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THE Rockefeller Foundation EVALUATION OFFICE information systems. There isalso a renewed political integrate andstandardize data across various health expand hiringand training, as wellasinitiatives to veloping national health workforce strategies that systems data includede actions collection. These to tackle human resource gaps and strengthen health some progress withefforts issues, inaddressing these hasmade (GoB) The Government ofBangladesh high. care, out-of-pocket onhealthcare spending remains primary care level andsubsidized at higherlevels of sector healthservicesare technically free at the substantial financialbarriers to care. Althoughpublic mation systems. face Inaddition,many Bangladeshis infrastructuresionals, poor andweakhealthinfor oftrainedincluding shortages healthcare profes- to services.Several factors contribute to gaps, these of healthcare, inaccess andsignificantinequalities duetochallenges gapsintheavailability andquality continues togladesh face significanthealthsector country over the However,last few decades. - Ban have contributed to impressive healthgainsinthe NGO,across its public, andprivate for-profit sectors and theincreasing availability ofcare options The pluralistic nature ofBangladesh’s healthsystem grants at regional, theglobal, levels. andcountry and inform reforms TheTHSinitiative inothercountries. hasinvested $115millionin development for ofcountry-specific models changethat alsohave potential to influence The Rockefeller Foundation’s Transforming SystemsHealth initiative (THS) has promoted toIn seeking expand universal coverage health countries, inlow- andmiddle-income (UHC) Bangladesh Lessons from TheRockefeller Foundation’s Transforming HealthSystems Initiative Country CaseStudyCountry Brief - - advocacy workstream (see THSgrant piechart). falling under the UHC and policy in Bangladesh tive’s workstreams, withnearlyhalfofthefunding awarded country-level grants inallfour oftheinitia - address key healthsystem barriers to UHC, THS To theGoB’s support andotherpartners’ efforts to put thecountry firmlyonthepath to UHC. and implement other health system reforms that will roll out abroader national healthinsurance scheme patient in- totion Scheme increase access to affordable developed Strategy and adopted its first national Health GoB Care Financing health insurance scheme.For example, the in2012, commitment anational from to roll-out theGoB tivities andprovidetivities guidance for future work. inform andstrengthen theFoundation’s country-level ac- and recommendations learned harvest lessons that will studies, completed in 2014, were undertaken in order to the Evaluation Office of The Rockefeller Foundation. The Policy Research inconsultation withtheTHSteam and uative country case studies conducted by Mathematica The information isfrom inthisdocument ofeval aseries - care. However, more to stillneeds done to be a Social HealthProteca Social -

Overview of grant-making and key strategies in seminating the UHC concept to a variety of health sector Bangladesh stakeholders. Health information THS explicitly decided to work in Bangladesh with a Health“high Stewardship risk” but potentially, “high reward” hypothesis. The 18% 17% Rockefeller Foundation selected Bangladesh as a focus UNCcountry Policy despite the absence of a strong national commitment to UHC and health sector “champions” because 18% Healthit calculatedFinancing that its extensive connections with in-country stakeholders and the strength of the local NGO sector 47% could address these limitations and foster growing national support for UHC. At the time this case study was conducted, leadership gaps within government and NGO partner institutions, as well as THS-related programmatic constraints, seem to have hindered progress in advancing UHC policy and advocacy UHC. Recently, however, there have been indications of Health systems stewardship & management increased government commitment to UHC, such as the Health information systems (eHealth) expansion of the Health Economics Unit (HEU) within Health financing the Ministry of Health and Family Welfare (MoHFW), and cabinet discussions on proposing a new law based on the national Health Care Financing Strategy. THS efforts to increase UHC-related dialogue and its targeted inputs activities in Bangladesh began in January 2009 and into the development and implementation of the national will continue through December 2015. As of July 2014, THS had awarded a total of 31 grants across 15 individual grantees.

