Health Sector Reform
Research Activities for the IHSP "Organizational and Policy
The organizational and policy process component of IHSP is involved in
three major areas in health systems research, all related to key policy
issues of health reform:
- decentralization of health systems
- political process of policy change
- organizational development and institutional reform
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The IHSP has pioneered in the area of decentralization of health systems.
It has developed an innovative analytical approach to decentralization,
called the "Decision Space Approach" that is based on principal agent
theory. (Publication Link:
DDM No. 54. Decentralization of Health Systems: Decision Space, Innovation,
and Performance). The approach was also published in 1998 in Social
Science and Medicine (see below). This approach provides a comparative
tool for analyzing the range of choice over different functions that is
allowed to decentralized authorities. IHSP has used the approach in studies
of decentralization in Chile, Colombia, Bolivia in Latin America (Publication
Link: Decentralization of Health Systems in Latin America: A Comparative
Study of Chile, Colombia, and Bolivia). Another set of studies
was done comparing Zambia, Uganda, Ghana and the Philippines, (Publication Link: Decentralization of Health Systems: Preliminary
Review of Four Country Case Studies). A seperate in depth study
of Zambia was completed recently, (Decentralization of the Health System
in Zambia). This research is funded by the United States Agency for
Development through two Harvard projects: the Data for Decision Making
Project and the Partnerships for Health Reform.
Supported by two USAID projects – the Data for Decision Making Project
and Partnerships for Health Reform -- teams of national researchers and
our team at Harvard used the decision space approach to analyze decentralization
in four countries: Chile, Bolivia, Colombia and Zambia. The studies collected
and analyzed nationally available data on income and expenditures, human
resources data, utilization of public health services, and socio-economic
conditions. Field case studies with interviews of officials and observers
in selected municipalities in the countries were also implemented.
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|"Decision Space" Analytical Approach
The studies found considerable variation in "decision space" allowed
in the different countries as shown in the following table. While none
of the countries grant wide choice over revenues, expenditures, and fees,
most grant a moderate range of choice over revenues and all grant a moderate
range of choice over expenditures. Only Zambia had little choice over
alternative revenue sources. Interestingly, the norms and standards established
by the Latin American Ministries limited local choice more than in Zambia.
Comparative Decision Space: Current Ranges of Choice
One of the major hypotheses about decentralization is that it contributes
to inequity of expenditures among wealthier and poorer localities. The
argument is that local governments with more resources will be able to
allocate more to health than can poorer localities. Our studies found
that although wealthier localities indeed were able to spend more per
capita on health, the gap between rich and poor was actually declining
over the period of decentralization. Decentralization seems to be good
for equity of per capita expenditures. Our studies found increasing equity
of per capita expenditures in Chile and Colombia at the municipal level.
One of the mechanism that was effective in achieving this degree of equity
was the use of earmarking of population based formula funding to the municipalities
in Colombia. Colombian municipalities received general revenues according
to a formula based on population and other factors. A percentage of these
revenues were earmarked for the health sector – forcing municipalities
to spend relatively similar amounts of the central government funds to
health. That they also began to assign similar amounts from their own
source revenues is a local choice that is encouraging. Bolivia used a
similar earmarking tool. In Zambia, the formula to allocate budgetary
to the districts was largely based on population size and it appears to
have been implemented as planned, resulting in relatively equal per capita
expenditures among districts.
In Chile we found an alternative mechanism – the Municipal Common Fund
which redistributed local own-source revenues from wealthy municipalities
to the poorer municipalities – resulted in a relatively equal per capita
expenditures in all but the wealthiest decile.
These research findings suggest that neither the advocates nor the detractors
of decentralization policies are 100% right. In most cases, decentralization
is neither likely to lead to radical improvement in a health system, nor
to produce a disaster. However, forms of decentralization that include
mechanisms to improve equity, like the Municipal Common Fund in Chile,
the earmarking of central funds in Bolivia and Colombia, and the population
based formula for allocating budgets to districts in Zambia can definitely
improve the equity of resource allocations. It also was related to increased
The range of choice allowed to municipalities is quite limited for certain
functions that might be needed to improve performance—such as hiring and
firing, payments to providers, and decisions about health service norms.
