimulate innovation, generate evidence, and share knowledge There is also an important role for global leadership – in the form of partnerships and efforts by international organizations—to support country efforts towards UHC. This includes support for the development of new technologies through innovative mechanisms, such as the Coalition for Epidemic Preparedness Innovations (CEPI), or new metrics to measure frontline performance, such as the Primary Health Care Performance Initiative (PHCPI) (See page 74). 8

72 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 73 R&D and Equitable Access Doing Better at the to its Benefits Remain Critical Innovation Frontier

Continued private-sector investment in research and development (R&D) is vital. However, Several organizations and platforms are trying to catalyze innovation towards UHC. for diseases which primarily affect the poor, private R&D companies may be reluctant to They have engaged businesses, researchers, and scientists around critical development invest lest the returns are too low. In addition, privately developed R&D solutions may be problems with the aim of identifying (and funding) innovations. unaffordable in low-income contexts. Between 1975 and 2004, less than 5 percent of new drugs were designed to tackle tuberculosis, malaria, and neglected tropical diseases. Sourcing Innovation. Organizations have used one or more of several approaches to Because such significant market failures exist, increased public-private collaborations and sourcing innovation: (i) crowdsourcing and contests (OpenIDEO, Grand Challenges); (ii) charitable investments are required. (Vaccine co-investments between the U.S. National peer-review (IC2030); (iii) competitive application and curated match-making to facilitate Institutes of Health (NIH) and the Gates Foundation, and between the U.K. Department partnerships (IFC TechEmerge); (iv) nominations by selected partners (Skoll Foundation); (v) for International Development (DFID) and the Wellcome Trust are notable examples.) Requests For Proposals (Wellcome Trust, USAID Development Innovation Ventures, and Global Health Innovation Technology (GHIT) Fund); and (vi) an online inventory of innovative Continued and expanded investment in discovery as a global public good is essential, projects (Global Health Exchange). Some platforms utilize a mix of two or more methods to through both push and pull incentives. Push incentives include co-financing between source innovation. For example, PATH’s Innovation Countdown 2030 (IC2030) applied both private and public partners, challenge funds, or grants or prizes for innovations in areas crowdsourcing and peer review by 60 health experts to select 30 innovations that can with market failures. Pull incentives include product pre-specifications that give R&D accelerate progress towards SDGs for health. investors clear product goals to work towards and, more ambitiously, advance market commitments which guarantee a set price for technologies meeting clear technological Sharing Innovation. Duplication of efforts can increase transaction costs. Consequently, specifications – such as the pneumococcal vaccine (Pedrique et al. 2013). the dissemination of information and knowledge exchange are critical to driving innovation, as well as ensuring coordinated investments for the strategic targeting of scarce resources. Together with increased R&D in areas of market failure, expanded access and affordability Approaches to sharing include reports and publication, data visualization, conferences and are critical. There are promising examples of technologies developed for lower-income summits, and online portfolios of innovations. countries, such as the dengue vaccine, or interventions which rapidly became accessible and affordable, such as HIV and HCV treatment. Lessons from these experiences, Measuring Impact. Different innovation platforms target different distinct elements of the including the role of voluntary licensing, patent pools, use of TRIPs flexibilities, and global innovation ecosystem. While some platforms, such as the UNICEF Innovation Fund, large-scale, low-cost generic production, must be expanded to other health innovations. focus more on fostering seed-funding for innovation or early stage R&D, other platforms focus explicitly on proof-of-concept and transition to scale. Most innovation platforms Alongside access and affordability, simplification is critical. Childhood immunization, oral include some element of impact evaluation to measure results. rehydration therapy, and HIV treatment are examples of interventions which were radically simplified and in consequence rapidly scaled-up to achieve major health impact. Organizations and platforms such as the ones featured here can help drive innovation and Complexity is a major impediment in the case of TB, where the lack of a simple, generate evidence. They represent an important effort to address some of the bottlenecks unequivocal TB test, particularly a point-of-care test, for example, remains a major that LMICs face in identifying, assessing, and scaling new technologies and solutions. Yet, obstacle to control. Similarly, the immense promise of powerful hepatitis C treatments important challenges remain to ensure the financial sustainability of efforts of this nature, remains constrained by the significant laboratory support required. and to provide complementary support to countries to strengthen institutional capacity, regulatory frameworks and other critical aspects of governance.