THS country strategy When THS began grantmaking in Bangladesh, it recog- nized two important and ongoing challenges: significant and wide-reaching health workforce constraints and weak health information systems. Health care professionals, especially nurses, were in short supply and many lacked training in key health care and health policy areas. In health informatics, many different actors and systems were collecting health care data, field staff received limited training on how to collect high-quality data and use it for program management, and data systems were not effectively integrated. THS grantmaking sought to address these health system issues by focusing investments on i) identifying gaps in health care training and providing training to current and future health sector professionals, ii) conducting assessments of existing health information systems and devising and implementing strategies to increase the reliability of management information systems data, and iii) introducing and dis-

2 Health Care Financing Strategy may have contributed to these advancements.1

THS outcomes Notable outcomes resulted from this work, including the following:

Increased awareness and commitment to UHC THS, along with other donors, has contributed to strengthening the commitment of the MoHFW’s HEU to advancing UHC. THS-sponsored study tours to other countries have helped HEU expand its understanding of how a national health protection scheme might be designed and rolled out, and informed inputs into Kasmauski/Corbis © Karen the national health care financing strategy. Trainings, study tours and dialogues supported by THS have also Contributed to the development of broadened the discussion on UHC – expanding from the technological infrastructure for integrating HEU and a few influential donors and NGOs to include health information systems Members of Parliament, journalists and a variety of urban To help build a reliable and useful health information and rural stakeholders. Moreover, Bangladesh is now system in Bangladesh, THS supported the design of a an Associate Member of the Joint Learning Network for systems architecture that would integrate data from a Universal Health Coverage (JLN), with HEU as the main variety of different health sector information systems. country representative – further indication that the As part of this effort, it supported eHealth scenar- country is interested in learning how it can implement io-planning workshops that encouraged the MoHFW to 2,3 UHC. be forward-looking in building a unified systems architecture that integrates data from a variety of sources Contributed to improving and standardizing across the ministry, other parts of the government and training at medical education institutions THS activities that focus on health care education the private sector. are helping to build the capacity of future health care professionals. For instance, with THS support, the nation’s premier postgraduate medical institu- THS lessons learned Significant lessons the Foundation learned in Bangla- tion, Bangabandhu Sheikh Mujib Medical University desh about this work include the following: (BSMMU), developed a curriculum for its Master of Public Health degree, which has been adopted by six Country-level progress on the UHC agenda requires other academic institutions and is now a requirement consistent, committed and cross-sectoral govern- for anyone seeking to join a government institute as a ment leadership. Moving the UHC agenda forward public health specialist. requires a strong institutional push from a cross-government coalition, which was lacking in Bangladesh at the time the case study was conducted. It is particular- 1 This information was provided by Rockefeller Foundation Transforming ly important to include the Ministry of Finance in the Health Systems initiative staff to Mathematica after the case study was dialogue, as it controls the health budget, and any policy complete. 2 JLN is a country-led network where practitioners and policymakers co-de- reform will typically require fiscal negotiations and velop global knowledge and tools that focus on the practical “how to’s” of shifts. However, since the case study was conducted, achieving UHC. To learn more see: http://jointlearningnetwork.org. 3 This information was provided by Rockefeller Foundation Transforming there appears to have been a shift in the Ministry of Health Systems initiative staff after the case study was complete. Finance’s understanding of the importance of UHC, as

3 signaled by the Minister indicating full support for UHC tifies activities, outputs, and outcomes can help ensure in his plenary speech at the UHC Conference in Dhaka that grants are well-aligned and target common objec- in April 2015.4 tives. Building a shared understanding of program priorities across grantees can strengthen linkages and ensure A targeted and unified vision across partners, as that the initiative stays on track to achieve its objectives. well as a country strategy with finite outcomes, are critical to leveraging small and diverse invest- A strong champion outside the government can ments. Grantmaking in Bangladesh was opportunistic ensure sustained attention to the UHC agenda. and designed to leverage The Rockefeller Foundation’s Fragmentation in the grant portfolio could have been extensive pre-existing network. However, as a result, addressed to some extent by a strong local organization- grants often focused on conducting activities rather than al lead, which was difficult to establish in Bangladesh due achieving outcomes, and were not well-integrated, in part to capacity and leadership constraints. An organization because they were addressing a wide variety of issues. in this role would ideally be able to coordinate across Developing an overarching country strategy that iden- grantees, support implementation of a unified strategy targeting long-term UHC-related outcomes, and engage 4 This information was provided by Rockefeller Foundation Transforming in ongoing advocacy efforts around strengthening health Health Systems initiative staff to Mathematica after the case study was complete. systems and UHC.

