Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance.

Despite limited evidence of successful development and implementation of contributory health insurance and low and middle income countries, many countries are in the process implementing such schemes. This commentary summarizes all available evidence on the limitations of contributory health insurance including the lack of good theoretical underpinning and the considerable evidence of inequity and fragmentation created by such schemes. Moreover, the initiation of a contributory health insurance scheme has not been found to increase revenues to the health sector or help health countries achieve universal health coverage. Low and middle income countries can improve equity and efficiency of the health sector by replacing out-of-pocket spending with pre-paid pooling mechanisms, but that is best done through budget transfers and not by contributory insurance that links payment to sub-population entitlements.

In Appreciation of Adam: Reflections from Friends and Colleagues.

Some of Adam Wagstsaff's colleagues and research collaborators submitted short reflections about the different ways Adam made a difference through his amazing research output to health equity and health systems as well as a leader and mentor. The Guest Editors of this Special Issue selected a set of six essays related to dimensions of Adam's contributions.The first contribution highlights his role early on in his career, prior to joining the World Bank, in defining and expanding an important field of research on equity in health ("Adam and Equity," by Eddy van Doorslaer and Owen O'Donnell). The second contribution focuses on Adam's early work on equity and health within the World Bank and his leadership on important initiatives that have had impact far beyond the World Bank ("Adam and Health Equity at the World Bank," by Davidson Gwatkin and Abdo Yazbeck). The next contribution focuses on Adam's deep dive into providing support, through research, for country-specific programs and reforms, with a special focus on some countries in East Asia ("Adam and Country Health System Research," by Magnus Lindelow, Caryn Bredenkamp, Winnie Yip, and Sarah Bales). The next contribution highlights Adam's many ways of contributing to the International Health Economics Association, from the impressive technical contributions to leadership and organizational reform ("Adam and iHEA," by Diane McIntyre). The next to last contribution focuses on Adam's long-term leadership in the research group at the World Bank and the long-lasting influence on integrating the research produced into World Bank operations and creating an environment that rewarded producing evidence for action ("Adam the Research Manager," by Deon Filmer and Damien de Walque). The last contribution pulls on the thread found in many of the earlier ones, mentorship with honesty, directness, caring, commitment, and equity ("Adam the Mentor," by Agnes Couffinhal, Caryn Bredenkamp, and Reem Hafez).

Making Health Insurance Pro-poor: Lessons from 20 Developing Countries.

The last 20 years have seen a substantial growth in research on the extent to which health sector reforms are pro-poor or pro-rich. What has been missing is knowledge synthesis work to derive operational lessons from the empirical research. This article fills the gap for the most popular form of health financing reform, health insurance. Based on publications covering 20 developing countries, we find that health insurance is no panacea for improving equity in the health sector. More importantly, we find certain design elements of health insurance can increase the likelihood of tackling inequality in the health sector in developing countries.

The Case Against Labor-Tax-Financed Social Health Insurance For Low- And Low-Middle-Income Countries.

An increasing interest in initiating and expanding social health insurance through labor taxes in low- and low-middle-income countries goes against available empirical evidence. This article builds on existing recommendations by leading health financing experts and summarizes recent research that makes the case against labor-tax financing of health care in low- and low-middle-income countries. We found very little evidence to justify the pursuit of labor-tax financing for health care in these countries and persistent evidence that such policies could lead to increased inequality and fragmentation of the health system. We recommend that countries considering such policies heed the evidence on labor-tax financing and seek alternative approaches to health financing: primarily using general taxes or, depending on the context, general taxes combined with adequately regulated insurance premiums.

When Both Markets and Governments Fail Health.

This paper presents the rationale and motivation for countries and the global development community to tackle a critical set of functions in the health sector that appear to be under-prioritized and underfunded. The recent eruptions of Ebola outbreaks in Africa and other communicable diseases like Zika and SARS elsewhere led scientific and medical commissions to call for global action. The calls for action motivated the World Health Organization (WHO) to respond by defining a new construct within the health sector: Common Good for Health (CGH). While the starting point for developing the CGH construct was the re-emergence of communicable diseases, it extends to additional outcomes resulting from failures to act and finance within and outside the health sector. This paper summarizes global evidence on failures to address CGHs effectively, identifies potential reasons for the public and private sectors' failures to respond, and lays out the first phase of the WHO program as represented by the papers in this special issue of Health Systems & Reform.