It seems likely that experimenting with wider decision space, and appropriate
incentives for guiding those choices might be worth evaluating for their
impact on efficiency and quality.
Finally, it is also clear that central authorities need more accurate
information about what is happening at the municipal level. This will
enable them to develop monitoring systems in order to adjust the decision
space, incentives, and use of central funding to achieve national policy
objectives in health.
Lessons drawn from the research are presented in a set of Guidelines
for Policy, (Publication Link: Guidelines for Promoting Decentralization of Health
Systems in Latin America). and included in the module on decentralization
prepared for the World Bank Flagship Course on Health Sector Reform and
presented special seminars in various countries. Future research in this
area will assess the impact of decentralization on vertical programs such
as immunization and HIV/AIDS and on health care logistics and supply systems
with support from several USAID projects.
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Politics of the Policy Process
IHSP has also engaged in major research on political processes of health
policy reform. This research includes a comparative study of the policy
process of reform in Chile, Colombia and Mexico, (Publication
Link: Enhancing The Political Feasibility of Health Reform: A comparative
analysis of Chile, Colombia and Mexico). Applying both stakeholder
and institutional approaches the research has developed the innovative
concept of "change teams" of politically astute technocrats from several
key ministries who drive the reforms forward.
IHSP with support from the USAID LAC Bureau's Health Sector Reform Initiative,
has done in-depth studies of the policy process of health reform in Chile,
Colombia and Mexico to develop lessons for the policy process of health
reform in other countries, (Publication Link: Enhancing the Political Feasibility of Health Reform:
A Comparative Analysis of Chile, Colombia, and Mexico). The studies
have shown significant similarities in the Chilean and Colombian "success
stories" that were lacking in the Mexican case that did not produce reform.
The studies do not evaluate the success or failure of the reform policy
itself, but rather the successful political strategies for adoption of
a significant reform, regardless of its effectiveness.
It is often argued that it should be easier to implement broad reforms
in authoritarian regimes because they can make decisions without having
to respond to different interest groups that, in democratic systems, can
often block reforms. Contrary to this expectation, we found that reforms
occur in both democratic Colombia and in Chile during the Pinochet dictatorship,
and that the limited democratic regime of Mexico did not produce reforms.
Furthermore, we found that within the restricted range of political actors
in Pinochet's Chile, there was significant bargaining and negotiating
among major stakeholders that were able to delay the reforms and limit
their reach during the adoption and implementation of the changes.
We found that a major factor in the success of reforms was that a relatively
stable and coherent "change team" was formed. This team was formed with
individuals from, and continuing links to, a macro-economic "change team"
which had successfully developed policies of economic reform. The health
sector change team was made up of technical experts with a coherent shared
ideological commitment but who did not see themselves as politicians.
These teams were supported by the presidents and other major political
actors in the governments of Chile and Colombia. Their members were from
the Ministry of Planning and the Ministry of Finance and had initially
worked on macro level reforms and pension reforms, usually with significant
success. Successful teams were initiated and recruited in a conscious
effort, usually by cabinet level officials or their immediate subordinates.
Members of the macro-economic change team then turned their attention
to health sector – in Colombia after being forced to by the Congress –
and sent key members to work in the Ministry of Health. Part of the reason
that Mexico failed to produce reform is that the efforts to create a coherent
change team in health were frustrated by intense internal competition
among key macro-economic change team members over the anticipated selection
of the next president.
The health sector change teams pursued different strategies to get their
policies adopted. One of the strategies was to isolate the change team
from the broader political process until it had developed a significant
technically defined package of reforms. This strategy appears to have
been more successful than a broadly public participatory debate that is
often recommended before the development of a health reform package. The
reform package was then presented as a complete reform and as the president's
own proposal for legislative attention. During the legislative process
(which occurred even in the Pinochet dictatorship) the change team was
able to overwhelm the opposition with well-developed technical arguments.