FOR DETAILS: https://openideo.com/ https://wellcome.ac.uk/funding/innovator-awards https://grandchallenges.org/ http://www.divportfolio.org/portfolio http://ic2030.org/ https://www.globalinnovationexchange.org/ http://www.techemerge.org/ http://www.grandchallenges.ca/ http://skoll.org/ https://www.innovationsinhealthcare.org/ https://www.ghitfund.org/

74 / Business Unusual In the past decade, the world has advanced towards UHC more swiftly than at any time in history. But progress must accelerate further if countries are to reach their 2030 UHC targets under the Sustainable Development Goals.

Part of the solution to accelerate progress is to learn from history. Health leaders can look at what has already worked elsewhere, adapting policies associated with earlier positive outlier countries’ success in expanding health service coverage and financial protection for their people.

Such reflective learning is critical and may be accelerated by concerted investment in systems science for UHC implementation and innovation, just as health technology assessment has advanced the science of priority setting, particularly for drugs, devices, and discrete interventions – but not for systems improvements. Such a systems science approach to UHC must undertake a rigorous analysis of systems progress to date and identify key opportunities for acceleration. It must develop a blueprint to build systems and policy research capacity and a culture of continuous learning and improvement in low- and middle-income countries. The new field must also incorporate global stewardship to incubate cross-country comparative systems research, set shared priorities for the measurement of UHC progress, and promote global best practices (Evans and Kieny 2017).

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84 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 85 Technical Annex 1 A. Identifying UHC rapid-progress countries Data and Methods

This appendix details the data and methods Selection of indicators used to identify Universal Health Coverage (UHC) We considered all eight indicators that make up the UHC Tracer Index published by the Institute for Health Metrics and Evaluations in 2017: 1 antenatal care visit (ANC1); 4 rapid-progress countries, including the analysis antenatal care visits (ANC4); in-facility delivery; skilled birth attendance (SBA); met need for family planning with modern methods; measles vaccine; three doses of the oral polio of inequalities in service coverage. vaccine or inactivated polio vaccine; and three doses of the diphtheria-tetanus-pertussis vaccine (DTP3). We used the unscaled versions of these service coverage indicators.

To select index components, we first assessed the correlation among the change in each indicator between 2000 and 2015, presented in Table A1. We identified the highest correlations across all the indicators. Correlation was highest among Measles, Polio3 and DPT3, ranging from 0.811 to 0.918. It was also high for in-facility delivery and SBA, at 0.833, and, between ANC1 and ANC4, at 0.622. All other correlations were below 0.52.

We selected one indicator from each of these three high-correlation clusters to reflect different types of service delivery capacities in the analysis. Institutional deliveries provide an important indication of how well systems operate across levels of care. ANC4 and DTP3 provide an indication of system abilities to overcome demand- and supply-side constraints and ensure regular contacts with the system, in compliance with clinical good practice. Finally, contraception uptake suggests how systems shape and respond to the evolving demand for health services. Restricting observations to low- and middle-income countries with more than 1.5 million in population, we constructed a simple arithmetic mean of these indicators to compute the index.