Financial support provided by

4 THE Rockefeller Foundation EVALUATION OFFICE the scheme and difficulty identifying the poor under under poor the the schemeanddifficulty identifying of highpremium rates, lackofpublicunderstanding of tion isstillnotcovered by theNHIS, mainly because achieving UHC. Roughly percent 65 - ofthepopula that have hampered its asa effectiveness vehicle for thisprogress,Despite NHIShasfaced challenges 1 percent to in2004 roughly percent 34 in2012. (NHIS), whichincreased insurance coverage from nation’s first National HealthInsurance Scheme reforms, introduction includingthe2003 ofthe Ghana hasundergone significanthealthsector delivery systems. To achieve objectives, these equitable, andsustainable servicesive, efficient, offering financialprotection, andensuring - respon improving healthoutcomes, reducing inequalities, works andstrategies, whoseobjectives include sector and economic development framepolicy They have consistently been featured inkey health protection – are national priorities. long-standing and equitable access to quality care andfinancial ponents ofUHC–includingensuringuniversal Keyand fiscalcommitments to achieving it. com- legislative,goal andhasmadesignificantpolitical, adopt universal healthcoverage asapolicy (UHC) Ghana was amongthefirst countries inAfrica to at regional, theglobal, levels. andcountry and inform reforms TheTHSinitiative inothercountries. hasinvested $115millioningrants development of country-specificfor models change that also have potential to influence The Rockefeller Foundation’s Transforming Systems Health initiative (THS) haspromoted toIn seeking expand universal coverage health countries, inlow- andmiddle-income (UHC) Ghana Lessons from TheRockefeller Foundation’s Transforming HealthSystems Initiative Country CaseStudyCountry Brief -

leveraging theprivate healthsector. have limited thegovernment’s progress ineffectively rangements. Butcapacity andresource constraints and developed some public-private partnership ar to thenon-statesector to gaps, helpaddress these thegovernmentpast decade, hasincreasingly looked sistent gapsinaccess to andquality ofcare. the Over a comprehensive reform agendathat per addresses that strengtheningacknowledged theNHISrequires and reduce fraud undertheprogram. hasalso TheGoG recently initiated several measures to contain costs dressing confronting themany issues theNHIS, and andshowncommitmentpublicly acknowledged to ad- made to date. has TheGovernment ofGhana(GoG) which financial threatensustainability issues, gains NHISalsofaces serious policy. exception NHIS’s tivities andprovidetivities guidance for future work. inform andstrengthen theFoundation’s country-level ac- and recommendations learned harvest lessons that will studies, completed in 2014, were undertaken in order to the Evaluation Office of The Rockefeller Foundation. The Policy Research inconsultation withtheTHSteam and uative country case studies conducted by Mathematica The information isfrom inthisdocument ofeval aseries - - -

Overview of grant-making and key strategies work in Ghana as an excellent opportunity to partner with in Ghana IFC and leverage its work in the private sector to advance HS UHC. It has supported UHC advancement in the country 4% 5% through interventions largely focused on building the HSSM public sector’s capacity to steward and manage a mixed public-private health system. In 2009, THS awarded its uhc 25% first country-level grant to IFC to support a comprehensive Financingassessment of the private health sector. The assessment, published by the World Bank in 2011, identified several 66% areas of action to support private sector development and public-private collaboration in the health sector.

Through a grant to the MoH, THS went on to fund three of these action items, including: i) building the capacity and influence of the MoH’s Private Sector Unit, ii) de- Health systems stewardship & management veloping a new national private health sector develop- UHC policy and advocacy ment policy, and iii) creating a platform to facilitate the Health financing engagement of the private sector in the policy progress. Health information systems (eHealth) This platform became the Private Health Sector Alliance of Ghana (PHSAG), an umbrella organization of private sector stakeholders. To support the GoG’s efforts to strengthen the NHIS and achieve UHC, THS awarded grants in all four of its work streams, with a particular focus on activities to THS outcomes strengthen health system stewardship and management Notable outcomes resulted from this work, including the capacity (see pie chart). THS’s activities in Ghana began following: in September 2009 and will continue through 2016. As of March 2014, THS had awarded a total of 13 grants to 9 Strengthened public sector capacity to steward individual organizations. and manage a mixed health system THS’s early focus on identifying influential country-level partners and scoping activities was strategic and THS country strategy important in developing and refining its country-level Ghana’s strategy to address gaps in access to health strategy. When THS started investing in Ghana, rela- care has included efforts to increase the participation of tively few donors were focused on increasing the MoH’s private providers in the NHIS by reimbursing accredited providers in the private sector for services delivered to NHIS members. While accreditation is automatic for public sector facilities, private providers must undergo an accreditation process. As a result, many private providers are still not accredited due to capacity and resource constraints within the Ministry of Health (MoH) and NHIS.