Common Goods for Health: Economic Rationale and Tools for Prioritization.

This paper presents the economic rationale for treating Common Goods for Health (CGH) as priorities for public intervention. We use the concept of market failure as a central argument for identifying CGH and apply cost-effectiveness analysis (CEA) as a normative tool to prioritize CGH interventions in public finance decisions. We show that CGH are consistent with traditional lists of public health core functions but cannot be identified separately from non-CGH activities in such lists. We propose a public finance decision tree, adapted from existing health economics tools, to identify CGH activities within the set of cost-effective interventions for the health sector. We test the framework by applying it to the 2018 Disease Control Priority (DCP) list of interventions recommended for public funding and find that less than 10% of cost-effective interventions unconditionally qualify as CGH, while another two-thirds may or may not qualify depending on context and form. We conclude that while CEA can be used as a tool to prioritize CGH, the scarcity of such analyses for CGH interventions may be partly responsible for the lack of priority given to them. We encourage further research to address methodological and resource challenges to assessing the cost-effectiveness of CGH intervention packages, in particular those involving large investments and long-term benefits.

How Labor Laws Can Transform Health Systems: The Case of Saudi Arabia.

Abstract-In 1999, the Kingdom of Saudi Arabia enacted a law that compels private employers to cover non-Saudi employees with health insurance. In the 16 years that followed, the health sector in the Kingdom has seen a dramatic shift in how services are provided and paid for, and the change continues at an accelerated speed. Based on interviews with 12 large private sector providers in Riyadh, Jeddah, and Khobar, we found that a labor law enacted in 1999 led to rapid expansion of the insured population, both expatriates and Saudis, which led to a drastic change in how hospitals and other facilities are paid, and considerable more consistency in revenue stream. This article describes how the 1999 labor law, combined with other market conditions and public incentives, led to unprecedented growth in private sector capacity and how the insurance system changed the labor market for health care providers and put more pressure on physicians to engage in dual job holding in both the public and private sectors. The Kingdom later introduced another labor program, known as Nitaqat, designed to implement the Saudization initiative that started in 2011, which put pressure on all private companies to hire Saudi nationals. The interviews with large private health providers found the Nitaqat program to be the largest barrier to the growth of the sector. The Kingdom presents a striking case of how the health sector can be drastically impacted by laws and policies outside the sector and how health systems and reforms can, and should, take into account the whole range of policy instruments available to a country.

Benchmarking Health Systems in Middle Eastern and North African Countries.

Abstract-Health systems are not easy to benchmark, in part because the health sector produces more than one outcome. This article offers two ways of benchmarking the health systems of countries in the Middle East and North Africa (MENA) focusing on two different outcomes, health status and financial protection. The first approach is by measuring the gap between predicted health outcomes based on country socioeconomic status and actual health outcomes. The second approach is by simply comparing the levels of out-of-pocket (OOP) spending in MENA countries. The article offers some interesting findings about the large heterogeneity in both health system outcome achievements despite considerable cultural and linguistic similarities in the region. Moreover, three discrete clusters of countries are found on the health status measure. The findings also give specific health system target outcomes for MENA countries to focus their reform efforts.

Lessons from 20 Years of Capacity Building for Health Systems Thinking.

In 2016, the Flagship Program for improving health systems performance and equity, a partnership for leadership development between the World Bank and the Harvard T.H. Chan School of Public Health and other institutions, celebrates 20 years of achievement. Set up at a time when development assistance for health was growing exponentially, the Flagship Program sought to bring systems thinking to efforts at health sector strengthening and reform. Capacity-building and knowledge transfer mechanisms are relatively easy to begin but hard to sustain, yet the Flagship Program has continued for two decades and remains highly demanded by national governments and development partners. In this article, we describe the process used and the principles employed to create the Flagship Program and highlight some lessons from its two decades of sustained success and effectiveness in leadership development for health systems improvement.

Immunization in India 1993-1999: wealth, gender, and regional inequalities revisited.