CORRELATION AMONG ABSOLUTE CHANGES IN THE 8 IHME UHC TRACER COMPONENTS, 2000-2015 Table A1

Indicator ANC1 ANC4 In-Facility SBA Met need for Measles Polio3 DPT3 Delivery modern contraception (Mnfmc)

ANC1 1.0

ANC4 .622 1.0

In-Facility Delivery .502 .454 1.0

SBA .452 .300 .833 1.0

Mnfmc .223 .029 .518 .453 1.0

Measles .416 .206 .414 .360 .441 1.0

Polio3 .494 .235 .333 .335 .388 .829 1.0

DPT3 .481 .263 .414 .370 .390 .811 .918 1.0

86 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 87 TECHNICAL ANNEX 1 TECHNICAL ANNEX 1 ______

Assessing progress toward UHC

The maximum service coverage attainable is 100%. As countries approach this bound, Where Index 2015 and Index 2000 are the values of the index for each country in 2015 each additional percentage point increase is more difficult to attain. Figure A1 captures and 2000 respectively. By subtracting the 2000 value from the 2015 value, we capture how the absolute change in the index approaches 0 at higher baseline index levels. As the net change, in percentage point terms, of the index between 2000 and 2015. In the full coverage nears, health providers and policymakers are required to expand coverage denominator, we subtract the index from 100, capturing the gap to full coverage in 2000, to more difficult-to-reach areas and populations. In contrast, a percentage point increase our baseline year. The % gap reduction therefore represents the share of the gap to full for countries starting with lower levels of service coverage will generally be easier coverage closed over the period of 2000-2015. to obtain; countries can expand coverage to communities near health facilities or to populations otherwise more amenable to the uptake of health services. Segmenting countries by baseline (2000) index values We incorporate the diminishing marginal progress at higher baseline values by representing advances in UHC in terms of the gap to full coverage. This puts more We divide countries into low-baseline (index below 50 in 2000) and high-baseline (index weight on advances at the higher levels of baseline coverage in 2000. The following above 50 in 2000) groups, based on the bimodal nature of the distribution of the index. equation represents the % gap reduction metric used. We segment countries according to the nadir in the central region of the density plot (Figure A2) at approximately 50. Thirty-seven countries had an index below 50, among which the average index was 34 in 2000. The average index was 75 among the 71 high- ( Index 2015 – Index 2000 ) baseline countries in 2000. % gap reduction = ( 100 – Index 2000 )

ABSOLUTE CHANGE (2000-2015) IN INDEX VERSUS 2000 INDEX VALUE Fig. A1 ______

DENSITY PLOT OF THE INDEX IN 2000 (50 HIGHLIGHTED) Fig. A2 50 ______

40

.03

Index (2000) = 50 30

.02

20 Densit y

Absolute change in index, 2000-2015 .01 10

0 .00 20 40 60 80 100

0102030405060708090 100 Index, 2000

Index, 2000 kernel = epanechnikov; bandwidth = 4.0000

88 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 89 TECHNICAL ANNEX 1 TECHNICAL ANNEX 1 ______

Highlighting low-baseline rapid-progress countries Highlighting high-baseline rapid-progress countries

Based on these initial groupings, we assessed the reduction in the gap to full coverage A similar method was used to identify high-baseline rapid progress countries. Figure A4 between 2000 and 2015. We first focused on the low-baseline countries. Figure A3 (page 92) captures a histogram of the % reduction in the gap to full coverage among high captures a histogram of the % reduction in the gap between 2000 and 2015 in this group. baseline countries.

We highlight the ten countries that achieved gap reductions beyond the main group of low- Rapid progress countries were identified as those who broke away from the main group baseline countries (see Table A2). These “rapid gap reduction” countries exceeded 39% of high-baseline countries – if their gap reduction exceeded 45.8% or above the 80th in gap reduction over 2000-2015, above the 75th percentile. These countries include: percentile in gap reduction. Based on these criteria, fourteen high-baseline countries Angola, Azerbaijan, Burkina Faso, Cambodia, India, Lao PDR, Liberia, Nepal, Rwanda, are highlighted as having rapid progress in service coverage: Botswana, Brazil, China, and Sierra Leone. Rapid gap reduction countries closed the gap to full coverage two times Colombia, Egypt, Honduras, Kazakhstan, Myanmar, Namibia, Nicaragua, Peru, Thailand, faster than the other low-baseline countries. The average gap reduction among low- Turkey, and Vietnam. On average, these countries closed the gap to full coverage by baseline, high gap reduction countries was 48.8%. The remaining low-baseline countries 51.3% from 2000 to 2015. Other high-baseline countries achieved 27.9% in average gap reduced the gap to full coverage by 24.0%. reduction over the same period.