Following the introduction of the country’s first private health sector policy in 2003, the International Finance Corporation’s (IFC) Health in Africa (HIA) initiative began working in Ghana to support the development of the private sector in health. The Foundation saw IFC’s HIA © Liba Taylor/Corbis

2 capacity to steward and manage the health sector, par- JLN’s information technology (IT) track then attended ticularly the private sector. THS intentionally targeted an IT track core working group convening in Dubai where this gap through training, technical assistance and staff they shared their experiences in developing a common support to the MOH’s Directorate of Policy, Planning, eHealth standard with other JLN members. Monitoring and Evaluation, and through support for the development of a new national private health sector development policy. It also supported a number of discrete THS lessons learned activities aimed at building public sector capacities, Significant lessons the Foundation learned in Ghana including the development of tools to strengthen accred- about this work include the following: itation processes, technical assistance to the National Health Insurance Authority (NHIA), and support for the Identifying and focusing on specific, high-impact creation of a doctoral program in health leadership at the health system levers can enhance grantmaking ef- University of Ghana’s School of Public Health. fectiveness under resource- and time-constrained initiatives. From a funding perspective, The Rockefeller Increased policy dialogue around UHC issues Foundation is a relatively small player in the Ghanaian THS grants to date have supported roughly 20 confer- health sector. However, the Foundation identified a key ences, meetings and policy dialogues focused on UHC health system strengthening lever – private health sector issues, as well as over 15 reports, concept notes, and development – that aligned with country priorities and policy briefs to build the evidence base for UHC-ori- needs and THS outcomes. Focusing initial grantmaking ented reform efforts in Ghana. Case study data suggest on this lever enabled THS to gain traction and recogni- that one of THS’s most far-reaching and visible agen- tion in Ghana. da-setting efforts was its support of the First Pan-Afri- can Health Congress: Creating a Movement for Universal THS’s grantmaking approach did not systematically Coverage in Africa through Health Insurance. Held in build or leverage linkages among grantees, or develop 2011 this reportedly was the first time the term “universal a shared understanding of the initiative’s objectives. Grantees in Ghana mostly worked in silos with little or health coverage” was used widely across the range of no knowledge of other organizations in Ghana receiving health sector stakeholders. Rockefeller Foundation funding, or of how their work fit Strengthened NHIS and Joint Learning Network into the THS initiative. However, despite little familiarity (JLN)1 with initiative-level goals, many grantees were able to ar- The JLN cross-country networking and learning platform ticulate how their work aligned with overall health system is well regarded among Ghana’s JLN members and has strengthening and UHC work in Ghana. helped the NHIA address several issues facing the NHIS. For example, the NHIA drew on India’s experience imple- Health system transformation toward UHC is a menting biometric identification cards to inform the in- long-term and ambitious endeavor that requires tegration of similar cards into the NHIS. JLN members in sustained effort, investments, and transition The goal of THS – to advance and ultimately Kenya and Ghana also collaborated to develop the NHIA planning. achieve UHC – is highly ambitious for a nine-year initia- eClaims management system. Ghanaian members of the tive. The amount of time and level of investment needed to move the needle on UHC at the country level is sub- 1 JLN is a country-led network where practitioners and policymakers co-develop global knowledge and tools that focus on the practical “how to’s” of stantial and will exceed THS’s lifespan and resources. It achieving UHC. To learn more see jointlearningnetwork.org. would be useful for the Foundation to work more closely with grantees on transition planning to ensure that the valuable contributions THS has made to the health Financial support provided by sector of Ghana are sustained.