It was important throughout the process that the change team demonstrated
full technical command of the issues and present evidence-based arguments.
The team's own legitimacy and effectiveness in building and maintaining
high level support depended on credible rational arguments.
The studies suggest the following lessons for major reform efforts Publications Link: Guidelines for Enhancing the Political Feasibility
of Health Reform in Latin America:
- Develop support for reform at the presidency, cabinet, and in the
planning and finance ministries. Reform initiated only in the health
sector is likely not to have sufficient support to be pushed through
the executive and legislative processes.
- Pay attention to recruitment of a like-minded technical competent
"change team" with strong vertical links to high level officials
and horizontal links to officials in other sectors.
- In political processes technical arguments and good data matter. The legitimacy and effectiveness of change teams depend on their ability
to marshal strong arguments and good data. This is the source of their
power and linkage to other stakeholders.
- Isolation of the change team in the formulation of policy may
be an effective strategy to create a single and coherent reform package
that has the support of major political actors.
Research on the policy process of health reform in Poland concluded that
usual stakeholder analysis is inadequate because many of the stakeholders
do not consistently pursue policy objectives, (Publications Link: DDM No. 74. Unpredictable Politics: Policy Process
of Health Reform in Poland). Continuing research in this area
is being funded by the Inter-American Development Bank through FUNSALUD
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Organizational Development and Institutional Reform
Research on organizational development and institutional reform involved
the transformation of the Colombian Ministry of Health during the period
of major health reform. This research developed a multi-dimensional approach
based on recent organization theories and assessed the existing structure
and human resource skills in relation to the desired functions in the
new health reform. Findings included:
- Inadequate analytical capacity needed for the new roles of policy
design and regulating a mixed market system
- Lack of a single unit with sufficient number of skilled economists,
policy analysts, legal experts to perform this analytical role
- High turnover of mid level and high level directors
- Rigid bureaucratic organizational culture in long term staff
The research resulted in proposed specific reorganization and transformation
- Creation of a Health Reform Analytical Unit at a high level of the
- Reassignment of existing experts to this unit
- Long term contracts to reduce turnover of directors
- Agreements at the political level to reduce turnover
- Processes of strategic planning, mission statements and recruitment
to change the organizational culture to a "learning culture"
This research was funded by the Colombian government and the Inter-American
Development Bank and published in Health Policy and Planning (see below).
Bossert T. "Analyzing the
Decentralization of Health Systems in Developing Countries: Decision Space,
Innovation and Performance," Social Science and Medicine, November
Bossert T., et.al. "Transformations of Ministries of Health in the Era
of Health Reform: the Case of Colombia," Health Policy and Planning, March, 1998.
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Health Sector Reform in Poland and the Development
of Regional Insurance Funds
HSPH faculty (Berman, Bossert, Campbell, Hsiao) first visited Poland
in October 1995 at the invitation of the U.S. Agency for International
Development (USAID) and the Polish Government. They began an extensive
consultation funded by USAID through the Data For Decision-Making (DDM)
Project that extended through June 2000. The project evolved through two
distinct periods, an initial (1995-1998) focus upon health sector reform
at the local government level, and then a later (1998-2000) focus on reform
at the national level.
The Harvard IHSP team forged an agreement with the Jagiellonian University
School of Public Health (JSPH) and called their collaboration the Consortium
for Health (Consortium). Andrzej Rys, then the JSPH Director, became Co-Director
of the Consortium along with Paul Campbell from Harvard. The Harvard and
Jagiellonian officials then joined with partners from local governments
representing different regions in Poland to draft a project design. These
local collaborators, from Suwalki, Leczyca, Krakow and later on, Nowy
Sacz, shared the goal of improving the quality and efficiency of health
care with the two universities.
The IHSP team was urged to initially focus on local reform for several
reasons. First, radical health sector reform at the national level was
developing more slowly in Poland than in other Central European nations
(e.g. Czech Republic, Hungary). Second, the Law of Large Cities had given
the larger municipalities responsibility for outpatient health services
that had previously been held by regional (but federally appointed, voivode)
authorities, and they were looking for guidance. Third, a small number
of regional and municipal officials in Poland had already begun to initiate
reforms at the local level and they would provide examples of reforms
in action. Fourth, strengthening local government was a strategic objective
of the Warsaw mission.
