Fairness and Accountability: Engaging in Health Systems in the Middle East

and North Africa (2013-2018)

World Bank MENA HNP Strategy Symposium

Marseille, France July 5th 2013

MENA HNP Strategy : Four Questions

Why • Why is WB developing a health strategy for MENA?

How • How can MENA health systems be made more fair and

accountable?

What • What WB products contribute to improving fairness and

accountability?

When • What is the process of implementation?

MENA: A region of diversity & contrasts…

• 20 countries, 355 million people • 85% of MNA’s population live in MICs, 8% in HICs, and 7% in LICs • Conflicts and fragility within a complex geopolitical environment • Oil-exporters, with the world’s most abundant reserves, and oil

importers • Countries with large populations and “low population density” areas

Maghreb

Mashreq

GCC 3

1. WHY IS WB DEVELOPING A HEALTH STRATEGY FOR MENA?

From Tunisia to the rest of the Arab World –The snowball effect

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Health as a priority--Opinion poll data, Egypt

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Amidst a mounting fiscal crisis

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Capitalizing on the demographic dividend

Fig. Population growth in MENA by age group, 1950-2050

Fig . Youth unemployment in MENA, age 15-29, 2010

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Midst an epidemiological transition

Fig. Composition of DALYs in MENA, 1990-2010

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Dual burden: Malnutrition and obesity among women and children in MENA

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Inequalities persist: Income inequality in early child health indicators in MENA

Low government spending on health

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Resulting in high out of pocket spending

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2. HOW CAN MENA HEALTH SYSTEMS BE MADE MORE FAIR AND ACCOUNTABLE?

What is fairness in health systems?

• Absence of systematic disparities

• Just distribution of burden of costs

• Equitable and timely response

• Resulting in a dignified interaction between patient and provider

Fairness in health outcomes

• Diseases of poverty

• Maternal and child health

• Mainstreaming gender into NCD programs

• Youth—Road traffic accidents and smoking

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Road safety compliance levels in MENA

Fairness in financial protection

• Increasing health coverage for vulnerable groups

• Reducing high out of pocket expenses

Who pays the bill?

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Total Health Expenditure (% of GDP) - Left Axis

Out-of-pocket health expenditure (% of TotalHealth Expenditure) - Right Axis

Sources: NHA; WHO - Data updated Jan, 20133

Fairness in responsiveness

• Eight domains of responsiveness

Interpersonal : Dignity, autonomy, communication, confidentiality

Structural : Quality of basic amenities, choice, access to social support networks, prompt attention

Improving responsiveness—rights based approach; surveys; training; feedback loops

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What is Accountability?

• Demonstrating and taking responsibility for performance to create high performing systems

• Respecting rules, regulations, performance standards

Accountable to whom?

Accountability to patients

• Social accountability interventions

– Patient bill of rights

– Citizen’s score card

• Defining minimum benefits package

• Tracking patient safety

Accountability of payers

• Informing payers of value created for each dollar spent—mechanisms to negotiate payment

• Incentivizing preventive and primary care

• Pharmaceutical reform

• Addressing fragmented health system

Accountability of providers

• Improving provider incentives

• Human resource planning

• Task shifting for rising NCD burden

Shortage of generalists in MENA

SUST

AIN

AB

ILIT

Y

Sustainability

• Fiscal sustainability

• Institutional sustainability

• Political sustainability

3. WHAT WB PRODUCTS CONTRIBUTE TO IMPROVING FAIRNESS AND ACCOUNTABILITY?

World Bank involvement

• Window of opportunity

• Reduce poverty and share prosperity

• Investment now can result in savings in the future

Bank’s value add

• Multi-sectoral system based approach

• Technical experience

• Global expertise

• Diverse financial products

• Convening ability

Areas of expertise in key issues facing MENA

• Non communicable diseases • Emerging infectious diseases • Malnutrition • Early childhood development • Maternal and child health • Expanded access and universal health insurance • Provider payment systems • Governance and accountability • Fiscal space • Quality of care

4.WHAT IS THE PROCESS OF IMPLEMENTATION?

World Bank Products

• Financial products

• Technical products

Partnerships, dialogue, consultations

• Government

• Civil Society

• Private Sector

• Academia

• NGOs

• Other development partners

• Beneficiaries

Monitoring framework

• Regional level

• Country level

• Individual level

Next steps • June 27: Launch in Tunisia

• June 3: Media launch in Morocco

• July 5: Symposium in Marseille

• September: Launch for Mashreq

..To free the world from absolute poverty by 2030, countries must ensure that all of their citizens have access to quality, affordable health services We can do so much more. We can bend the arc of history to ensure that everyone in the world has access to affordable, quality health services in a generation. Together, let’s build health equity and economic transformation as one single structure, a citadel to shelter the human future. Now is the time to act. --Jim Kim, World Health Assembly, Geneva, May 21 2013.

THANK YOU!