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Health Financing Regional Profile 2018TRANSITIONING TO INTEGRATED FINANCING AND SERVICE DELIVERY OF PRIORITY PUBLIC HEALTH SERVICES

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Health Financing Regional Profile 2018TRANSITIONING TO INTEGRATED FINANCING AND SERVICE DELIVERYOF PRIORITY PUBLIC HEALTH SERVICES


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CONTENTSHealth Financing Regional Profile: Transitioning to Integrated Financing and Service Delivery of Priority Public Health Services

iv

v

1

3

17

25

27

28

Country and area abbreviations

Acknowledgements

Introduction

Overview of regional context

Transitioning to integrated financing and service delivery

• Strengthening service delivery across core programme elements

• Making better use of resources• Increasing domestic financing for public health

Summary

References

Annexes

iii

AUS Australia

BRN Brunei Darussalam

KHM Cambodia

CHN China

COK Cook Islands

FJI Fiji

JPN Japan

KIR Kiribati

LAO Lao People’s Democratic Republic

MYS Malaysia

MHL Marshall Islands

FSM Micronesia (Federated States of)

MNG Mongolia

NRU Nauru

NZL New Zealand

NIU Niue

PLW Palau

PNG Papua New Guinea

PHL Philippines

KOR Republic of Korea

WSM Samoa

SGP Singapore

SLB Solomon Islands

TON Tonga

TUV Tuvalu

VUT Vanuatu

VNM Viet Nam

Country & areaabbreviations(in figures and tables)

iv

Acknowledgements

This paper was based on the WHO Regional

Framework of Action on Transitioning to Integrated

Financing of Priority Public Health Services in the

Western Pacific that was adopted at the sixty-

eighth session of the Regional Committee for the

Western Pacific in October 2017. The framework

served as guidance to Member States and was

produced through collaboration of several units:

Health Policy and Financing; End Tuberculosis and

Leprosy; HIV, Hepatitis, and Sexually Transmitted

Infections; Expanded Programme on Immunization;

and Integrated Service Delivery. This paper was

developed by the Health Policy and Financing

team including Peter Cowley, Annie Chu, Maria

Peña, Ronald Tamangan and Luke Elich and with Ke

Xu, Rochelle Eng and Marlon Sison. Management

support was received from Vivian Lin, Director of

the Division of Health Systems at the WHO Regional

Office for the Western Pacific. Valuable comments

were received from Susan Sparkes, Joe Kutzin and

Agnes Soucat, and administrative support from

Enrico Sevilla and Nuria Quiroz Chirinos.

Financial support for the work was provided by the

Ministry of Health, Labour and Welfare, Japan; the

Ministry of Health and Welfare, Republic of Korea;

and the Department for International Development,

United Kingdom of Great Britain and Northern Ireland.

The views expressed in this publication are those

of the authors and do not necessarily reflect those

of WHO.

HEALTH FINANCING REGIONAL PROFILE v

vi

Introduction

Strengthening essential public health functions

is relevant for all health systems as they

underpin priority public health services in all

countries. A resilient health system requires the

capacity to adapt to change, including in the

areas of public health preparedness, community

engagement in disease prevention and

emergency preparedness and response, and an

ability to withstand economic shocks. Essential

public health functions refer to a set of functions

fundamental to the protection of population

health that addresses the determinants of

health and treats disease. The need to secure

essential public health functions is relevant

for countries undergoing service delivery and

budgeting reforms, and particularly critical to

countries facing reduced external funding, such

as funding from global health initiatives.

During the sixty-eighth session of the Regional

Committee for the Western Pacific in October

2017, Member States endorsed the Regional

Framework for Action on Transitioning to

Integrated Financing of Priority Public Health

Services in the Western Pacific (1). In consultation

with Member States, independent experts and

development partners, WHO developed the

Regional Framework for Action, which provides

guidance to countries on using a whole-of-

system approach to secure essential public

health functions and respond to changing

population needs for more sustainable and

resilient systems that deliver the best health

outcomes. It builds on the regional action

framework Universal Health Coverage: Moving

Towards Better Health and the Regional

Action Agenda on Achieving the Sustainable

Development Goals in the Western Pacific, both

adopted by the Regional Committee (2,3).

This paper contains three major sections.

The first section outlines the regional health

financing context and key challenges in

the Western Pacific. The second section

highlights the need to take a whole-of-system

approach to move towards more integrated

financing and care through improving health

system efficiencies and increasing domestic

financing for health, drawing from the Regional

Framework for Action and the regional analytical

approach for policy development on improving

the efficiency and sustainability of priority

public health programmes (Annex 1). The last

section emphasizes the importance of political

commitment and governing the transition

process in a phased implementation approach.

HEALTH FINANCING REGIONAL PROFILE 1

2

Overview ofregional context

In the Western Pacific Region, great progress has

been made in reducing the burden of communicable

diseases, such as tuberculosis (TB), HIV/AIDS, malaria

and others, over the past few decades. Since 2000,

TB prevalence has been reduced by over 25% and

TB mortality has declined by over 53%1 (4). There have

also been impressive gains in lowering the burden of

HIV/AIDS and increasing antiretroviral therapy (ART)

coverage in the Region (5). Nine out of 10 malaria-

endemic countries achieved their malaria-related

targets in the Millennium Development Goals (6), and

millions of deaths and disabilities have been prevented

due to the work of the Expanded Programme on

Immunization (EPI) (7). However, sustaining the

progress requires continued and targeted efforts to

ensure equitable coverage and access to treatment

for vulnerable and hard-to-reach populations.

In addition, the health needs of the populations in

the Region are changing. Environmental, workplace

and lifestyle diseases have accompanied economic

progress. Noncommunicable diseases (NCDs)

account for nearly 80% of preventable deaths in the

Region (8), while many countries are also undergoing

accelerated ageing. Over 200 health security threats

are detected each year. Epidemics and disasters

continue to threaten millions of people each year,

and health inequalities in some rapidly developing

countries are growing rather than shrinking. The

fiscal context with rapid economic development

in many countries may favour increasing public

spending on health.

These ongoing and new challenges, in addition

to the increasing expectations from citizens and

communities for access to quality health services, are

posing complexities in terms of how to address public

health priorities from a whole-of-system perspective.