During this initial period the Consortium was active in policy as well
as management issues. At the policy level project participants met with
collaborators throughout Poland, and through the new municipal government
associations. They worked hard to develop an appropriate role for municipal
governments in a health system that could be expected to evolve continually
for the foreseeable future. Consortium members met to discuss international
experience on this issue as well as to host national meetings.
The general and component planning processes led to the following Consortium
roles in local government strengthening and health reform:
- Involvement in the policy-making process. Project participants
influenced legislative and executive (regulatory) activity that supported
the local government role in health. This was accomplished through involvement
in selected municipalities (gminas), zones and municipal government
associations, as well as through direct contact with both elected and
appointed government at all levels. (Publication Link: DDM No. 64. Poland Health Policy: Democracy and
Governance At Local Levels In International Perspective)
- Work with local governments to develop and test models of health
delivery. The project assisted Krakow Gmina, for example, from the
initial planning through implementation of a complex set of reforms.
Citizens of Krakow were eventually given the choice to be cared for
by one of four competing city-funded health plans (developed from ZOZ’s).
In addition they could also select a primary care doctor within the
health plan who became responsible for coordinating their full range
of care needs. While project staff worked intensively in a few areas,
like Krakow, they also traveled throughout the country to learn from
local officials who were implementing an array of different health delivery
models, (Publication Links:
DDM No. 67 Enrollment Procedures
and Self-selection by Patients: Evidence From A Family Practice in Krakow,
DDM No. 60 Quality of Outpatient
Services, Krakow Gmina,
DDM No. 73 Provision
of Ambulatory Health Services in Poland: A Case Study from Krakow.
- Enhancement of managerial capacity at the local level. The
project recognized from the outset that managerial skills would be in
increasing demand regardless of the type of models of health delivery
system implemented. Managers throughout the system were going to have
more autonomy and they needed the skills to make use of their new authority
and responsibility. Project experts, from both the United States and
Poland, provided on-site consultation and training, as well as workshops
in a variety of relevant areas, including: provider contracting, cost
accounting, planning and control methods, quality monitoring and policy
analysis. Manuals on these subjects were published in Polish and have
been utilized throughout Poland.
During the initial local government phase, the project: 1) completed
Poland’s first application of market research methods (focus groups and
patient surveys) at the health facility level, 2) facilitated the rapid
spread the practice of provider contracts across the country through conferences
and training programs, 3) developed and implemented new approaches for
quality monitoring of gmina-managed outpatient services, and 4) assisted
with the establishment of the nation’s first truly private non-profit
hospital of the post- communist period.
It became clear in 1998 that Poland was on the verge of national health
sector reform. Legislation initially proposed in 1977 was modified and
passed. The piece of legislation finally implementing a broad set of reforms,
the Health Insurance Act, became effective on January 1, 1999. On that
date the government also initiated a new set of county-level governments,
new regional or state governments, a new educational system built on the
new levels of government, a new pension system and finally a new educational
With the agreement of the Warsaw USAID mission the project became increasingly
involved in providing technical assistance on national health care issues.
The IHSP team jprepared papers offering advice on topics from financing
to the design of delivery systems. These papers have included the following:
Roberts and Campbell facilitated a four-day retreat for MOH officials
and members of the Polish Parliament on health sector reform. The first
day of the retreat was held at a seminar center outside Warsaw and subsequent
days were spent in Vienna studying relevant elements of the Austrian health
system. The Polish government ultimately decided to implement health sector
reform that included the following major features:
- Decentralization: Since the political changes of 1989 many
responsibilities previously under the total control of the central government
had been devolved to local authorities. This was true for the health
sector as well. For example, responsibility for outpatient primary and
specialty care services, as well as in some cases inpatient care, was
transferred to large cities and local government service zones. The
1999 Health Insurance Law took the additional step of establishing 16
new regional insurance funds. The regional funds are responsible for
financing the system largely through required employer/employee payroll
contributions, and also for contracting for care from a largely public
but also some private providers.