3 THE Rockefeller Foundation EVALUATION OFFICE management andservice delivery. and reporting to mechanisms improve healthsector system, financing aswellperformance-based (ICT)nology to transform the country’s healthcare effort to useinformation and communications - tech hasalsomadeasignificant theGoR vancement, as partofits broader UHCad- agendasupporting revenue andimprovements inequity. Inaddition, resulting challenges, dressing inincreases these in revisions to theCBHIsystem showpromise inad- programmatic over challenges theyears, recent Although theCBHIprogram hasfaced financialand penditures, andimprovements inhealthindicators. inout-of-pocketservice use,declines healthcare ex 91 percent in2010, withcoinciding increases inhealth coverage increased from 7percent to in2003 introduction oftheCBHIprogram, healthinsurance ularly amonginformal sector workers. Through the care and financialprotection partic- againstillness, UHC – sought to provide universal access to quality program –akey component ofefforts to achieve a national community-based health insurance (CBHI) universal healthcoverage launchof The2003 (UHC). at strengthening its healthsector andachieving hasundertaken ofreforms anumber support, aimed withdonor The Government ofRwanda (GoR), at regional, theglobal, levels. andcountry and inform reforms TheTHSinitiative inothercountries. hasinvested $115millioningrants development for ofcountry-specific models changethat alsohave potentialto influence The Rockefeller Foundation’s Transforming Systems Health initiative (THS) haspromoted toIn seeking expand universal coverage health countries, inlow- andmiddle-income (UHC) Rwanda Lessons from TheRockefeller Foundation’s Transforming HealthSystems Initiative Country CaseStudyCountry Brief -

eHealth workstream (see piechartonPage 2). health financing–withthemajority falling underthe health system and stewardship andmanagement, work streams –healthinformation systems (eHealth), to 7organizations inRwanda, inthree ofTHS’s four of May 2014, THShadawarded atotal of11grants 2009andcontinuedOctober through mid-2015. As vehicles. THS’s grant inRwanda in began activities the GoR’s efforts to achieve UHCthrough these reform Systems initiative (THS) helpingto hasbeen advance The Rockefeller Foundation’s Transforming Health eHealth andtechnology platforms. At time, thesame development strategy thatinvestment included in committed toIn theearly2000s,GoR ICT asa THS country strategyTHS country tivities andprovidetivities guidance for future work. inform andstrengthen theFoundation’s country-level ac- and recommendations learned harvest lessons that will studies, completed in 2014, were undertaken in order to the Evaluation Office of The Rockefeller Foundation. The Policy Research inconsultation withtheTHSteam and uative country case studies conducted by Mathematica The information isfrom inthisdocument ofeval aseries -

The Rockefeller Foundation was developing a vision Overview of grant-making and key strategies for eHealth as a valuable resource for supporting UHC in Rwanda globally. In 2008, a month-long conference, Making the eHealth Connection, hosted by The Rockefeller Foun- dation at its conference center in Bellagio, Italy, was 15% attended by the President of Rwanda, signaling his government’s commitment to building the country’s eHealth infrastructure. 20% 65% THS has made important contributions to building local capacity in Rwanda for stewardship and management of eHealth systems, as well as the development of eHealth tools aimed at improving health system management and service delivery. With THS support, Rwanda estab- lished an eHealth Secretariat within its Ministry of Health Health information systems (eHealth) (MoH), and an eHealth Centre of Excellence to build Health systems stewardship & management country capacity to design, implement, and sustain in- Health financing novative eHealth reforms. THS also created a Centre of Excellence in Health Systems Strengthening (CoEHSS) at the National University of Rwanda School of Public technology architecture. Although several donors work Health to strengthen broader capacities around health in the eHealth space in Rwanda, the Foundation’s in- sector management and reform processes. vestments addressed an unmet need for increased local capacity for stewardship and management of eHealth systems. Key THS outcomes included the establishment THS outcomes and institutionalization of an eHealth Secretariat within Notable outcomes resulted from this work, including the the MoH to guide and support implementation of the following: country’s eHealth Strategic Plan (2009-2014), and the Improved capacity to develop and implement development of an informatics training program within sustainable eHealth solutions the eHealth Centre of Excellence to strengthen national THS has made important contributions to eHealth ca- competency and capacity to support and sustain eHealth pacity-building and the development of key eHealth efforts. Increased efficiency in complementary global and country strategies THS’s investment strategy in Rwanda developed out of and effectively leveraged several of THS’s global-level investments designed to support greater use of technology tools for strengthening health systems in low- and middle- income countries. For example, global-level THS investments in the development of an OpenMRS platform and eHealth architecture framework in developing countries led to the creation of a customized OpenMRS electronic medical records (EMR) system in Rwanda and a Rwandan Health Enterprise Architecture (RHEA). THS country-level grants supported the implementation of RHEA in one district and the national roll out of an OpenMRS EMR system for primary care.