Over the past decade, several countries in the Western

Pacific Region have increased their current health

expenditure as a share of gross domestic product

(GDP). The lower-middle- and upper-middle-income

Asian countries spend between roughly 3% and over

6% of their GDP on health, while there is a much larger

range in the Pacific island countries (Figs 1 and 2),

with some reaching more than 13% given significant

external funding and government spending.

1 This considers only HIV-negative individuals.


Fig. 1Current health expenditure as a share

of GDP for Asian countries, 2015LMI: lower-middle-income; UMI: upper-middle-income; HI: high-income; GGHE-D: domestic general government health expenditure; PVT-D: domestic private health expenditure.Note: From the OECD countries: Australia, New Zealand and Japan have been incorporated using their latest estimates. 2014 estimates for Australia and Japan and 2013 estimates for New Zealand.

Source: WHO Global Health Expenditure Database (accessed 6 February 2018) and OECD Stat Database (accessed6 April 2018).

Fig. 2Current health expenditure as a share of GDP

for Pacific island countries, 2015

LMI: lower-middle-income; UMI: upper-middle-income; HI: high-income; GGHE-D: domestic general government health expenditure; PVT-D: domestic private health expenditure.Note: Cook Islands and Kiribati estimates are based on 2014.

Source: WHO Global Health Expenditure Database (accessed 6 February 2018). World Bank income classifications. (accessed 13 June 2018)

LAO MNG PHL

LMI UMI HI

VNM KHM MYS CHN BRN SGP KOR AUS NZL JPN

4

6

8

10

12

14

GGHE−D (%) PVT−D (%) External (%)

0

2

LMI UMI HI

GGHE−D (%) PVT−D (%) External (%)

0

2

4

6

8

10

12

14

16

18

20

22

VUT PNG SLB KIR FSM COK FJI NRU WSM TON NIU TUV MHL PLW

4

For the lower-middle-income Asian countries, the proportion of private health expenditures,

mostly from out-of-pocket payments, is nearly half or more of current health expenditures

(Fig. 3). Several countries have a mixed health financing system that includes social health

insurance, such as China, Mongolia, the Philippines and Viet Nam. Some countries also have

other voluntary schemes, such as private health insurance. Cambodia, the Lao People’s

Democratic Republic, Mongolia and Viet Nam receive external funds from donors, including

from global health initiatives.

In Pacific island countries, the composition of health expenditures shows that the majority

derive from government and external funds, with social health insurance in a few countries

(Fig. 4). While the out-of-pocket health expenditures are lower than compared to Asian coun-

tries, there are still geographical and financial barriers to accessing health services, which

include spending on transport costs. Also, estimates over time show that there is significant

volatility in external health expenditures in several Pacific island countries.

Several countries in the Region are facing a decline of external funding from bilateral partners

and global health initiatives, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria;

Gavi, the Vaccine Alliance; and the United States President’s Emergency Plan for AIDS Relief

(PEPFAR). The global health initiatives, in particular, triggered a rapid, large-scale response

to disease through direct cash and in-kind funding to develop disease control programmes.

Since 2003, the Global Fund has disbursed US$ 2.5 billion in treating and preventing AIDS, TB

and malaria, and in building more resilient and sustainable systems for health in the Western

Pacific Region. Of the total Global Fund grants disbursed, 35.3% was allocated for HIV/AIDS

programmes, 32.6% for TB, 28.3% for malaria and 4.2% for others/health systems strengthening.

In the Global Fund Round 8 grants.2 health systems strengthening funding allocated to coun-

tries accounted for 37% of the total Global Fund funding (9).

2 From 2002 to 2013, the Global Fund operated through a rounds-based funding model andRound 8 was launched in March 2008. The Global Fund launched a new funding model in 2013.


LMI: lower-middle-income; UMI: upper-middle-income; HI: high-income; “Public” refers to domestic public revenues; “External” refers to transfers from foreign origin; “Other private” refers to other domestic revenues from corporations or non-profits; OOP: out-of-pocket payment. Note: From the OECD countries: Australia, New Zealand and Japan have been incorporated using their latest estimates, 2014 estimates for Australia and Japan and, 2013 estimates for New Zealand.

Source: WHO Global Health Expenditure Database (accessed 6 February 2018) and OECD Stat Database (accessed6 April 2018).

External Other private Household OOPPublic Social insurance contributions Voluntary prepayment

0(%) 10 20 30 40 50 60 70 80 90 100

HI

UMI

LMI

KORSGPAUSJPNNZLBRN

MYSCHN

KHMPHLLAO

VNMMNG

PLW

FJIWSMTONMHLCOKNIU

NRUTUV

VUTPNGSLBFSMKIR

HI

UMI

LMI

External Other private Household OOPPublic Social insurance contributions Voluntary prepayment

0(%) 10 20 30 40 50 60 70 80 90 100

Fig. 3Current health expenditure in select Asian

countries by health expenditure source, 2015

Fig. 4Current health expenditure in Pacific island

countries by health expenditure source, 2015

LMI: lower-middle-income; UMI: upper-middle-income; HI: high-income; “Public” refers to domestic public revenues; “External” refers to transfers from foreign origin; “Other private” refers to other domestic revenues from corporations or non-profits; OOP: out-of-pocket payment. Note: From the OECD countries: Australia, New Zealand and Japan have been incorporated using their latest estimates. 2014 estimates for Australia and Japan and 2013 estimates for New Zealand.

Source: WHO Global Health Expenditure Database (accessed 6 February 2018). World Bank income classifications (accessed 13 June 2018).

6

Gavi has disbursed US$ 373.8 million in the Region since 2001. A total of 67% of the invest-

ments was for vaccine support, while 33% was for non-vaccine support, which included health

systems strengthening (10). Four countries in the Region have entered the five-year acceler-

ated transition phase – the Lao People’s Democratic Republic, Papua New Guinea, Solomon

Islands and Viet Nam – and are expected to increase co-financing commitments for vaccines

to eventually fully finance them by the end of the fifth year. Funding from PEPFAR has also

supported a majority of treatment costs for people living with HIV, as well as prevention and

community support systems. PEPFAR spent over US$ 250 million in select Asian countries3 in

the Region from 2012 to 2015; 71% of its spending was channelled to HIV/AIDS programmes,

while 29% was spent on health systems strengthening (11).