- Separation of payer and provider: Strategic authority previously
held by central government officials was also granted to managers of
officially “independent” (and relatively autonomous) health institutions,
including hospitals and ZOZ’s. This was done on an experimental basis
at first and then later established as the dominant model. The creation
of more autonomous units limited first the central government and now
the regional insurance fund role to financiers rather than direct providers
of health services.
- Market and market like-incentives: The reforms have reflected
the government’s multi-sector acknowledgment of the need for organizational
and individual economic incentives in order to gain widespread and sustainable
improvements. With the separation of payers and providers, local government
health authorities began to take official advantage of the opportunity
to compensate providers on a performance basis.
The project also convened a series of meetings in Poland to facilitate
communications on the evolving reform. Officials from the new regional
government health offices attended as well as representatives from municipal
governments and the Ministry of Health. In addition the Consortium also
invited the leaders of three of the regional funds to Harvard for a strategic
planning retreat, mirroring the program held a year earlier for the Krakow
city health department. The senior Ministry official in charge of social
sector reform, Mrs. Knysok, also attended. A large number of Harvard faculty
were involved and the Polish officials also made visits to relevant facility
and government offices.
During the final national policy phase, the project: 1) drafted a white
paper on the new reforms; 2) conducted applied research on relevant topics
such as physician contracting and independent units; 3) produced a number
of other reports, articles and books on reform-related subjects; 4) provided
models on provider contracting, quality monitoring, planning, and public
relations for the new health system; 5) held workshops on the general
reform process as well as on specific skills such as provider contracting
for senior Ministry as well as local government bureaucrats and elected
officials and facility managers; and, 6) introduced senior officials and
Ministry managers to relevant international experience, especially in
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Harvard and Health Reform in Colombia
In the mid 1990's Colombia initiated one of the most innovative and ambitious
health reform efforts in the world with the passage of Law 100 in 1993.
This law and earlier laws on decentralization, reflected some of the most
advanced thinking on the design of new financing, organization and payments
systems. Following the concepts of "managed competition" that had also
influenced the Clinton health reform package, Law 100 promoted a two tiered
competition -- among providers and among insurance plans, in both the
public and private sectors. Harvard was asked to support the implementation
of this ambitious reform in a project funded by the Government of Colombia
and the Inter-American Development Bank. The Project was a collective
effort of various departments and programs at Harvard and was headed by
William Hsiao as Principal Investigator. IHSP Senior Political Scientist,
Thomas Bossert was Project Director and IHSP Director, Peter Berman, managed
the National Health Accounts component.
The project supported the Ministry of Health and Social Security in the
initial three years of the implementation of Law 100. The project was
designed to develop a Ten Year Work Plan for the implementation of the
reform, and to develop the terms of reference for projects to support
reform leadership, training and applied research for the reform. The project
provided applied research in financing and organization issues, human
resources development, technical assistance and training in a variety
of key areas of the reform. We conducted surveys of the new insurance
programs, assessments of capacities of public and private hospitals, evaluation
of funding flows and payments mechanisms. We developed improved collection
strategies, recommended policy modifications to expand coverage of the
subsidized population, encouraged support for decentralization, provided
basis for new formulae for allocation of resources, developed reorganization
plans and plans for human resource development and recruitment.
Harvard support was effective in promoting the initial stages of the
reform and alterting the government to modifications needed for a more
effective implementation. However, subsequent government decisions, along
with a major economic decline and deterioration of the security situation
have undermined the reform, making it difficult to evaluate the effectiveness
of the ambitious program. Lessons from our experience, suggest caution
in the implementation of two tiered competitive systems, especially competition
among insurance plans. However, lessons on organization of the Ministry,
decentralization, and payments mechanisms have been disseminated through
journal articles, our participation in the World Bank Flagship Course
in Health Reform and Sustainable Financing, and our Harvard School of
Public Health courses.