2 THS lessons learned Significant lessons the Foundation learned in Rwanda about this work include the following:

Leveraging synergies between global and country grantmaking, and between grant and non-grant activities can increase the efficiency and effectiveness of initiative investments. THS’s strategy of leveraging synergies and complementarities across its global and country-level activities to support country-level reform efforts proved successful in Rwanda. Global investments aimed at setting a global eHealth agenda, building momentum for the integration of technology in health systems, and developing interoperable eHealth platforms and tools had direct effects on eHealth devel- RHEA (now Rwandan Health Information Exchange) is opment in Rwanda. Combined with support under THS’s in the process of being scaled-up nationally with donor country-level grants and from other partners, THS was support. THS grantee Partners in Health will continue to able to make valuable contributions to Rwanda’s eHealth support the roll out and expansion of the OpenMRS EMR space. system, in collaboration with the MoH. Identifying countries and partners with pre-existing Scaled-up and sustainable results interest in and commitment to THS’s priorities can Nearly all THS/Rwanda grant proposals include sustain- improve initiative effectiveness. The MoH’s extensive ex- ability plans, with most indicating that grantees planned perience experimenting with and implementing CBHI, per- to extend, operationalize, scale-up or institutionalize grant formance-based financing and other health sector reforms, outputs, often with support from the MoH. In several cases, combined with its strong cross-sector commitment to using steps toward sustainability have been made. The MoH, for ICT to drive the country’s development, created a strong example, transitioned funding for the eHealth Secretariat enabling environment for THS and for leveraging The from Rockefeller Foundation grant funding to the MoH’s Rockefeller Foundation’s existing (and growing) expertise annual budget. The GoR also plans to provide funding in eHealth. The MoH’s distinctive eHealth experience and for the eHealth Centre of Excellence. A CBHI financial leadership helped align the THS strategy with national pri- modeling tool developed with THS funding has been orities. transitioned to the MoH, with plans to transform it into a web-based tool with donor support. The U.S. Centers for Scaling up and institutionalizing eHealth tools is not Disease Control and Prevention (CDC), U.S. President’s a short-term endeavor and concrete effects on health Emergency Plan for AIDS Relief (PEPFAR), and the U.S. sector performance take significant time to emerge. Agency for International Development (USAID) are report- The amount of time and level of investment required to edly supporting further scaling-up of the Rwanda Health develop, implement, and scale-up eHealth tools, and to Information Exchange, and Partners in Health continues build and sustain capacity to support these tools, is sub- to support the MoH in rolling out and expanding the stantial and extends well beyond THS’s lifespan and level functions of the OpenMRS EMR platform. of resources. The Rockefeller Foundation’s strategy has focused on seeding and providing foundational support for eHealth innovation and scaling-up. While relatively suc-

Financial support provided by cessful in Rwanda, this strategy does not guarantee that the tools and capacity-building institutions supported under THS can be fully operationalized and sustained after their grants have ended.

3 THE Rockefeller Foundation EVALUATION OFFICE of health insurance to schemes improve health 1990s, thegovernment avariety establishing began ing accessto public healthinsurance. Intheearly coverage withaparticularfocus onincreas (UHC), major reform efforts to advance universal health T grants at regional, theglobal, levels. andcountry and inform reforms TheTHSinitiative inothercountries. hasinvested $115millionin development for ofcountry-specific models changethat alsohave potential to influence The Rockefeller Foundation’s Transforming SystemsHealth initiative (THS) has promoted toIn seeking expand universal coverage health countries, inlow- andmiddle-income (UHC) Vietnam end, thegovernment hasmadeseveral efforts over as well as broader health system reforms. To this government achieving universal coverage willrequire further Improving financial protection under SHI and of-pocket payments for health care remain high. sector workers remains low, andhouseholdout- ing. Coverage andinformal amongthenearpoor achievingdecade, challeng UHCwithSHIhasbeen rapidDespite increases inenrollment over thelast subsidized rate. of thoseinsured accessing coverage at nocost ora percent was covered by health insurance, with60 by 2020. 67 percent of2012, As ofthepopulation and setauniversal target of80percent coverage into schemes asinglenational programof these HealthInsuranceSocial (SHI)Lawintegrated several and informal sector groups and the poor. The 2009 coverage andprovide financialprotection for formal he Government of Vietnam has undertaken several subsidization oftheSHIprogram, Lessons from TheRockefeller Foundation’s Transforming HealthSystems Initiative Country CaseStudyCountry Brief - - 1 reforming capitation at theprimarycare level, and Recognizing this,thegovernment iscommitted to ofthecapitation ofthedesign system.part because to capitationshift hasnotresolved in equity issues, form ofpayment at healthfacilities.However, the payments, bycaused thedominant fee-for-service resource inservice provision useandinequities the primary-carelevel to in address inefficiencies ment introduced capitation-based payments on provider payment reform. thegovern In2004, savings inthehealthsystem, withagrowing focus recent years to reduce andcreate inefficiencies cost