Several countries in the Region that receive funding from global health initiatives are in the

process of transition or have already transitioned. While the meaning of transition and how

it is implemented may vary across global health initiatives, early planning and graduated

co-financing commitments that are embedded in the programme design are at the core of

transition and sustainability policies. Both the Global Fund and Gavi have clear eligibility and

transition policies that outline predictable timelines and triggers for a transition. Gavi’s trig-

ger for a transition is economic development classified by gross national income (GNI) per

capita, while the Global Fund’s support is reduced in accordance with both country income

classification and the reduction of disease burden indicators for HIV, TB and malaria. During

the transition, global health initiatives will require countries to co-finance and at an increasing

share as countries are further along the transition stage. For example, the portion of domestic

financing of HIV programmes ranges widely across countries in Asia, which are at different

stages in the transition (Fig. 5).

Most upper-middle-income countries fund the bulk of their HIV programmes domestically, with

some countries such as China and Malaysia fully or nearly fully self-financed, while lower-mid-

dle-income countries are gradually mobilizing more funds from domestic sources. HIV expen-

diture estimates in selected countries over time show this gradual transition of health financing

towards more domestic resources, while still heavily dependent on external funding (Fig. 6).

3 PEPFAR has investments in Cambodia, Papua New Guinea and Viet Nam, and also channelled funding

for HIV/AIDS and health systems strengthening through its Asia Regional Program, covering China, the

Lao People’s Democratic Republic and Thailand.


Fig. 5Proportion of domestic financing of HIV programmes

in selected Asian countries, latest available year

MYS (2013)

CHN (2012)

THA (2011)

FJI (2013)

LKA (2010)IDN (2012)

PHL (2013)

PAK (2013)

VNM (2012)

MNG (2011)

PNG (2012)

BGD (2013)KHM (2012)

IND (2011/12)MMR (2011)

LAO (2011)

AFG (2013)

TLS (2009)NPL (2009)

HI

UMI

LMI

0(%) 20 40 60 80 100

HI: high-income; LMI: lower-middle-income; UMI: upper-middle-income.

Source: Investing for results: how Asia Pacific countries caninvest for ending AIDS, 2015 (AIDS Data Hub)

8

Fig. 6HIV expenditure by financing source over time

in selected countries in the Western Pacific Region(in million US$), 2006–2015 (or latest available data)

Source: UNAIDs data (accessed December 2017)

China

200620072008200920102011201220132014

2006

2007

2008

2009

2010

2011

2012

2007

2008

2009

2010

2011

2012

2013

2014

FijiCambodia

Lao People's Democratic Republic Viet Nam

2006

2007

2008

2009

2010

2011

2006

2007

2008

2009

2010

2011

2012

2008

2009

2010

2011

2012

2013

2014

Malaysia

0200400600800

10001200

010203040506070

0

3

6

9

12

15

0

30

60

90

120

150

0.00.51.01.52.02.53.0

010203040506070

Domestic public International Domestic private


Fig. 7TB health budget by funding source

in selected countries in the Western Pacific Region (in million US$), 2006–2014

Source: Tuberculosis country profiles (WHO, 2017).

Domestic

Global Funds

United States Agencyfor International Development

Grants

0

2

4

6

8

10

0

2

4

6

8

10

Mongolia

Philippines

20062006

2007

2008

2009

2010

2011

2012

2013

2014

2007

2008

2009

2010

2011

2012

2013

2014

2006

2006

2007

2008

2009

2010

2011

2012

2013

2014

2007

2008

2009

2010

2011

2012

2013

2014

Cambodia

0

5

10

15

20

02468

1012

Papua New GuineaLao People's Democratic Republic

0.0

1.0

2.0

3.0

5.0

4.0

2006

2007

2008

2009

2010

2011

2012

2013

2014

2006

2007

2008

2009

2010

2011

2012

2013

2014

0

5

10

15

20

25Viet Nam

China

0

100

200

300

400

2006

2007

2008

2009

2010

2011

2012

2013

2014

10

0(%) 5 10 15 20 25 30 35 40

Programme management

TB care and prevention

First-line anti-TB drugs

HSS: Health informationsystems and M&E

MDR-TB

Community systemsstrengthening

HSS: Procurement supplychain management

TB/HIV

Ministry of Health and Medical Services Global Fund

Fig. 8Proportion of TB expenditure by funding source

and programme area in Fiji, 2016/2017

HSS: health systems strengthening, M&E: monitoringand evaluation, MDR-TB: multidrug-resistant tuberculosis,

TB: tuberculosis, TB/HIV: tuberculosis and HIVcollaborative activities

Sources: National TB Programme of Fiji, 2017; WHO Fiji case study on the Tuberculosis and Immunization Programme

Transition to integrated financing, 2017.


Similar trends are also seen with TB funding in selected countries in the Region where

the different stages of transition are reflected and there is increasing co-financing from

domestic sources as in countries moving from lower-middle- to upper-middle-income

status (Fig. 7). Some countries are increasing domestic financing of their health budgets

for TB, although the Global Fund still comprises a significant part of the health budget and

the budget itself can vary over time. Other grants, including bilateral support, have been

supporting several countries in the Region. In several countries, local governments also

help finance costs of priority public health services.

While Figs 6 and 7 show how some countries have gradually increased their domestic

financing for HIV and TB programmes over time at different rates depending on their

stage of transition, further details on countries’ expenditures reveal how the external and

domestic funds and their distributions have contributed across programme areas. As an

example, the proportion of TB expenditure by funding sources and programme areas in

Fiji and Mongolia show external funds for several areas, such as programme management,

patient support, TB care and prevention, multidrug-resistant TB (MDR-TB), diagnosis,

community systems strengthening, monitoring and evaluation, and TB/HIV (Figs 8 and 9).

Domestic funding typically first covers staff and other human resource costs, including

programme management and supervision, and first-line drugs. Financing for MDR-TB is

still heavily financed through external funding for countries that are transitioning.

Certain programme areas may be more vulnerable than others to the withdrawal of external

funding during the transition phase. External funding can contribute towards several

areas of support, including prevention and HIV testing, care and treatment, and systems

strengthening and programme coordination.

The challenges lie in how to gradually integrate and finance the programme areas that

are all interlinked and rely on each other to provide a continuum of care for priority public

health services, such as treating HIV and TB.

12

Fig. 9Proportion of TB expenditure by funding source

and programme area in Mongolia, 2013-2014

ACSM: advocacy, communication and social mobilization; FLD: first-line drug; HRD: human resource development; IPC: infection prevention and control; M&E: monitoring and evaluation; MDR-TB: multidrug-

resistant tuberculosis; OR: operational research; PPM: public–private mixed approach; TB: tuberculosis; TB/HIV: tuberculosis and HIV collaborative activities.

