Combating Corruption in Global Health

In the past 20 years, the international community has begun to fully recognize the devastating effect of corruption on global health. Poor governance, marked by weak institutions, absence of rule of law, and lax enforcement of health policy, creates conditions for corruption to thrive. This can contribute to health system failure and deprive citizens of access to even basic health services. This paper explores the extent of corruption in health services, as well as  emerging anti-corruption tools and inter-agency frameworks that could prove effective in limiting corruption in global health. While corruption has gained attention in the international sphere, more action is needed in the specific context of global health. This paper was co-written by Maureen Lewis (CEO of Aceso Global), Tim K. Mackey, Jillian Kohler and Taryn Vian.

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Measuring Public Hospital Costs: Empirical Evidence from the Dominican Republic

This paper presents a methodology and analysis to determine the actual costs of inpatient, emergency and outpatient services in a Dominican hospital. By developing and applying a set of survey instruments to a large sample of patients, the authors were able to measure and cost all hospital staff time, in-kind goods, overhead and the depreciated value of plant and equipment related to the treatment of each patient. The study finds that the hospital budget was 50 percent higher than actual costs of services. Further, while spending on personnel comprised the vast majority of the total hospital budget, actual personnel costs for patient treatment were low. Based on these results, the authors suggest that the hospital suffers from gross inefficiency, chaotic medical care organization and poor management.

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Guidance for Analysis of Country Readiness for Global Fund Transition

Aceso Global was tasked by the Global Fund to develop a tool to help countries through the transition process as Global Fund contributions wane and consequently national governments and other in-country stakeholders are expected to shoulder an increasing burden of disease financing and programmatic responsibilities. This Guidance is the culmination of these efforts. It aims to help countries identify financial, programmatic and governance gaps, bottlenecks and risks in the health system that might affect transition.

Specific areas of investigation include service delivery, procurement and supply chain management, human resources, information systems, monitoring and evaluation (M&E), community systems and responses, and health financing, among others. A modular approach allows for flexibility and analysis tailored to country-specific context.

The Guidance was refined following a pilot in Paraguay led by Aceso Global in January 2017, and has since been successfully implemented in Panama and the Dominican Republic.  

 

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Health Investments and Economic Growth: Macroeconomic Evidence and Microeconomic Foundations

Improvements in health status over the last 50 to 100 years have been nothing short of spectacular. Vaccines, antibiotics, and other pharmaceutical developments have drastically reduced the incidence of illness and death. Economic growth has also helped: richer people are better nourished and educated, and richer countries are more able to afford the public goods (such as supply of clean water and sanitation and control of disease vectors such as mosquitoes) that reduce the transmission of disease.

Do improvements in health themselves help to boost economic growth? A resolution of this debate could boost the urgency of the quest for growth, inform that quest, or both. For example, a finding that economic growth reduces infant mortality could hasten the adoption of potentially growth-enhancing policy reforms. To help inform decision making on public policy, this review aims to: i) examine the routes by which improvements in health might indeed increase incomes and growth, and the related evidences; and ii) investigate the determinants of health itself, particularly evidence on the impact of public expenditure policies on health.

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Better Hospitals, Better Health Systems, Better Health

Despite their central role in healthcare delivery and their consumption of the lion’s share of national health budgets, hospitals in many emerging markets remain poorly governed, underfunded, and unevaluated. Hospitals have long been neglected by external stakeholders such as donors and multilateral institutions, and considered “black holes” by government ministries that fund facilities but provide limited governance or accountability. Historically, patients have borne the brunt of this negligence, shouldering high costs for poor quality of care.

This report proposes a Global Hospital Collaborative to transform the emerging market hospital landscape by promoting knowledge sharing, research, and cooperation between global experts and stakeholders in hospital governance, management, financing, and related fields. It was produced by the Hospitals for Health Working Group housed at the Center for Global Development, in collaboration with Aceso Global CEO Maureen Lewis and CTO Gerard La Forgia.

The proposed Collaborative would synthesize and centralize the vast but fragmented knowledge, research, and best practices related to hospital management and financing, as well as integration with the broader health system, and add to this knowledge base through additional research. The Collaborative is imagined as a forum for exchange that can lead to concrete improvements in health on the ground. Potential projects and products could include a web-based knowledge clearinghouse, conferences and webinars, data measurement and analysis, peer-to-peer learning exchanges, and in-country technical assistance. 

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Health and Growth

This volume, comprising six articles and related commentary, examines the relationship between economic growth and investment in health. It emerged from the Commission on Growth and Development, which convened from 2006 through 2008 to discuss the diverse causes and impacts of economic growth.