rather thanapayment service per provided. Capitated payment systems are onapayment based person, per tivities andprovidetivities guidance for future work. inform andstrengthen theFoundation’s country-level ac and recommendations learned harvest lessons that will studies, completed in 2014, were undertaken in order to the Evaluation Office of The Rockefeller Foundation. The Policy Research inconsultation withtheTHSteam and uative country case studies conducted by Mathematica The information isfrom inthisdocument ofeval aseries 1 at at - - -

Overview of grant-making and key strategies in Vietnam systems 10% 2% nancing

Steward 25% UNC 63%

is also exploring the use of diagnostic-related group2 (or Health systems stewardship & management case-mix-based) payment systems at secondary and Health financing tertiary hospitals. Health information systems (eHealth) UHC policy and advocacy The Transforming Health Systems (THS) Initiative has supported Vietnam’s efforts to achieve UHC by funding activities in three out of its four work streams, with almost two-thirds of all grant funding falling under the health To propel UHC reforms forward, THS has supported systems stewardship and management work stream (see research efforts that aim to inform provider payment pie chart). THS’s grant activities in Vietnam began in reforms, as well as capacity-building activities for local September 2009 and will continue through 2017. As of health sector stakeholders. THS effectively identified July 2014, THS had awarded a total of 16 grants to 10 and targeted an unmet need for rigorous data collec- individual organizations. tion and analysis to guide the provider payment reform process. Leveraging country-level grants, as well as technical assistance activities and products under THS country strategy The Rockefeller Foundation-supported Joint Learning When THS began investing in Vietnam, the govern- Network for Universal Health Coverage (JLN),3 THS ment was actively looking for ways to expand coverage, has supported efforts to assess Vietnam’s current mix improve financial protection, and reduce inequalities of payment systems, collect the cost data needed to under its SHI program. It was particularly focused on calculate capitation rates across geographic areas and improving the provider payment system. It had also population groups, and design and test alternative supported several capitation pilots over the past decade, capitation methods to inform revisions to the existing developed the beginnings of a diagnostic-related capitation system. In addition, THS has addressed gaps group payment system, and sought to learn from other in local capacity for evidence-based policy formula- countries’ reform experiences. Despite these efforts, lim- tion, implementation, and management. It has sought itations in the design of the payment system continued to build expertise in health sector planning and man- to have negative implications for health care equity. In agement, as well as technical research and evidence addition, local health sector stakeholders did not have generation to inform policy making. Overall, THS grant the technical know-how needed to address those limita- activities have strengthened linkages among key health tions in an evidence-based and comprehensive manner. sector organizations, transforming what were mainly

3 2 With a diagnostic-related group payment system, a hospital would be paid JLN is a country-led network where practitioners and policymakers co-de- a single amount based on a patient’s diagnosis, rather than on what it did to velop global knowledge and tools that focus on the practical “how to’s” of treat the patient. achieving UHC. To learn more, see jointlearningnetwork.org.

2 personal connections into more functional relation- ships, and highlighted the value of evidence as a key factor in guiding policy reform.