Sources: National TB spending assessment report 2013–2014, Mongolia; WHO sustainable financing of the priority public health programmes in Mongolia 2018: a case study on HIV and TB programmes (in press).

0(%) 10 20 30 40 50

HRD and staff 41.7%

Patient support 13.1%Management

and supervision 11.8%

MDR-TB 6.4%

5.5%

4.7%

3.5%

3.2%

2.3%

2.1%

1.9%

1.3%

0.8%

0.7%

0.6%

0.3%

Diagnosis

OR

IPC

FLD

Trainings

Public participation

PPM

Pediatric TB

M&E

High risk group

ACSM

TB/HIV

Domestic public International Domestic private

Similar to the TB programme, for HIV, countries have a distribution of external and domestic

funding across different programme areas. For example, in Malaysia, the majority of external

funds were spent on care and treatment, while, in Mongolia, prevention and HIV testing

was the main area of external support. In Viet Nam, the majority of external funds are spent

on prevention and HIV testing, and care and treatment (12).


14


Fig. 10Whole-of-system approach to essential

public health functions

Amount of funding, resource allocation and payment methods

Funding agents and flow

Funding sources

Governanceand

stewardship

Legislation

Regulations

National health

strategy

Organizational

structures

Coordination

Monitoring and

evaluation

Essential public health

functions

Ministry of Health

Disease control agencies

Laboratories

Health-care facilities

Procurement agencies

Communities and civil society organizations

Surveillance, health promotion and protection, disease prevention and management, emergency response

Core programme elements

Human resources, health information, research, social participation and health communication

Institutions

Source: WHO Regional Office for the Western Pacific

Financing

16

Transitioning to integrated financing and service delivery

Health systems need to respond to the increasing

pressures on health expenditures for priority public

health services and changing health needs. While

strengthening health financing is fundamental,

taking a whole-of-system approach for sustainable

and resilient systems is needed to deliver the best

health outcomes (Fig. 10). Essential public health

functions entail surveillance, health protection and

promotion, disease prevention and management, and

emergency response (13) – the interlinkages between

financing, governance and role of institutions in

discharging essential public health functions enable

the protection of health. Securing essential public

health functions is pressing for countries undergoing

service delivery and budgeting reforms, in particular

for certain countries confronting reductions in external

funding – including from global health initiatives – for

disease control programmes.

While global health initiatives have brought about

massive immediate cash and in-kind support to

countries, they have also enlarged core programme

elements and fragmented systems that support

essential public health functions.

To transition from a vertically funded to a whole-of-

system approach, countries can develop a phased

transition plan, which includes a four-part analytical

approach (Annex 1). This requires changing the way

of work and enables countries to do more with

available resources and achieve efficiencies at the

health system level in addition to mobilizing domestic

resources. Given that each donor may have its own

transition plan and systems, partners and govern-

ments are to coordinate and collaborate to smooth

the overall transition in countries. Government lead-

ership is critical to establishing the vision for health

sector development, ensuring active participation of

stakeholders, sustaining health gains and driving the

entire transition process.


ELEMENTS DESCRIPTION

Policy, guidelines, stewardship and regulations

Government has fundamental stewardship and regulatory functions, including setting national policies and strategies, developing guidelines, preparing annual work plans and budgets, and overseeing programme implementation, including monitoring, evaluation and supervision.

Prevention

Includes individual-based interventions (e.g. counselling; risk mitigation) and population-based interventions (e.g. immunization; promotion of prevention commodities; environmental control, including vector control; and health promotion and communication).

Surveillance

Continuous process of collecting information through notification, validation and registration of cases, and assessing the burden, trends and distribution of diseases and risk factors.

Evaluating effectiveness, accessibility, coverage and quality of individual- and population-based health services.

Monitoring and investigating unusual occurrences of health events, including disease outbreaks.

Outbreaks and emergency response

Response to disease outbreaks, disasters and emergencies.

Capacity to act on health-related issues and events that are identified by monitoring and evaluation activities, including routine surveillance systems.

Diagnosis, treatment and care (clinical services)

Quality clinical services such as diagnosis, treatment and care are a fundamental element of many public health programmes such as TB, malaria, sexually transmitted infections, HIV and NCD programmes.

Laboratory (clinical and reference laboratories)

Any public health programme requires quality-assured laboratory capacity for both diagnosis and surveillance purposes.

Requires a tiered laboratory network at various levels such as reference laboratory, secondary (referral) laboratory, district laboratory and point-of-care facilities. Small-country contexts may have regional reference or referral laboratories.

Procurement and supply management systems

Process of selecting, quantifying, purchasing and distributing quality-assured medical products that are essential for public health programmes.

Community-based support and social participation

Community-based support is critical to many public health programmes such as community patient support for TB, peer education programmes, self-help groups and social mobilization for outreach activities.

Targeted approaches for vulnerable and high-risk populations

Specific strategies and approaches are often needed to address the needsof vulnerable populations.

With decreasing incidence among general populations, some diseases are highly concentrated among high-risk populations

Table 1Core programme elements

Source: Regional framework for action on transitioning to integrated financing of priority public health services in the Western Pacific,

Table 1 (2018).

18

Strengthening service delivery across core programme elements

Critical to the process of transition are the mapping and analysis of core programme

elements that are included in national public health programmes and part of essential

public health functions and other health system functions (Table 1). While global health

initiatives have supported the development of the core programme elements and

disease-specific systems, further strengthening of these elements and their linkages

should contribute towards securing essential public health functions and improving the

sustainability and resilience of the health system. Some of the main challenges are how

to move towards more sustainable and integrated systems, given the large fractures

brought about by vertically funded disease control programmes, and to encourage staff

to more closely link across the core programme elements to provide more integrated and

coordinated care.

For each of the core programme elements, it is important to understand how they are

organized, financed and implemented or delivered to explore options on how to reduce

fragmentation, integrate into the general health system or better harmonize across the

system, and improve efficiency and coordination (Table 2). This includes how the core

programme elements are linked together to provide a continuum of care. Surveillance,

laboratory, procurement and supply management systems, and a community-based

approach are some of the elements that may gain efficiencies in integration. However, not

all core programme elements are necessarily expected to be integrated as some may still

need to fulfil specialized technical requirements. For example, in Viet Nam, the flow of funds

and procurement of medicines and vaccines can be complex and fragmented among the

various donors (Annex Fig. A1); however, efforts are being made to move towards a more

harmonized procurement and supply management system.