These achievements in UHC bear out in the 2015 values of the index. The average index High-baseline, rapid gap reduction countries achieved 87.5 in coverage, based on the in 2015 was 67.0 among rapid gap reduction, low-baseline countries. Other low-baseline index, by 2015. Other high-baseline countries did not lag substantially behind, with an countries attained 49.5 in the index by 2015. average 2000 index value of 82.7.

For each of the countries that exceeded the 75th percentile in index growth, we present the For each of the countries that exceeded the 80th percentile in index growth, we present the index in 2000 and 2015, as well as the share of the gap closed (Table A2). The averages of index in 2000 and 2015, as well as the share of the gap closed (Table A3 on page 92). The countries in the bottom 25th and 50th percentiles are also presented for comparison. averages of countries in the bottom 25th and 50th percentiles are likewise presented for comparison.

LOW-BASELINE, RAPID GAP REDUCTION COUNTRIES Table A2

DENSITY PLOT OF GAP REDUCTION, 2000-2015 (LOW BASELINE COUNTRIES, 75TH Country/Group Index (2000) Index (2015) % gap reduction PERCENTILE IN GAP REDUCTION HIGHLIGHTED) Fig. A3 ______(2000-2015)

Angola 29.3 57.3 39.6

.08 Azerbaijan 42.3 72.0 51.5

Gap reduction = 39% Burkina Faso 33.7 64.1 45.8

Cambodia 27.4 77.7 69.3 .06 India 46.9 71.1 45.6

Lao PDR 31.9 61.2 43.1

.04 Liberia 40.0 65.6 42.7 Nepal 36.9 63.9 42.8

Rwanda 30.8 70.8 57.8 .02 Sierra Leone 33.2 66.5 49.8

Average, bottom 50th percentile 33.5 46.1 19.5 countries in gap reduction .00 20 40 60 80 Average, bottom 25th percentile 29.8 39.3 13.8 countries in gap reduction % reduction in gap to full coverage

90 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 91 TECHNICAL ANNEX 1 ______B. Constructing the dataset for the inequality analysis

DENSITY PLOT OF GAP REDUCTION, 2000-2015 (HIGH BASELINE COUNTRIES, 80TH List of indicators PERCENTILE IN GAP REDUCTION HIGHLIGHTED) Fig. A4 ______The inequality analysis in this report focuses on four indicators: (1) SBA: Births attended by skilled health personnel (in the two or three years preceding the survey) (%), (2) ANC4: Antenatal care coverage - at least four visits (in the two or three years preceding the

.06 survey) (%), (3) DTP3: Three doses of the diphtheria-tetanus-pertussis (DTP3) vaccine immunization coverage among one-year-olds (%), and (4) FP: Demand for family planning Gap reduction = 45.8% satisfied (%).

.04 In contrast to the service coverage index, we use skilled birth attendance (SBA) instead of institutional deliveries due to data limitations.These four indicators are disaggregated by wealth quintiles from 1998 to 2015 to track income-related inequality in coverage. Data by quintile are from the WHO Health Equity Monitoring (HEM) data base for SBA, ANC4, .02 and DTP3. Data on FP were extracted from Demographic and Health Surveys (DHS). Details on the data sources are included below.