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A Decade of Health Sector Reform in Developing Countries:
Within the last decade, the concept of “health sector reform” for middle
and lower income countries has gone from being a new idea to becoming
an overused “buzz word” that is attached to any and all efforts to improve
health systems. Today, one can often hear health sector reform referred
to in negative terms, cited as the cause of poor health system performance.
How did a notion of substantial change to improve health systems so quickly
become accused of causing their problems? What can be done to develop
better approaches to health sector reform?
At the conclusion of nine years of project activity through the Data
for Decision Making Project, IHSP organized a symposium to review a decade
of experience in health reform in developing countries. The background
paper "A Decade of Health Sector Reform in Developing Countries: What have we learned?" for that
symposium cited the following:
- Health sector reform should refer to substantial strategic change
efforts that are built on a strong evidence base and logical framework
for health system change, i.e. are purposeful and sustainable.
- Many programs and projects using the term “health sector reform” as
a label do not meet these criteria. They fall into two broad groups:
- Rapid health system change that is a response or reaction to broader
social, political, or economic changes, not part of an intentional
effort to improve health system performance. This includes many of
the changes in transitional economies, the responses to structural
adjustment programs, and major state reforms that impact on the health
sector. Typically, the health system response must be quick and may
be poorly thought out and planned.
- “Solutions looking for problems”. International organizations and
national authorities often latch onto the latest fashions in health
system change, such as user fees, hospital autonomy, or decentralization,
without clearly laying out the priority problems they want to solve
and whether these “solutions” are right for the problems.
- Well-designed health reform programs have been relatively rare. These
can be classified as “Big R” reforms, which address broader health system
changes and use multiple mechanisms, and “little r” reforms, which are
typically focussed on one part of the health system and perhaps only
- Few low income countries have tried to effect a Big R reform There
is much more experience with little r.
- Experience to date has been mixed, with few dramatic successes. Reform
is difficult, especially Big R. And this difficulty has been underestimated.
Reform needs some institutional stability, good evidence and information,
and the right human resource capacities to be successful. Often this
- Does this mean that reform is too hard? No, not at all. There is no
going back to a simpler world of hierarchical vertical interventions.
The urgent health problems of the day: HIV/AIDS, reproductive health,
integrated management of childhood illness, emerging or resurgent infectious
disease, will all require substantial improvements in overall health
system performance. Reform must be seen as a partner to these urgent
public health programs, not as a competitor.
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Getting Health Reform Right: A Framework for Assessing
Health System Performance and Designing Reform Strategies
IHSP faculty Berman and Bossert are working with Harvard faculty colleagues William
Roberts, and Michael
Reich to develop and teach more systematic approaches to health sector
reform in collaboration with the World Bank Institute’s Flagship Course on Health Sector Reform and Sustainable
As part of this effort, Hsiao, Roberts, Berman, and Reich authored Getting
Health Reform Right, (GHRR) a framework and guide for assessing
health system performance and designing reform strategies. This book was
published in 2004 by Oxford
University Press. Early drafts of GHRR have been used in the WBI Flagship
GHRR includes several useful contributions to more systematic thinking
about health sector reform:
- a well-developed ethical framework
- significant role for politics and political analysis
- a recommended framework of health system performance criteria
- a set of key health system “control knobs” that make up much of the
content of reform programs, including:
- a systematic approach, with examples, to “diagnosing” health system
problems and developing “therapy” for their improvement.
The innovative approaches in GHRR have increasingly become the conceptual
base for much of IHSP’s work as well its teaching and research.
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Health Sector Analysis and the Development of a Primary
Care Reform Strategy in the Arab Republic of Egypt
In 1994, an IHSP team led by Professor Peter Berman was invited to the
Arab Republic of Egypt to begin a collaboration with the Ministry of Health
and Population. This activity was supported by the U.S. Agency for International
Development through the Data for Decision Making Project.
Egypt was already engaged in several major system change initiatives
prior to our work their, including a major expansion to social health
insurance, by expanding the Health Insurance Organization’s coverage to
schoolchildren and the introduction of cost recovery in government hospitals.