Table 2Current organization of core programme elements

and future directions

Source: Regional framework for action on transitioning to integrated financing of priority public health services in the Western Pacific,

Table 2 (2018).

PROGRAMME ELEMENT

CURRENT ORGANIZATION FUTURE DIRECTIONS

Policy, guidelines, stewardship and regulations

National public health programmes in collaboration with specialized institutions.

Retain policy and stewardship functions under ministries of health.

Prevention

Largely through primary health care network, often with significant input from specific programmes and funding.

Mostly retained under public responsibility with ongoing collaboration with civil society organizations.

Civil society organizations may play a significant role in health promotion, service delivery and communications.

Some can be shifted to health insurance or other funding sources.

SurveillanceParallel reporting procedures created substantial burden, especially at the peripheral levels.

Integrated systems, including disease notification systems, and national health management information systems.

Outbreaks and emergency response

Often organized by specific programmes, and not linked with general surveillance and response capacity of the country.

Strengthened linkages between general surveillance and response systems and disease control programmes.

Build response capacity along with declining disease incidence.

Diagnosis, treatment and care (clinical services)

Largely through the primary health care network. Task-shifting in some settings that may be associated with integration of clinical care under health insurance schemes.

Ensure quality of care especially where the role of general clinical facilities, including private sector, is expanded.

During the transition, it is critical to monitor service uptake and coverage, as well as financial burden to patients.

Laboratory (clinical and reference laboratories)

Often vertically organized under each health programme. Often separated from the general public health laboratory network.

Integrated public health laboratory networks using existing infrastructure and human resources. Investment made by specific programmes to be fully utilized (bio safety, molecular diagnostic platforms, etc.).

Procurement and supply management systems

Programme-specific supply management systems due to programmatic necessities and requirements for accountability by donors.

Programme-specific parallel systems gradually merged. Programmatic expertise critical for product selection, sound quantification and harmonization with national protocols.

Central procurement may be continued for efficient procurement practices.

Community-based support and social participation

Critical to many public health programmes such as treatment support for TB patients, HIV prevention and testing, and peer support programmes.

Explore options to maintain services provided by civil society organizations that are currently funded by external donors.

May require different contractual modalities or merging into the government sector function.

Targeted approaches for vulnerable and high-risk populations

Often needed but under the purview of specific disease programmes with the engagement of community-based organizations.

Continue with strategies to effectively address the needs of vulnerable and high risk populations with active engagement of civil society organizations.

20

Making better use of resources

Strengthening financing institutions to improve system-wide efficiency involves both allocative

and technical efficiency efforts and changing the way of work. Key considerations include

prioritizing and ensuring sufficient public funding for core programme elements, aligning

different funding sources and funding flows, and determining the role of health insurance in

mixed health financing systems.

Having a transparent, evidence-informed and participatory process for decision-making is

important in prioritization of interventions and how this is translated into the health budget.

This is also critical in holding decision-makers and health managers accountable for how

funds are spent. Ensuring that vulnerable and high risk populations have access to health

services needs to be considered in the prioritization process. Further, the funding gap should

not be equated to exactly replacing the external funding amount that will be reduced.

Some of the more difficult actions countries consider are with managing and absorbing

the programme staff within the general health system, how to strengthen and utilize

the public financial management system, and how to align incentives for providers to

improve equitable access to quality services. In particular, one of the major challenges

countries face is having flexibility in the public financial management system to contract

nongovernmental organizations, which play a vital role in core programme elements, such

as prevention and community outreach. In addition, several countries channel or are in the

process of channelling their external funding through the government system to better align

priorities, coordinate funding and make use of resources (Fig. 11). Transfers distributed by

the government from foreign origin are channelled through the government, while direct

foreign transfers are those funds that are directly received by the health financing schemes.

As countries transition towards integrated financing or increased domestic financing,

channelling external funding through the government system can reduce fragmentation

across various sources, improve monitoring of how external funds are used and encourage

strengthening of accountability mechanisms within the system.


Transfers distributed by government Direct foreign transfers

0(%) 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75

PLW

NIUTONNRUMHL

WSMFJI

MYS

FSMSLBPNGKHMLAOVUT

MNGVNMPHL

UMI

LMI

HI

LMI: lower-middle-income; UMI: upper-middle-income; HI: high-income.Note: Only those countries with external funding are included

Source: WHO Global Health Expenditure Database (accessed 6 February 2018). World Bank income classifications (accessed 13 June 2018)

Fig. 11External funding as a share of current

health expenditure, 2015

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22(%)

Pacific

Asia

MHLPLWTUVVUT

WSMSLBPNGTON

FJIKIR

FSMNRUCOKNIU

KORSGPCHNMYSVNMPHLBRNKHMMNGLAO

Fig. 12Government health expenditure as a share

of total government expenditure, 2015

Source: WHO Global Health Expenditure Database (accessed 6 February 2018).

22

During the transition, several countries with mixed health financing systems are also determin-

ing the role of health insurance and potential ways in which the health financing mechanism can

be used to cover the cost of some core programme elements. Health insurance may be another

way to raise funds for health, but it may not necessarily result in more total funding than through

other mechanisms. Government subsidies may also be needed to sustain the health insurance

system. Individual-based clinical services can be covered by health insurance, while this would

not be suitable for population-based services or functions. Individual-based prevention may

depend on the existing insurance function. Some of the key concerns of the transition with

health insurance entail ensuring a continuum of care and no disruptions in the treatment course

given what may or may not be covered in the benefit package. In middle-income countries

with growing health insurance systems, not all of the population is covered and vulnerable

and high risk populations may require special arrangements and subsidies to avail of services.

Other aspects of providing services paid through a health insurance system may be themselves

complicated given that members register with personal information and social stigma may

prevent people from accessing the care they need, in particular for TB and HIV.

Increasing domestic financing for public health.

In the Region, Asian countries have experienced steady economic growth, while in the

Pacific island countries, growth has been limited. Countries that do have favourable fiscal

contexts may not necessarily have increasing budgets for health. There is a wide range in

the government expenditure on health as a share of overall government spending in Asian

and Pacific island countries (Fig. 12). Over the past decade, countries have made efforts to

increase domestic spending for health in their health sector reforms and are strengthening

the engagement and trust between ministries of health and finance. Ministries of health are

often faced with questions regarding how effectively they spend their funds, what evidence

they have and what they are doing to improve efficiency. Also, having a clear and realistic

health sector plan with performance indicators and costing and budgetary implications is

important to evaluating how public funds are used to achieve health policy goals.