.00 -50 0.0 50 100 Data Sources

% reduction in gap to full coverage We used two types of global dataset on inequality between 1998 and 2015: (i) Health Equity Monitor Database, which is based on more than 280 Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) conducted in 102 countries, 100 of which are low- or middle-income countries, in the period 1993-2014; and (ii) HIGH-BASELINE, RAPID GAP REDUCTION COUNTRIES Table A3 Demographic and Health Surveys (DHS), based on more than 260 surveys in over 90 countries from 1984 to 2016. Country/Group Index (2000) Index (2015) % gap reduction (2000-2015)

Screening process Botswana 77.5 88.4 48.5

Brazil 92.1 95.9 48.1 Consistent with the analysis of service coverage and financial protection, countries were

China 78.5 93.6 70.2 selected based on the following criteria:

Colombia 82.2 92.5 57.9 1 Countries that have at least two years of available financial protection data from 1998 Egypt, Arab Rep. 69.3 88.3 62.0 onwards, where the difference between the baseline and endline year has to be more Honduras 75.2 87.1 47.9 than five years, and the endline year is after 2009. Kazakhstan 84.7 91.8 46.6 2 Countries categorized as high-income in 2015 are excluded. Myanmar 53.1 75.2 47.1 3 Countries with populations of less than 1.5 million in 2000 are excluded. Namibia 72.3 86.0 49.5

Nicaragua 77.2 88.8 51.1 Given these criteria, data for only 34 low-baseline countries and 49 high-baseline

Peru 73.0 85.8 47.4 countries were available (see Table A4 on page 94).

Thailand 84.5 91.9 47.9

Turkey 59.8 79.4 48.8

Vietnam 64.0 80.5 45.8

Average, bottom 50th percentile 77.0 82.3 21.4 countries in gap reduction

Average, bottom 25th percentile 77.8 81.2 12.9 countries in gap reduction

92 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 93 Table A4 C. Constructing the financial protection dataset List of countries with data available for the inequality analysis

List of Indicators

We focus on two indicators of financial protection: (1) the percentage of the population facing catastrophic payments, and (2) the percentage of the population facing impoverishing expenditures. The catastrophic payment indicator is the official indicator adopted for the monitoring of financial protection in the SDG monitoring framework (SDG 3.8.1). Because it directly relates to the first SDG goal (“End poverty in all its forms everywhere”), we also choose to look at the effect of OOP on the poverty headcount. Low-baseline countries High-baseline countries In the analysis, we use two thresholds for each indicator. For catastrophic payments, ______we present country level estimates for the share of the total population spending 10% or more (CATA10) of their budget on health payments (OOP), and for the share of the population spending 25% or more (CATA25) of their budget on health payments. For Afghanistan Albania Serbia impoverishment, we look at the share of the population pushed below the extreme Azerbaijan Argentina South Africa poverty line of $1.90 per capita/day at 2011 PPP factors. We also look at the percentage Bangladesh Armenia Syrian Arab Republic of the population pushed below a higher poverty line at $3.10 per capita/day. In the Burkina Faso Belarus Tajikistan report, we present only data for CATA10 and the extreme poverty line. Burundi Benin Thailand Cote d’Ivoire Bolivia (Plurinational State of) The former Yugoslav Republic of Cambodia Bosnia and Herzegovina Macedonia Data Cameroon Colombia Tunisia Central African Republic Congo Turkey We use a recently compiled global dataset on financial protection which is based on 552 Chad Costa Rica Turkmenistan surveys conducted in 132 countries between 1991 and 2014. Together, these countries Democratic Republic of the Congo Cuba Ukraine represent about 93% of the world population in 2015 (Table A5). Ethiopia Dominican Republic United Republic of Tanzania Guinea Egypt Uzbekistan Haiti Georgia Viet Nam India Ghana Zambia Lao People’s Democratic Republic Guatemala Zimbabwe Liberia Honduras Madagascar Indonesia Mali Iraq Mauritania Jamaica Mozambique Jordan Nepal Kazakhstan SUMMARY OF AVAILABLE HOUSEHOLD SURVEYS Table A5 Niger Kenya Nigeria Kyrgyzstan NUMBER OF NUMBER OF YEAR MEDIAN POPULATION Pakistan Lesotho SURVEYS COUNTRIES SPAN YEAR COVERAGE Rwanda Malawi Senegal Mongolia GLOBAL 552 132 1984 - 2015 2005 93% Sierra Leone Morocco AFR 114 36 1991 - 2014 2005 91.8% Somalia Namibia EAP 43 12 1992 - 2015 2006 95.3%