But the MOHP lacked some of the essential information needed to assess
their situation and design and monitor reform strategies. IHSP was asked
to help develop this information base and the sustainable capacity to
expand and use it in the Department of Planning of the MOHP.
Over the next three years, our Egyptian colleagues created an outstanding
core of health system data that provided the basis for design of Egypt’s
current health sector reform program. The Department of Planning recruited
and trained staff who still provide key capacity for Egypt’s reform efforts.
IHSP fielded long-term advisor A.K. Nandakumar from Harvard to assist
this effort in Egypt for two years as well as regular supporting inputs
from Harvard faculty and researchers such as Berman, Dr. Julia Walsh,
Prof. Winnie Yip, Dr. Thomas Bossert, Dr. Hassan Salah and others. Close
collaboration was established with the American University of Cairo and
several other institutions.
Developing the evidence base for health sector analysis and reform in
Egypt included the following:
These studies and reports demonstrated convincingly that Egypt could
greatly strengthen its health system performance. Government services
had been receiving a declining share of total health spending, while at
the same time expanding the built-up capacity and staffing. Quality and
efficiency appeared to be declining over time and the population, including
the poor, was increasingly making use of non-government health care, which
imposed a regressive cost burden on the poor. Resource allocation goals
of shifting funding to primary care services were not being systematically
Building on this evidence base, the Department of Planning with the support
of the Minister of Health launched a program of national consultations
and workshops on health reform. IHSP helped facilitate the input of senior
staff of the MOHP to discuss and analyse health and health care system
problems and strategies for Egypt, culminating in the report "Egypt: Strategies
for Health Sector Change," which was widely discussed and used by Egyptian
and international authorities.
This initiative was further stimulated by strong interest from the World
Bank and European Union to support health reform efforts in Egypt. With
support from the Partnerships for Health Reform Project, Prof. Berman
and other senior Harvard faculty and other colleagues worked closely in
1997 with the new Minister of Health, Prof. Ismail Sallam, in applying
the data and analysis to the design of a reform strategy for primary care
in Egypt. The process of collaboration included intensive meetings with
the Minister to review options, in-depth reviews and discussions with
a high-level working group in Egypt, and production of new policy strategy: "A Reform
Strategy for Primary Care in Egypt." This strategy was adopted as
official government policy and became the basis for a major multi- donor
program in Egypt.
The primary care reform strategy was designed through innovative use
of the evidence base on health problems, health care use, and health financing.
A team of international and national experts developed a series of scenario
papers which were reviewed step by step with senior Egyptian officials.
These scenarios indicated the a reform strategy should include changes
in financing, financial incentives to providers, and the fundamental organization
of public and private health care delivery to extend coverage with a core
package of effective primary care services to all Egyptians. Initial estimates
suggested that a well-designed system could actually increase coverage
and benefits while reducing total health expenditures, given the wastefully
structured public-private mix in Egypt’s health care system.
The Government of Egypt is now implementing key elements of this primary
care reform program on a pilot basis in three governorates. IHSP researcher
Dr. Hassan Salah was part of the field team working on the Alexandria
pilot until summer 2000 and continues to work with the successor project
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Insurance in Uganda: Is it Feasible?
In spring 2001, a team from
the Harvard School of Public Health and the Institute of Public Health,
at Makere University, set out to determine the answer to the question
posed above. They were able to conclude that social health insurance is
potentially feasible, although it will not be easy to develop and may
pose significant risks.
Social health insurance (SHI)
is one of many methods used by countries to raise financial resources
for health and to ensure that all or part of a nation's population has
access to care and risk protection. Typically, SHI is initially focused
on civil servants and the formal sector labor force and its dependents.
This is because this group can be enrolled relatively easily for collection
purposes, is of middle to upper income, and has an emerging high demand
for health care. Also, for the most part, this group tends to be located
in and around cities and towns and thus, has access to covered services.
To assess the feasibility of
SHI in Uganda, three important dimensions have to be reviewed: (1) financial
feasibility and affordability; (2) institutional capacity and experience:
and (3) the knowledge, attitudes, and expectations of the potential beneficiaries
and funders of SHI (i.e., is it politically feasible?).