Regarding earmarking funds, this is often a political decision rather than purely a financial one.

There are advantages and disadvantages to earmarking, the flexibility of which depends on

the country’s public financial management system (14). Some countries in the Region have

earmarked funds for health, such as the Philippines (Annex Fig. A2), where a percentage of

tobacco and alcohol taxes and gambling revenues are used to subsidize health insurance

coverage for poor populations and assist needy patients for inpatient care.

Furthermore, collaboration with various partners, such as other government sectors and non-state

actors has supported health promotion and objectives in several countries in the Region. Improving

cooperation and coherence across government sectors for public health and health promotion

will be instrumental in meeting public health standards and supporting a country’s efforts towards

universal health coverage (UHC) and achievement of the Sustainable Development Goals (SDGs).

Social protection policies that have been put in place can include subsidies to patients to enrol

in social protection mechanisms and to provide patient support. For example, the Fiji National

Tuberculosis Programme negotiated with the Ministry of Women, Children and Poverty Alleviation

for preferential inclusion of needy or vulnerable TB patients in a social protection scheme with the

provision of food vouchers and a monthly stipend for the duration of treatment (15). While funding

channels directly from the Ministry of Women, Children and Poverty Alleviation to patients, the

Ministry of iTaukei Affairs also supports non-state actors that contribute to health (Annex Fig. A3).


24

Summary

Given the changing population needs and fiscal

pressures, many countries in the Region are

undergoing transitions towards more integrated

service delivery and financing for priority public

health services. Health financing serves as a trigger

to broader service delivery and health sector reform.

The transition process itself may last a long period

of time and may be country-specific with various

opportunities and risks. Political commitment and

long-term vision are needed from the government to

smooth the transition.

Governing the transition process is important

towards ensuring a well-planned and implemented

phase-wise approach. This also entails having a

transparent and participatory process throughout to

build consensus and coordinate among the several

partners. Having an oversight mechanism and being

able to routinely monitor and evaluate progress of

the transition to be able to adjust where needed in a

timely manner are essential.

One of the major challenges in the transition

will be managing the change in the way of work

and workforce involved. Having the support and

commitment of the workforce – particularly those

from disease control programmes – early on in the

transition is fundamental to mitigating potential staff

demotivation and attrition. Another major challenge

in the transition will be reconstructing the public

health system from a fractured, distorted system

using a whole-of-system approach. Doing so will also

translate to investing not just in human resources, but

in the core programme elements and their linkages

across one another, such as laboratories, treating

MDR-TB, outreach and preventive activities, to be

able to provide a continuum of care that is affordable.


26

1. Regional framework for action on transitioning to integrated financing of priority public health

services in the Western Pacific. Manila: WHO Regional Office for the Western Pacific; 2018.

2. Universal health coverage: moving towards better health – action framework for the

Western Pacific Region. Manila: WHO Regional Office for the Western Pacific; 2016

http://iris.wpro.who.int/bitstream/handle/10665.1/13371/9789290617563_eng.pdf

3. Regional action agenda on achieving the Sustainable Development Goals in the Western

Pacific. Manila: WHO Regional Office for the Western Pacific; 2017

http://iris.wpro.who.int/bitstream/handle/10665.1/13553/9789290617891-eng.pdf

4. Global tuberculosis report 2017. Geneva: World Health Organization; 2017

http://www.who.int/tb/publications/global_report/en/

5. HIV data and statistics [website]. Manila: WHO Regional Office for the Western Pacific; 2016

www.wpro.who.int/hiv/data/en/

6. Regional action framework for malaria control and elimination in the Western Pacific:

2016–2020. Manila: WHO Regional Office for the Western Pacific; 2017 (http://iris.wpro.who.

int/bitstream/handle/10665.1/13578/9789290618157-eng.pdf

7. Regional framework for implementation of the Global Vaccine Action Plan in the Western

Pacific. Manila: WHO Regional Office for the Western Pacific; 2015


8. Health topics: noncommunicable diseases [website]. Manila: WHO Regional Office for the

Western Pacific; 2018

www.wpro.who.int/topics/noncommunicable_diseases/en/

9. Warren AE, Wyss K, Shakarishvili G, Atun R, de Savigny D. Global health initiative

investments and health systems strengthening: a content analysis of Global Fund

investments. Global Health. 2013;9(1):30. doi: 10.1186/1744-8603-9-30.

10. Country hub [fact sheets]. Geneva: Gavi, the Vaccine Alliance; 2018

www.gavi.org/country/

11. Country and regional program results, FY 2015 [online database]. Washington, (DC):

PEFPAR; 2018

https://data.pepfar.net/country/impact?country=Global&year=2015

12. HIV financing status in selected countries of the Western Pacific Region (2009–2015).

Manila: WHO Regional Office for the Western Pacific; 2016.

http://iris.wpro.who.int/bitstream/handle/10665.1/13520/WPR-2016-DCD-002-eng.pdf

13. Essential public health functions, health systems and health security: developing

conceptual clarity and a WHO roadmap for action. Geneva: World Health Organization; 2018.

14. Cashin C, Sparkes S, Bloom D. Earmarking for health: from theory to practice. Health

Financing Working Paper No. 5. Geneva: World Health Organization; 2017

http://apps.who.int/iris/bitstream/10665/255004/1/9789241512206-eng.pdf

15. Regional framework for action on implementation of the End TB Strategy in the Western

Pacific, 2016–2020. Manila: WHO Regional Office for the Western Pacific; 2016


References


The purpose of this annex is to support countries in sustaining the progress made by priority

public health programmes within the health system context through the development of

a phased transition plan. This includes a four-part analytical approach which consist of:

(1) identifying options for integration and coordination by understanding the health

system and its context; (2) setting up of up-to-date, clearly defined essential public

health functions and the mapping of core programme elements within programmes and

their prioritization; (3) mapping of core programme elements and commonalities across

programmes and the rest of the health system including options for integration and

coordination; (4) development of a phased and systematic transition plan that is situation-

specific and responsive to a number of factors during the process to ensure long-term

sustainability. The analytical approach will guide the examination of priority public health

programmes from a health systems perspective, applying the principles of improving

quality of services, equity and efficiency.