South Sudan Nicaragua ECA 214 18 1985 - 2014 2005 86.7%

Sudan Panama LAC 39 13 1984 - 2015 2001 89.3% Togo Peru MNA 11 9 1995 - 2015 2006 64.1% Uganda Philippines SAR 29 8 1991 - 2011 2005 100% Yemen Republic of Moldova

Note: Financial Protection data are based on LSMS, HBS, LIS, and other HIES types of survey instruments.

94 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 95 TECHNICAL ANNEX 1 TECHNICAL ANNEX 1 ______

Screening Process ANNUAL PERCENTAGE POINT CHANGE IN CATA10 VERSUS BASELINE VALUE Fig. A5 ______

Unlike service coverage data, which involves annual data from 2000 to 2015, financial Note: X-axis is expressed in logarithmic scale protection data are survey-based. A number of countries therefore suffer from lack of data

availability. To have an analysis that closely parallels the analysis of countries with rapid 3 progress on service coverage, we selected the final list of countries for financial protection analysis using the following screening categories:

) 2 1 Countries with at least two years of available financial protection data from 2000 onwards 2 Countries with first and last years of available financial protection data spanning 5 years 1 3 Countries categorized as high-income in 2015 are excluded

0 Restricting the list of countries to only those that have two years of available data is necessary to allow for analysis of changes in financial protection. This is not sufficient, however, as an equally important condition is to have the start and end years of available -1 data be at least 5 years apart to allow for sufficient change in the financial protection variable. Using these categories, a final set of 46 countries out of 220 countries were Annual percentage point change in catastrophic health spending (10% -2 selected (15 among low-baseline countries in terms of service coverage, 31 among high- baseline countries). -3 Figures A5 to A8 capture the final set of countries and how the initial values of the financial 510152025 protection indicators compare with their respective annual absolute percentage point Catastrophic health spending (10%), baseline year changes. One similar pattern that arises across all financial protection variables is that the variability of change increases as the value of the financial protection indicator increases.

The following legend applies to Figures A5 to A8: ANNUAL PERCENTAGE POINT CHANGE IN CATA25 VERSUS BASELINE VALUE Fig. A6 Low-baseline rapid progress countries ______High-baseline rapid progress countries Note: X-axis is expressed in logarithmic scale Low-baseline other countries High-baseline other countries 1.0 )

0.5

0.0

-0.5 Annual percentage point change in catastrophic health spending (25%

-1.0 246

Catastrophic health spending (25%), baseline year

96 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 97 TECHNICAL ANNEX 1 TECHNICAL ANNEX 1 ______

ANNUAL PERCENTAGE POINT CHANGE IN IMPOV190 VERSUS BASELINE VALUE Fig. A7 Tables A6 and A7 show the list rapid progress countries with sufficient data on ______catastrophic and impoverishment health spending data.

0.2 LIST OF SC RAPID PROGRESS COUNTRIES WITH SUFFICIENT CATASTROPHIC HEALTH SPENDING DATA Table A6

COUNTRY BASELINE END CATA10 CATA10 CATA25 CATA25 YEAR YEAR (BASELINE) (END) (BASELINE) (END) 0.0 Low-baseline countries in terms of SC index

Burkina Faso 2003 2009 8.5 3.5 2.4 0.6

India 2004 2011 13.4 17.3 2.2 3.9

-0.2 Lao PDR 2002 2007 3.1 3.0 0.1 0.3 Nepal 2003 2010 10.0 27.4 0.8 3.3

Rwanda 2000 2010 8.4 4.6 1.3 0.7 nnual percentage point change A High-baseline countries in terms of SC index

in health spending impoverishment ($1.90) -0.4 China 2000 2007 12.2 17.7 2.7 4.8

Kazakhstan 2001 2013 2.2 1.8 0.1 0.1

Nicaragua 2001 2014 15.9 27.7 3.2 8.9 0 2 46 Peru 2000 2015 11.8 8.3 2.9 1.2

Health spending impoverishment ($1.90), baseline year Turkey 2002 2012 6.0 3.1 1.1 0.3

