The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. Health Sector Reform and Priority Services: Options for USAID Engagement ANE/E&E SOTA October 9, 2002

What Is Health Reform (HSR) A sustained process, guided by government of strengthening systems to achieve fundamental change in health systems and services to improve health outcomes. This change affects the delivery of priority services and the outcomes in priority service areas.

Most USAID Countries In the ANE/E&E Region Are Engaged in HSR

Questions to Consider  Why are countries pursuing health sector reform?  What types of reforms are countries pursuing?  What are USAID’s options?

Why Are Countries Pursuing Health Sector Reform?  Expectations of citizens and patients  Political requirements  Macroeconomic realities  Epidemiologic, and demographic pressures

Egypt: Per Capita OP Expenditures by Income Deciles Unless Specifically Targeted the Poor Lose Out Source: Egypt Equity Study (PHR and DDM)

Distribution of Public Health Expenditures  Poorest quintile has the lowest expenditure for public health  Higher expenditures in richest quintiles reflects more use of public services by richer households.

The uninsured are more likely to be in the non-formal sector. Innovative methods (such as community financing) are needed to cover these populations Source: Profile of the Uninsured in Jordan, PHR 1999 Forty percent of the population in Jordan is not covered by health insurance

Inequitable Distribution of Public Health Resources Public Health Expenditure Per capita (1995) quintiles Source: National Health Accounts, Fundación Mexicana para la Salud. Inequidad en México, Fundación Mexicana para la Salud, to to to to to 535 Health Expenditure 1995 USD 0 to 110 (838) 110 to 210 (673) 210 to 410 (528) 410 to 1,169 (341) 1,160 to 3,750 (23)

Source: WHO, PHR Report 1999 With donor assistance decreasing, financial sustainability in priority programs is of concern

What Reforms Are Countries Pursuing?  Financing  Resource Mobilization (e.g. insurance schemes, user fees)  Resource Allocation (e.g. provider payment mechanisms)  Organizational Change  System structure (e.g. decentralization, MOH stewardship)  Service delivery (e.g. patient-centered care, integrated care)  Policy Change  Priority Setting (e.g. public/private roles, benefit packages)  Legislative Change  Regulatory Change (e.g. accountability)  Consumer Participation  Patient involvement and responsibility (e.g. quality improvements, health promotion)  Community participation

What Are USAID Options Limited involvement with reform Use reform agenda to achieve sustainable results in priority program areas

Focus on Priority Services in the Reform Context Baseline Pilot Utilization in Albania Clinic Number of Visits, Women Number of Family Planning Encounters Total Number of Visits Total

Build Capacity to Deliver Priority Services Developing human resources Creating culture of information Aligning health policy to social development goals

Tap Into Universe of Information to Support Program Priorities

Progress Against Indicator Year 97/98 Design Year 2 22% Year 3 11% Year 4 10% Year 01/02 10% (not yet official) % of MOHP funding allocated for Identifiable PM and PHC services increased by at least 10% per year using GOE FY 95/96 as the baseline.

Morocco NHA: Resources Provided to Maternal Care

USAID Options For Using Reform Agenda  Focus on priority services in the reform context  Build capacity to deliver priority services in integrated systems  Tap into universe of information to support and monitor reform priorities

Abt Associates Inc.

The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. Thank You