1. Health system architecture and context • Brief overview of the health system architecture (governance, financing mechanisms,

institutions involved, essential public health functions and core programme elements)

and the overall governance and stewardship (legislation, regulations, national health

strategy, organizational structures, coordination, monitoring and evaluation), which

significantly influence the functioning of the health system.

2. Within-programme mapping and prioritization

• Mapping of core programme elements by financing mechanisms and service providers

within a specific programme

• Funding and other gap analyses

• Prioritization of interventions within each programme

3. Across-programme mapping and options for coordination and integration

• Mapping of core programme elements and commonalities across programmes and

the rest of the health system

• Options for coordination and integration

4. Phased and systematic transition plan • Assessment of the options for coordination and integration, including feasibility,

enabling factors, and associated benefits and risks

• Identification of entry points and sequence of actions

• Development of road map, including division of labour and key milestones

within a time frame

• Monitoring and evaluation of progress

AnnexAnnex 1: Analytical approach

28

1. Health system architecture and context

HEALTH STATUS AND HEALTH SYSTEM CONTEXT

• What are the major health issues that the country is facing, including major causes of

mortality and morbidity?

• What are the characteristics of the current political and economic environment?

• Which ongoing public sector reforms are relevant to the health system?

GOVERNANCE

• What important legislations and regulations are in place that shape the whole

health system? How does the national health strategy align with the overall country

development plan(s)?

• Which government agencies are important to the health system (health sector

agencies as well as central agencies and other bodies)? What are their functions and

their authority?

• How can the country’s health system be described – including the roles of the public

and private sectors and available information on current performance?

• What is the level and distribution of resources, including infrastructure, human

resources, equipment, essential medicines and technologies?

• What is the process for national health planning (annual planning and budgeting and

long-term planning) and which stakeholders are involved?

• What is the current capacity – including managerial – of the government to strengthen

the health system? What are the roles of the private sector and civil society?

• What donor activity is present and planned within the health system and how is it

coordinated?

• How is information on health system performance generated and used?

Guiding questions


FINANCING

• What are the past, current and forecast levels of expenditure on health by the

government? How much is the general health budget and what is it allocated towards?

• Is there earmarked funding for programmes (and what are the sources)? Are there any

plans for more earmarked revenues for health?

• Is there any leveraging of resources from and for non-state actors for health?

• What is the level of external funding provided and what is it used for (e.g. budget

support)?

CORE PROGRAMME ELEMENTS AND ESSENTIAL PUBLIC HEALTH FUNCTIONS

• What are the core programme elements in different priority public health programmes

and how are they aligned with the essential public health functions?

• How are the core programme elements delivered in the health system? Which

providers are involved in delivering them?

• How are services regulated? How is quality managed at the population and individual

levels and within health facilities and by whom?

• What are the arrangements and logistics for procurement of supplies? How is

procurement regulated? How is compliance ensured?

• Is there any community-based support and social participation within priority public

health programmes?

• What strategies and approaches are taken to target vulnerable and high-risk

populations?

2. Within-programme mapping and prioritization

HEALTH STATUS

• What is the prevalence of the disease and its incidence rate? What is the target

population? What is the burden of disease (including geographical, epidemiological

risk and evolution, most at-risk population groups, etc.)?

• What is the programme strategy and relevant evidence base?

30

ESSENTIAL FUNCTIONS AND SERVICES

• What are the core programme elements for the particular programme?

• Which providers are involved in delivering the various functions and services and how

are they funded?

GOVERNANCE

• What are the legal and regulatory frameworks relevant for the programme?

• What are the institutional arrangements for the programme? How are decisions made

and who is involved in the decision-making process?

• What are the responsibilities at the different levels of government and institutions for

implementing the programme?

• What is the prioritization process for interventions in the programme? Which

interventions are prioritized and which populations are affected?

• What are the management structure and mechanisms for the programme?

• How are donors currently involved in the programme? What is the forecast in relation

to future donor involvement?

• Who is responsible for creating and enforcing the technical guidelines and standards for

the programme? What are these and who will manage the training in these guidelines?

• What monitoring and evaluation mechanisms are used for the programme?

FINANCING

• How much funding goes towards which functions and from which sources? (Sources

include government – excluding social protection schemes; external – bilateral,

multilateral, global health initiatives, etc.; social protection schemes; private insurance;

and out-of-pocket payments.)

• How do funds flow across the levels of the health system, between central

government and local governments, including for donor funding? How is donor

funding used?

• What financing mechanisms are in place for providers and patients?

• What are the requirements for reporting on financial management and performance of

the programme? Who determines these requirements and how well are they currently

being met?

• How much funding is forecast for the programme?


3. Across-programme mapping and options for coordination and integration

MAPPING ACROSS PROGRAMMES

• Are there common core programme elements that can be better coordinated or

integrated to improve efficiencies? Are there functions that need to remain vertical?

How can these functions be distributed or merged among the different levels of

service delivery networks within the continuum of health care (primary, secondary and

tertiary care) and among stakeholders, including private and civil society groups?

• Are there governance arrangements or financing mechanisms across programmes

that can be better coordinated or integrated to improve efficiencies?

• What are the potential options and their associated benefits and risks? What

conditions are needed for implementation? How do they align with other reforms?

• What implications would changes have for the mainstream health system and the

vertical programme(s)?

OPTIONS FOR COORDINATION AND INTEGRATION – CORE PROGRAMME ELEMENTS

• What interventions are high-impact, evidence-based and aligned with the country’s

burden of disease? What aspects should be prioritized in accordance with the

country’s principles and national health priorities?

• How will the system continue to provide affordable, quality health services to target

populations?

OPTIONS FOR COORDINATION AND INTEGRATION – GOVERNANCE ARRANGEMENTS

AND FINANCING MECHANISMS

• Given the funding gap, how can domestic funding be increased and efficiency

improved? What is the capacity of the government to increase domestic funding?

What types of domestic funding options can be used to mobilize more funding?

• How can the different funding sources and funding flows be aligned? How will

programme staff be absorbed into the general health system?

• How can public financial management (PFM) systems and payment mechanisms

be strengthened? How can flexibility be built into the PFM systems for contracting

nongovernmental organizations? Can external funding be channelled through the

PFM system?

32

HOW CAN THE COVERAGE OF TARGET POPULATION GROUPS BY THE DIFFERENT

FUNDING MECHANISMS BE COORDINATED OR STREAMLINED?

• How are incentives aligned for the appropriate provision and use of health services?