THS outcomes Notable outcomes resulted from this work, including the following:

Built capacity of academic and research institutions to participate in policy-making processes Education and training opportunities provided under THS have helped to strengthen the professional and through the JLN to fill these gaps. This led to evidence technical capacities of academic and research orga- generation that has strengthened awareness of the nizations. These opportunities have enabled staff to need for provider payment reforms, increased technical engage meaningfully in policy dialogue and research knowledge about reform models, and shaped the design efforts on health systems, health financing, and health of alternative capitation models, which have been piloted information systems, while training students to eventu- in four sites. Under a THS grant awarded in 2014, results ally take on those roles. The creation of the Center for from the pilot will be analyzed and used to inform the Health Systems Research (CHSR) at the Hanoi Medical reform of the SHI Law. University, which serves as an active training vehicle for academics, government officials, and health profession- Generated evidence to shape universal health als represents a key outcome in this area. insurance policies Under a grant to the MoH, THS supported development Strengthened government capacity in health of a UHC “roadmap”, which was submitted to the govern- system management and planning ment in late 2012. This roadmap is now the official plan THS has helped develop health sector planning and for the roll-out of national health insurance, approved management capabilities at various levels, a need pri- by the Prime Minister in 2013. THS also supported a oritized by the Ministry of Health (MoH) and other de- study of low SHI enrollment rates among the near poor, velopment partners. THS’s contributions have included which recommended that government subsidization of support for a number of training courses at the national, insurance premiums for the near poor be increased from provincial, and hospital levels, support for tools and as- 50 to 70 percent – a recommendation the Prime Minister sessments to guide provincial-level planning efforts, approved. Currently, the MoH is redesigning the SHI and development of health sector work plans. THS-sup- benefits package per the SHI Law, and HSPI is playing a ported trainings have continued with donor and MoH crucial role in that process.4 funding, and THS-supported work plans and planning tools, including a framework for health planning at the provincial level and a master plan for UHC, have been THS lessons learned adopted by the government. Significant lessons the Foundation learned in Vietnam about this work include the following: Increased support for the provider payment reform process Targeting existing national priorities which have THS identified well-defined data gaps that were impeding active support from key government players and provider payment reform and strategically connected the Health Strategy and Policy Institute (HSPI), a strong 4 This information was provided by Rockefeller Foundation Transforming country-level grantee, with regional resources available Health Systems initiative staff to Mathematica Policy Research after the case study was complete.

3 which strong country-level partners have the capacity for UHC-related priority setting, whereby local capacity to address, can position country-level pro- academic and research partners supported by THS were gramming for strong policy-level impact. Given the paired with regional grantees, such as the UK’s National time-bound nature of the THS initiative, the Foundation Institute for Health and Care Excellence International was strategic in concentrating its UHC reform efforts on (NICE International) and Thailand’s Health Intervention provider payment reform, which is required by the SHI and Technology Assessment Program (HITAP). Drawing Law and strongly supported by influential MoH leaders. on technical support provided by NICE International and Government commitment to provider payment reforms, HITAP, these local partners are currently engaged in joint coupled with the presence of HSPI – a strong local research on priority health conditions and treatments partner with interest in and the capacity to support the which will inform revisions to the SHI benefits package.5 reform process – created an enabling environment for relatively small, strategic investments to influence the Institutional capacity-building grants may lay the policy process within the THS initiative’s lifespan. groundwork for future impacts on health system reforms, but often will not produce immediate, Pairing international technical experts with local concrete outcomes unless they are closely tied to high-capacity research organizations can yield the policy process. THS’s institutional capacity-build- relevant and useful outputs. THS skillfully connected ing grants have helped strengthen organizations and its regional and country-level grantees to ensure that allowed grantees to test new ideas and launch new ini- its evidence generation effort had two key ingredi- tiatives – such as a new civil society network on health ents for success – extensive local research capacity equity created under a THS grant. Some of THS’s seeding and deep technical knowledge and expertise. THS’s efforts are being carried forward with donor assistance. provider payment work represents the outcome of the While these activities represent important steps toward timely alignment of several complementary trends: i) the building a sustainable foundation for UHC in Vietnam, MoH was displaying a strong interest in increasing the they have not always produced outputs with direct and efficiency of its payment mechanisms, ii) the JLN was close links to policy outcomes. In contrast, THS’s in- preparing to engage with its country partners on capi- vestments to build the infrastructural and operational tation reforms, and iii) The Rockefeller Foundation had capacity of HSPI, which have a strategic focus on a par- developed a relationship with HSPI though the MoH and ticular reform effort, are more likely to yield measurable identified its potential to contribute to policy reform. THS influence on policy outcomes in the short term. adopted a similar approach in its efforts to build local

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5 This information was provided by Rockefeller Foundation Transforming Health Systems initiative staff to Mathematica Policy Research after the case study was complete.