Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized GOING UNIVERSAL GOING UNIVERSAL How 24 Developing Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up Daniel Cotlear, Somil Nagpal, Owen Smith, Ajay Tandon, and Rafael Cortez © 2015 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 18 17 16 15 This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Direc- tors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Contents Foreword xiii About the Authors xv Acknowledgments xvii Abbreviations xix Overview 1 1. Introduction 19 Going Universal—A Focus on “How” 20 Methodology—Countries, Programs, and Data 23 Attacking Inequality—The Common Starting Point for Diverse Paths to UHC 27 A Guide to the Book 30 References 31 2. Covering People—The Bottom-Up Approach 35 Segmented Populations, Fragmented Health Systems 36 Identifying and Targeting the Poor—And Getting Better at It 39 Enrolling People—Two Phases, Two Paths 44 Using Fundamentals and Investing in Learning 54 Conclusions and Policy Implications 60 Notes 62 References 63 3. Expanding Benefits: Exercising Choices to Expand the Scope of Health Care Services 67 Adding Services—Moving Beyond the MDGs 69 Defining Benefits—Toward Explicit Benefit Packages 76 Prioritizing Services—Mechanics and Complexities 79 Breaking Promises—De Facto Benefit Packages 86 v vi Going Universal Contracting Benefits—Engaging Private Providers, Using Closed-Ended Payments, and Improving Linkages to Performance 90 Conclusions and Policy Implications 94 Notes 95 References 96 4. Managing Money: Financing the Bottom-Up Expansion of Universal Health Coverage 99 Spending Some, Leveraging More 101 Collecting Contributions—Government and Other Sources 111 Sharing Costs—Low Copayments but Still-High OOPE 119 Pooling Risk and Allocating Resources 122 Conclusions and Policy Implications 131 Annex 4A 134 Notes 136 References 137 5. Improving Health Care Provision 141 Introduction 141 Human Resources for Health—Trends in Retention and Outreach 141 Increasing Managerial Flexibility in Public Facilities 144 Increasing Participation of Private Providers 146 Accrediting Health Facilities 147 Continuum of Care: Integrating the Health System, Strengthening Primary Care 152 Conclusions and Policy Implications 156 Note 158 References 158 6. Strengthening Accountability 161 Introduction 161 Features and Key Relationships 162 Delegating—Toward Arm’s-Length Relationships and Explicit Responsibilities 166 Financing—Paying for Outputs and Results Instead of Inputs 172 Information and Enforcement—Collecting More Data, but Not Always Making Use of It 175 Empowerment—Strengthening Citizen Voice and Client Power 179 Contents vii Conclusions 181 References 183 7. Conclusions 187 Policy Convergence, Implementation Variations 187 Policy Choices and Paths to UHC 190 Stepping Stones 191 New Risks 192 Final Words … 194 Appendices A. Universal Health Coverage Studies Series—Studies and Authors 195 B. UNICO Country Context 197 Macroeconomic Indicators 198 Key Population Health Outcomes 203 Health Financing 207 Health Inputs and Coverage 208 Notes 216 References 216 C. The Impact of Universal Health Coverage Programs on Access, Financial Protection, and Health Status—A Literature Review 217 Introduction 217 Impact of UHC Programs in a Nutshell 217 Methods 218 The UHC Programs Evaluated 220 Does the Evidence Show Beneficial Impacts of UHC Programs? 221 A Synopsis of Some Other Literature Reviews 228 Thoughts on the Strengths, Limitations, and Usefulness of Evidence for Policy Advice 230 Notes 242 References 243 D. UNICO Questionnaire and Universal Health Coverage Study Series 249 Index 251 viii Going Universal Boxes 1.1 Before the “How”—“What?” and “Why?” 21 2.1 Targeting Populations with Supply-Side Programs 41 2.2 Targeting Methods 42 2.3 Benefits of Enrollment 45 2.4 Does the Bottom-Up Approach Create Poor Services for the Poor? 48 2.5 Voluntary Insurance 53 3.1 Criteria for Defining Benefit Packages 81 4.1 What Is Actuarial Analysis? 111 4.2 Earmarking 115 4.3 Three Cost-Sharing Modalities in UNICO Countries 120 4.4 Pooling Risk 124 5.1 Accreditation—A Key Condition for Getting Value for Money 149 5.2 What Is Integrated Health Care and Why Can It Make a Difference? 153 6.1 Why Is It So Hard to Achieve Accountability in the Health Sector? 165 Figures 1.1 The UHC Cube 22 2.1 Trickle-Down and Bottom-Up Expansion of Health Care 36 2.2 Health Systems in UNICO Countries before the Introduction of UHC Programs 37 B2.1.1 Distribution of UHC Program Coverage by Family Income Quintile, Brazil, 2008 41 2.3 Noncontributory Path to UHC 49 2.4 Contributory Path to Covering the Informal Sector 52 2.5 Share of Informal Employment and of Poor Populations, Selected UNICO Countries 55 2.6 Enrollment of the Poor by Maturity of UHC Programs 57 2.7 Enrollment in Health Insurance by Income 58 2.8 Distribution of Enrollment by Economic Quintile in Selected UHC Programs 59 4.1 UHC Program Expenditures per Beneficiary versus GDP per Capita in UNICO Countries, 2011 103 4.2 UHC Program Expenditures as Share of GDP in UNICO Countries, 2011 104 4.3 UHC Program Expenditure Share in Total Public Health Expenditures in UNICO Countries, 2011 106 Contents ix 4.4 UHC per Beneficiary Program Expenditures as a Share of per Capita Public Health Expenditures in UNICO Countries, 2011 107 4.5 Public Expenditure Share of GDP versus GDP per Capita, 2011 (UNICO Countries Highlighted) 108 4.6 Annual Growth in Public Health Expenditure as Shares of Public Expenditure and of GDP, 2000–12 (UNICO Countries Highlighted) 109 4.7 OOPE Share of Total Health Expenditures versus GDP per Capita in UNICO Countries, 2011 (UNICO countries highlighted) 122 4.8 Annual Change in OOPE Share of Total Health Expenditures in UNICO Countries, 2000–12 (UNICO countries highlighted) 123 5.1 Density of Health Workers in UNICO Countries 142 6.1 Five Features of Accountability 163 6.2 Key Relationships of Accountability 164 B.1 Democratization, UNICO Countries, 2011 200 B.2 Income and Income Classification of UNICO Countries, 2011 201 B.3 Absolute Poverty Rates in UNICO Countries, circa 2011 202 B.4 Distribution of Gini Index across UNICO Countries, 2011 203 B.5 Median GDP Growth in UNICO and Non-UNICO Developing Countries, 2000–12 204 B.6