Vietnam 2002 2014 12.7 9.8 3.0 2.1

Note: CATA10 – catastrophic health spending at 10%; CATA25 – catastrophic health spending at 25%; all financial protection numbers are in percentages. ANNUAL PERCENTAGE POINT CHANGE IN IMPOV130 VERSUS BASELINE VALUE Fig. A8 ______

LIST OF SC RAPID PROGRESS COUNTRIES WITH SUFFICIENT IMPOVERISHING HEALTH SPENDING DATA Table A7 0.6

COUNTRY BASELINE END IMPOV 190 IMPOV 190 IMPOV 310 IMPOV 310Z YEAR YEAR (BASELINE) (END) (BASELINE) (END) 0.4 Low-baseline countries in terms of SC index

Burkina Faso 2003 2009 1.7 1.2 1.0 0.9

0.2 India 2004 2011 4.1 4.2 2.3 4.6

Lao PDR 2002 2007 1.0 0.4 1.2 1.0

Nepal 2003 2010 3.9 1.9 2.1 5.6 0.0 Rwanda 2000 2010 0.9 0.9 0.7 0.4

High-baseline countries in terms of SC index nnual percentage point change

A China 2000 2007 2.8 2.1 2.2 3.1 -0.2

in health spending impoverishment ($3.10) Kazakhstan 2001 2013 0.3 0.0 0.9 0.0

Nicaragua 2001 2014 1.8 3.1 3.0 5.2

-0.4 Peru 2000 2015 1.2 0.1 2.3 0.2 0 1 2 45 Turkey 2002 2012 0.2 0.1 0.3 0.2

Health spending impoverishment ($3.10), baseline year Vietnam 2002 2014 4.0 0.3 2.5 1.4

Note: IMPOV190 – health spending impoverishment using $1.90-a-day poverty line; IMPOV310 – health spending impoverishment at $3.10-a-day poverty line; all financial protection numbers are in percentages.

98 / Business Unusual TECHNICAL ANNEX 1 ______D. Technical appendix references

Data availability at country level DHS Program. Demographic and Health Survey Reports. https://www.dhsprogram.com/

Table A8 below shows the list of countries with rapid progress on service coverage (both GBD 2016 SDG Collaborators.“Measuring progress and projecting attainment on low and high baseline) for which we do have country level information allowing us to draw the basis of past trends of the health-related Sustainable Development Goals in 188 trends on financial protection, and the countries for which we don’t. countries: an analysis from the Global Burden of Disease Study 2016.” The Lancet. 12 Sept 2017: 390; 1423–59.

LIST OF NON-HIGH-INCOME SC RAPID PROGRESS COUNTRIES Table A8 United Nations Children’s Fund (UNICEF). Multiple Indicator Cluster Surveys. http://mics.unicef.org/ LOW BASELINE HIGH BASELINE World Health Organization (WHO). Global Health Observatory data repository.

Countries with FP trend data Countries with FP trend data Health Equity Monitor. http://apps.who.int/gho/data/

Burkina Faso China

India Kazakhstan

Lao PDR Nicaragua

Nepal Peru

Rwanda Turkey

Vietnam

Countries without FP trend data Countries without FP trend data

Angola Botswana*

Azerbaijan Brazil

Cambodia Colombia

Liberia Egypt, Arab Rep.*

Sierra Leone Honduras

Myanmar*

Namibia*

Thailand

*Countries that did not achieve SDG neonatal mortality target in 2015.