Specifically, how are the provider-payment mechanisms aligned with the incentives

and services to be delivered?

• What services and functions can be potentially covered by health insurance

(if applicable)? How will the different funding mechanisms be coordinated and

integrated with health insurance? How can effective coverage of appropriate benefit

packages for priority populations be ensured? Can government funding subsidize

health insurance for programme-related services?

• What governance arrangements can enable the transition and which stakeholders

are involved?

4. Phased transition plan

ENTRY POINTS

• What entry points can be helpful in achieving coordination and integration? Which of

the different authorities is responsible for doing what? How can the entry points be

aligned with current reforms?

• What are some of the benefits and risks associated with the merging of certain

functions? What can be done to minimize those risks?

• Who are the different stakeholders and what are they responsible for in the

implementation phase?

• What are the different scenarios that can be envisaged based on funding conditions

and/or enabling environment?


ENABLING FACTORS

• How willing are donors to make long-term plans to slowly reduce funding?

What can be done by the government to negotiate a predictable and gradual shift

(or withdrawal) of funding?

• What types of institutional change(s) are needed for integration to happen – including

social rules and norms on how the health system functions and is governed?

• What are the implications of the proposed changes for planning, monitoring and

evaluation, and how can these be coordinated? How might the different national

programme plans be aligned with each other and with the national plan?

• What processes are in place to build a consensus on a plan to move forward?

Who needs to be involved?

• What are the enabling factors that may affect the change?

ROAD MAP AND MILESTONES

• What are the key milestones that measure progress and what is their timeline within

the road map?

• What monitoring and evaluation framework will be used to track performance of

implementation?

34


Pro

cure

me

nt

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t ProcurementAgent

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(SR)

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National Instituteof Malariology,

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(DPF) for HealthSystems

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ARV = Antiretroviral therapy

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PEFPAR HIV/AIDS

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Sto

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Legend:

Fig. A1Viet Nam Flow of Fund and Procured Drugs/

Vaccines for Donor-Assisted Programmes

Pro

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me

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Ag

en

t ProcurementAgent

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PrincipalRecipient (PR)

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RegionalStores

ProvincialStores

DistrictStores

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Provincial Hospital

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National Instituteof Malariology,

Parasitology andEntomology (NIMPE)

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National Institute forHygiene and

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Provincial AIDSCommittee (PAC)

District HealthCentres (DHCs)

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ImplementingPartners, Non-state

Actors

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IDA/GLC = International DispensaryAssociation/Green Light Comittee

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ARV = Antiretroviral therapy

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Legend:

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External donor financing PCSO = Philippine Charity Sweepstakes OfficePAGCOR = Philippine Amusementand Gaming Corporation

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Fig. A2The Philippines’s Health System Funding Flows

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StateBudget

General Government Budget FlowsLegend:

LGU Budget / Flows

PhilHealth / Social Health Insurance

Private Voluntary Health Insurance / Micro-health insurance


Direct payments from fees and charges

External donor financing PCSO = Philippine Charity Sweepstakes OfficePAGCOR = Philippine Amusementand Gaming Corporation

TA = Technical AssistanceLGU = Local government unitDOTS = Directly-Observed Treatment, Short-course

Coordination

NationalBudget

Departmentof Budget andManagement

Departmentof Health

(DOH)

General governmentbudget flows

Direct payments for fees and charges


Tertiary care

Secondary care

Secondary care

Primary care

Provincial HealthSystem

Flows from the gaming sector

Private voluntary health insurance flows

Social healthinsurance flows

Specialtyhospitals

Corporatespecialtyhospitals

RegionalOffices

Provincialhealth

offices /team

LGUProvince

Provincialhospitals

Districthospitals

LGUMunicipality

/ City

LGUBarangay

LocalGovernments

Departmentof Finance

PhilHealth

PCSO PAGCOR

Privatevoluntary

healthinsurance

Ruralmicro-health

insurance

People/employers

Patients

Reimbursements

Regionalhospitals

DOH-retainedhospitals

Externaldonor

partners

Ruralhealth units

Privatehospitals

Privatemedicalclinics

Pharmacies

Non-stateactors /


Privateproviders

Barangayhealth

stations

Suppliers /vendors /

contractors

Capital spending plusother procurement flows

exceeding 50 000 FJD

Procurement of goodsand services

Taxes

Premiums

User chargesto servicedeliveryfacilities

Payments

Socialassistance topoor patients

Remuneration /allowances of

volunteer

Directsupport toNGOs or


User chargespaid to

consolidatedfund account

Programme fundingtransfers / aid-in-kind

Agency budget



State budget flows

Direct paymentsfor fees and charges

Nationalbudget

Ministry ofEconomy

12 costcentres

Grant MgtUnit

Publichealth

facilities

Privatehealth

facilities andpharmacies

Non-stateactors(NGOs,CHWs)

ExternalDonor

Partners

Ministry ofi-TaukeiAffairs

Ministry ofWomen,

SocialWelfare and

PovertyAlleviation

Privatevoluntary

healthinsurance

People /Patients

Ministry ofHealth and

MedicalServices

Third-partyprocurement

agent

Programmefunding

transfers

Legend: CHW = Community health worker

NGO = Non governmental organization

Fig. A3Fiji’s Health System Funding Flows

Suppliers /vendors /

contractors

Capital spending plusother procurement flows

exceeding 50 000 FJD

Procurement of goodsand services

Taxes

Premiums

User chargesto servicedeliveryfacilities

Payments

Socialassistance topoor patients

Remuneration /allowances of

volunteer

Directsupport toNGOs or


User chargespaid to

consolidatedfund account

Programme fundingtransfers / aid-in-kind

Agency budget



State budget flows

Direct paymentsfor fees and charges

Nationalbudget

Ministry ofEconomy

12 costcentres

Grant MgtUnit

Publichealth

facilities

Privatehealth

facilities andpharmacies

Non-stateactors(NGOs,CHWs)

ExternalDonor

Partners

Ministry ofi-TaukeiAffairs

Ministry ofWomen,

SocialWelfare and

PovertyAlleviation

Privatevoluntary

healthinsurance

People /Patients

Ministry ofHealth and

MedicalServices

Third-partyprocurement

agent

Programmefunding

transfers

Legend: CHW = Community health worker

NGO = Non governmental organization


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Health Financing Regional Profile 2018 · Enrico Sevilla and Nuria Quiroz Chirinos. Financial...

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