Previously published evidence from the 1992-1993 Indian National Family and Health Survey (NFHS) on the state of childhood immunization showed the importance of analyzing immunization outcomes beyond national averages. Reported total system failure (no immunization for all) in some low performance areas suggested that improvements in immunization levels may come with a worsening of the distribution of immunization based on wealth. In this paper, using the second wave of the NFHS (1998-1999), we take a new snapshot of the situation and compare it to 1992-1993, focusing on heterogeneities between states, rural-urban differentials, gender differentials, and more specifically on wealth-related inequalities. To assess whether improvements in overall immunization rates (levels) were accompanied by distributional improvements, or conversely, whether inequalities were reduced at the expense of overall achievement, we use a recently developed methodology to calculate an inequality-adjusted achievement index that captures performance both in terms of efficiency (change in levels) and equity (distribution by wealth quintiles) for each of the 17 largest Indian states. Comparing 1992-1993 to 1998-1999 achievements using different degrees of "inequality aversion" provides no evidence that distributional improvements occur at the expense of overall performance.

Real and perceived threats to reproductive health: a way forward.

Ten years ofter the International Conference on Population and Development finds the reproductive health community under threat from at least three sources: global initiatives, reforms of the health sector, and new financial modalities from donors and lenders. These challenges, however, mainly reflect the complete system failure in many low-income countries in providing basic reproductive health services to women, especially those who are poor and socially vulnerable. The reproductive health community can do a lot more to address the system failures and potential threats and take advantage of opportunities offered. The starting point should be an internal look at how the reproductive health community has performed in helping low-income countries. Understanding these changes and opportunities in the health sector is another important step, but understanding will only be effective if representatives of the reproductive health community in low-income countries are armed with the skills and tools needed to engage in health sector reforms, to take advantage of global initiatives and to effectively influence the implementation of new holistic forms of aid.

What's in a country average? Wealth, gender, and regional inequalities in immunization in India.

Recent attention to Millennium Development Goals by the international development community has led to the formation of targets to measure country-level achievements, including achievements on health status indicators such as childhood immunization. Using the example of immunization in India, this paper demonstrates the importance of disaggregating national averages for a better understanding of social disparities in health. Specifically, the paper uses data from the India National Family Health Survey 1992-93 to analyze socioeconomic, gender, urban-rural and regional inequalities in immunization in India for each of the 17 largest states. Results show that, on average, southern states have better immunization levels and lower immunization inequalities than many northern states. Wealth and regional inequalities are correlated with overall levels of immunization in a non-linear fashion. Gender inequalities persist in most states, including in the south, and seem unrelated to overall immunization or the levels of other inequalities measured here. This suggests that the gender differentials reflect deep-seated societal factors rather than health system issues per se. The disaggregated information and analysis used in this paper allows for setting more meaningful targets than country averages. Additionally, it helps policy makers and planners to understand programmatic constraints and needs by identifying disparities between sub-groups of the population, including strong and weak performers at the state and regional levels.

Pro-poor health policies in poverty reduction strategies.

Since 1999, the International Monetary Fund and World Bank have required low-income countries soliciting for debt relief and financial support to prepare a Poverty Reduction Strategy Paper (PRSP). The objective of this study is to arrive at a systematic assessment of the extent to which the first batch of interim PRSPs actually addresses the health of the poor and vulnerable. A literature study was used to design and test a semi-quantitative approach to assess the pro-poor focus of health policies in national documents. The approach was applied to the existing interim proposals for 23 Highly Indebted Poor Countries. Results show that a majority of proposals lack country-specific data on the distribution and composition of the burden of disease, a clear identification of health system constraints and an assessment of the impact of health services on the population. More importantly, they make little effort to analyze these issues in relation to the poor. Furthermore, only a small group explicitly includes the interests of the poor in health policy design. Attention to policies aiming at enhancing equity in public health spending is even more limited. Few papers that include expenditure proposals also show pro-poor focused health budgets. We conclude that our systematic assessment of a new international development policy instrument, PRSP, raises strong concerns about the attributed role of health in development and the limited emphasis on the poor, the supposed primary beneficiaries of this instrument. There is a need and an opportunity for the international development community to provide assistance and inputs as poor countries shift their policy thinking from an interim stage to fully developed national policies. This paper presents a menu of analytical and policy options that can be pursued.