Health-care investments for the urban populations, Bangladesh and India.

OBJECTIVE: To estimate the costs and mortality reductions of a package of essential health interventions for urban populations in Bangladesh and India. METHODS: We used population data from the countries' censuses and United Nations Population Division. For causes of mortality in India, we used the Indian Million Death Study. We obtained cost estimates of each intervention from the third edition of Disease control priorities. For estimating the mortality reductions expected with the package, we used the Disease control priorities model. We calculated the benefit-cost ratio for investing in the package, using an analysis based on the Copenhagen Consensus method. FINDINGS: Per urban inhabitant, total costs for the package would be 75.1 United States dollars (US$) in Bangladesh and US$ 105.0 in India. Of this, prevention and treatment of noncommunicable diseases account for US$ 36.5 in Bangladesh and U$ 51.7 in India. The incremental cost per urban inhabitant for all interventions would be US$ 50 in Bangladesh and US$ 75 in India. In 2030, the averted deaths among people younger than 70 years would constitute 30.5% (1027/3362) and 21.2% (828/3913) of the estimated baseline deaths in Bangladesh and India, respectively. The health benefits of investing in the package would return US$ 1.2 per dollar spent in Bangladesh and US$ 1.8 per dollar spent in India. CONCLUSION: Investing in the package of essential health interventions, which address health-care needs of the growing urban population in Bangladesh and India, seems beneficial and could help the countries to achieve their 2030 sustainable development goals.

Health-financing reforms in southeast Asia: challenges in achieving universal coverage.

In this sixth paper of the Series, we review health-financing reforms in seven countries in southeast Asia that have sought to reduce dependence on out-of-pocket payments, increase pooled health finance, and expand service use as steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor-supported health equity funds to reach the poor, and reliable funding and appropriate identification of the eligible poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam, social health insurance financed by payroll tax is commonly used for formal sector employees (excluding Malaysia), with varying outcomes in terms of financial protection. Alternative payment methods have different implications for provider behaviour and financial protection. Two alternative approaches for financial protection of the non-poor outside the formal sector have emerged-contributory arrangements and tax-financed schemes-with different abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both important in accelerating financial protection. Expanding coverage of good-quality services and ensuring adequate human resources are also important to achieve universal coverage. As health-financing reform is complex, institutional capacity to generate evidence and inform policy is essential and should be strengthened.

A systems approach to improving maternal health in the Philippines.

OBJECTIVE: To examine the impact of health-system-wide improvements on maternal health outcomes in the Philippines. METHODS: A retrospective longitudinal controlled study was used to compare a province that fast tracked the implementation of health system reforms with other provinces in the same region that introduced reforms less systematically and intensively between 2006 and 2009. FINDINGS: The early reform province quickly upgraded facilities in the tertiary and first level referral hospitals; other provinces had just begun reforms by the end of the study period. The early reform province had created 871 women's health teams by the end of 2009, compared with 391 teams in the only other province that reported such teams. The amount of maternal-health-care benefits paid by the Philippine Health Insurance Corporation in the early reform province grew by approximately 45%; in the other provinces, the next largest increase was 16%. The facility-based delivery rate increased by 44 percentage points in the early reform province, compared with 9-24 percentage points in the other provinces. Between 2006 and 2009, the actual number of maternal deaths in the early reform province fell from 42 to 18, and the maternal mortality ratio from 254 to 114. Smaller declines in maternal deaths over this period were seen in Camarines Norte (from 12 to 11) and Camarines Sur (from 26- to 23). The remaining three provinces reported increases in maternal deaths. CONCLUSION: Making health-system-wide reforms to improve maternal health has positive synergistic effects.

Social health insurance in a developing country: the case of the Philippines.

Very little is known about the Philippine health care system, and in particular its experience with social health insurance (SHI). Having initiated an SHI programme 35 years ago, the Philippines hold many lessons for the development of such schemes in other low and middle-income countries. We analyse the challenges currently facing PhilHealth, the national health insurer. PhilHealth was formed in 1995 as a successor to the Medicare programme and was given a mandate to achieve universal coverage by 2010. To date, PhilHealth has been quite successful in some areas (e.g. enrollment), but lags behind in others (e.g. quality and price control). We conclude that SHI in the Philippines has been a success story so far and provides lessons for countries in a similar situation. For example: (i) SHI is based on value decisions and the clear statement of societal goals can give guidance in the technical execution, (ii) SHI is a financing institution and needs to be treated accordingly, (iii) SHI can be implemented independently of the current economic situation and might actually contribute to economic development, (iv) community-based health care financing schemes should be merged with the national SHI in the long run, and (v) there is a strong need to push for high quality care and improved physical access. No clear suggestions can be given with respect to the benefit catalogue and the balance between economies of scale and decentralisation. Although riddled with many inadequacies, PhilHealth was set up as a strong and largely politically independent institution for the development of SHI. SHI can act as a stabilizing institution in a politically and economically volatile environment.