Note: Low-baseline rapid-progress SC countries are those whose service coverage indices were below 50 in 2000 and which exceeded the 75th percentile in index gap reduction among low-baseline countries between 2000 and 2015. High-baseline rapid- progress SC countries are: (1) those that already had a service coverage index above 90 in 2000 and that maintained an index > 90 in 2015; and (2) those that had a service coverage index above 50 in 2000 and achieved index gap reduction above the 80th percentile for all high-baseline countries between 2000 and 2015.

100 / Business Unusual Technical Annex 2 Endnotes Outliers in Progress on Service Coverage and Financial Protection, All LMICs, 2000-2015

Countries with less than 1 The idea of “relative gap reduction” involves the following considerations. The higher Countries with insufficient data 1.5 million population a country’s starting point, the more difficult it is to reduce coverage gaps. To take this dynamic into account, we used the relative (not absolute) reduction in the gap as the measure of progress. For example, an absolute coverage increase of 20 percentage American Samoa Grenada Nauru Suriname Bhutan Swaziland points from a starting point of 20 percent yields a relative reduction in the gap (from 20 Belize Guinea-Bissau Niue The Gambia Cabo Verde Sao Tome percent to 100 percent) of 25 percent. In comparison, an absolute coverage increase Comoros Guyana Samoa Tonga Dominica and Principe of 20 percent from a baseline of 60 percent yields a relative reduction in the gap of 50 Cook Islands Kiribati Solomon Islands Tuvalu Fiji Timor-Leste percent. For a more detailed discussion, see the Technical Appendix. Croatia Marshall Islands St. Lucia Vanuatu Gabon Djibouti Mauritius St. Vincent & Maldives 2 LMIC categorization is based on countries’ income status in 2015. Countries with Equatorial Guinea Micronesia Grenadines Montenegro a population of less than one million were excluded from the analysis. The total 2015 population of all 108 low- and lower-middle income countries was 6.1 billion.

3 The 37 original low-baseline countries achieved the following average results: >> Average starting point: 34 percent Countries with SC Data >> Average coverage increase: 20 percent >> Average gap reduction: 31 percent

4 Data are only available for slightly more than half of all LMICs, with some variation Rapid SC Progress across indicators.

Angola Honduras* Burkina Faso FP Progress 5 We also explored the impact of using a cut point of 25 percent of total expenditure—­ Azerbaijan Liberia Kazakhstan* even higher OOPs. Botswana* Myanmar* Lao PDR Albania* Guinea Brazil* Namibia* Peru* Bangladesh Mozambique 6 The sensitivity to a poverty line of $3.10 per day was explored. Cambodia Sierra Leone Rwanda Bosnia* Pakistan Colombia* Thailand* Turkey* Congo Rep.* Zambia* 7 This discussion draws on El-Sadr, Harripersaud, and Rabkin 2017. Egypt* Vietnam* Guatemala* 8 For details, see: http://cepi.net/ and https://phcperformanceinitiative.org/

China* Nicaragua* India Nepal Countries with FP Data

Mali Iran Morocco South Africa Kosovo Cote d’Ivoire Indonesia Macedonia Sri Lanka Lithuania Cameroon Georgia Mexico Ukraine Senegal Costa Rica Moldova Zambia Nigeria Bulgaria Mongolia Niger Belarus Romania Philippines Kyrgyz Rep. Serbia

Afghanistan Mauritania Algeria El Salvador Lesotho Tajikistan BurundiCAR PNG Argentina Ghana Libya Tanzania Chad Somalia Armenia Iraq Malawi Tunisia Congo DR South Sudan- Benin Jamaica Malaysia Turkmenistan Eritrea Sudan Bolivia Jordan Panama Uzbekistan Ethiopia Togo Cuba Kenya Paraguay Venezuela Haiti Uganda Dominican Rep. North Korea Russia West Bank / Gaza Madagascar Yemen, Rep. Ecuador Lebanon Syria Zimbabwe

102 / Business Unusual Accelerating Progress Towards Universal Health Coverage / 103 ABOUT THIS REPORT

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