Existing Socio-Economic Conditions
and Financial Feasibility and Affordability
To understand the scope of
the task facing Uganda in developing SHI, it is important to know some
facts about its present-day human development. Its statistics are similar
to many other low-income countries on Sub-Saharan Africa. Life expectancy
is just 47 years, with approximately 1/3 of all children suffering from
malnutrition. 500 per 100,000 deliveries result in the mother's death.
Only 65% of the population is literate (74% for males and 57% for women).
Communicable diseases are still the main cause of disease and death. However,
while these numbers may seem dismal, significant achievements have been
made in human development indicators, thus demonstrating that improvement
is possible. For example, the number of children in primary education
has more than doubled since 1996.
Where would the financing come
from for SHI within Uganda? The combined team estimated various scenarios
of the potential labor force of civil servants and formal sector workers
and their dependents who could contribute to SHI, taking into account
their wages and possible contribution levels. While not able to undertake
a detailed technical analysis of financial feasibility due to the available
data, the team estimated Uganda could finance a package of benefits in
the range of 8-10% of wages, with specific assumptions regarding wages,
utilization, and prices/costs (this 8-10% being deducted from those employees'
Institutional Capacity and
Major areas of institutional
development are needed in order to carry out a system of social health
insurance. These include collections, management of insurance and provider
payment, regulation and supervision of insurance and health care delivery,
provider registration, accreditation and quality control. Those organizations
in Uganda that currently collect funds from civil servants and formal
sector workers would need to be strengthened before they could reliably
carry out collections for SHI purposes. The same can be said of those
organizations in Uganda responsible for insurance management and regulation,
accreditation and quality control (i.e., the ability to detect fraud and
control such abuse). The report expands on some of the major technical
areas of capacity development needed and some of the current "best
practices" and pitfalls that should be considered.
In order to determine if it
is politically feasible to implement SHI in Uganda, the team met with
focus groups and held interviews with key employee and employer groups
who would be likely to participate in SHI. The focus groups were generally
aware of SHI, but did not completely understand how the specifics of how
such a system would work. The members of the focus groups recognized that
coverage under SHI would have limits, but nonetheless still expected an
improved quality of inpatient and outpatient services and care when compared
to free public services, although responses widely varied as to what those
services should encompass. Most notable, the members were very skeptical
about the existing institutions' ability to operate a SHI system efficiently
and effectively. Clearly, a supervisory structure would need to be put
into place in order to monitor the finances and assets that a SHI system
would accumulate. A new SHI system in Uganda must assure contributors
that it is financially reliable and able to provide them with good quality
services to be acceptable.
Should Uganda Develop SHI Now
The team concluded that at
the current time, developing a SHI in Uganda does entail a high level
of risk. The concept of SHI was not thoroughly understood by those most
likely to contribute to such a system. SHI is a program that must be well-designed
and managed from the start, or the government of Uganda would face bearing
the brunt of the financial burdens it would impose for several years,
thereby placing many other important social priorities in jeopardy, a
cost that Uganda might not be able to afford. Moreover, if it is not regulated
and kept isolated from politics, it could become a means for manipulation
and patronage, with the common people paying higher-than-intended costs
for SHI. Finally, in developed countries, implementing SHI generally takes
a decade to ensure that the capacity and institutions to operate SHI effectively
exist. For a developing country such as Uganda, that time line may need
Acknowledging these risks,
the team discussed four options that Uganda could choose: (1) do nothing;
(2) implement a scheme of SHI that would only cover high-end "catastrophic
coverage"; (3) developing a comprehensive scheme; and (4) starting
small and expanding coverage over time in a series of "steps".
The team suggested that Uganda start small and work with option #4. Implementing
option #4 would allow Uganda the needed time to develop and improve upon
its already existing institutional capacity in the key areas of care management,
provider payment, and quality assurance.
The report concludes with an
outline work plan for a natural SHI task force which would develop a more
comprehensive analysis and a process of stakeholder consultation and specific
The full report is available
upon request to the International Health Systems Program.
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