While evidence clearly shows that positive economic growth contributes to better health outcomes, as measured by better nutrition, longer life expectancy, and lower communicable disease rates, among other indicators, the extent of the reverse relationship—that is, whether improved population health directly contributes to economic growth—is less clear. The lack of comprehensive metrics to measure health makes determining the degree of this causation challenging, as do other potential compounding factors; for example, countries with more effective health systems often benefit from greater institutional strength overall, complicating the identification of individual causal relationships. The articles in this volume explore existing evidence around this relationship, which is tenuous.

The final article explores the impact of early childhood investment in health and nutrition on future individual and household earnings. On this topic, the scientific evidence demonstrates clearly that investing in health and nutrition at an early age can lead to higher incomes, help break cycles of intergenerational poverty, and contribute to long run economic growth.

 

Co-editor Michael Spence is a senior fellow at the Hoover Institution and Philip H. Knight Professor and Dean, Emeritus, at Stanford University. He was awarded the Nobel Memorial Prize in Economic Sciences in 2001. 

 

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Parallel Systems and Human Resource Management in India's Public Health Services

Increasingly, evidence in India suggests that the delivery of health services suffers from not only a shortfall in trained health professionals, but also from unsatisfactory performance of existing service providers working in the public and private sectors. This study focuses on the public sector and examines de facto institutional and governance arrangements that may give rise to well-documented provider behaviors such as absenteeism, which can adversely affect service delivery processes and outcomes.

The paper considers four human resource management subsystems: postings, transfers, promotions, and disciplinary practices. The four subsystems are analyzed from the perspective of frontline workers, that is, physicians working in rural healthcare facilities operated by two state governments. Physicians were sampled in one state that has instituted human resource management reforms and one state that has not.

The findings are based on quantitative and qualitative measurements. The results show that formal rules are undermined by a parallel modus operandi in which desirable posts are often obtained through political connections and side payments rather than merit. The evidence suggests an institutional environment in which formal rules of accountability are trumped by a parallel set of accountabilities. These systems appear so entrenched that reforms have borne no significant effect.

 

This working paper was co-authored by Gerard La Forgia, Shomikho Raha, Shabbeer Shaik, Sunil Kumar Maheshwari, and Rabia Ali. 

 

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Aceso Global CTO Cited in Bloomberg Article on Healthcare Access for China’s Rural Poor

Gerard La Forgia, Aceso Global’s CTO, was cited in a Bloomberg Business article regarding China’s rural poor and the high cost of healthcare access in the country.

La Forgia, the lead author of Healthy China: Deepening Health Reform in China stated that the average cost of a hospital is 1.3 times the annual income of rural residents, compared to only 50% of the annual income of city residents. According to the article, nearly 60% of senior citizens in China live in rural areas marked by poverty and poor healthcare.

The Chinese government instituted a rural medical insurance scheme over a decade ago; in 2009 it introduced a pilot rural pension program. La Forgia points out that “On paper it looks great—90-some percent of the rural population is covered, and that is probably true.” However, both of these programs are limited and impose high out-of-pocket payments and copayments.

Read more: China’s Rural Poor Bear the Brunt of the Nation’s Aging Crisis

Case Studies: White Paper on Hospital Autonomy Potential in India

These case studies supplement Aceso Global’s White Paper on Hospital Autonomy Potential in India and assess hospital autonomy reforms in Brazil (Sao Paulo), Hong Kong, Vietnam, Portugal, Spain, the UK, and the US (NYC). Each case study introduces the country- or city-specific context leading to reforms, then details how the governance model functions in terms of operational and organizational autonomy, financial management, and accountability. Finally, each case study concludes with an analysis of the model’s strengths and weaknesses, and lessons learned. 

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Preparing for Transition from Donor Funding: Developing a Stakeholder Engagement Tool for the Global Fund in LAC

This presentation introduces Aceso Global’s work for The Global Fund to Fight AIDS, Tuberculosis and Malaria, conducting Transition Readiness Assessments in Latin America to help middle-income countries transition away from reliance on donor funding for these diseases. The work, as outlined in the presentation, includes the development and testing of a transition tool comprised of specific modules that will help assess whether countries are ready – financially, managerially, and politically – to shoulder a greater share of disease funding and program oversight. The findings will inform analytical reports and country-specific recommendations on this topic.  

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White Paper: Hospital Autonomy Potential in India

Public hospital autonomy reforms emerged out of frustration over poor hospital performance, citizen distrust of public care and evidence from other sectors of the benefits of delivery models that incorporate or build on private sector incentives. Hierarchical bureaucracy, limited managerial decision-making authority and nonexistent accountability have resulted in poorly performing hospitals, and driven the search for alternative models of health care delivery.

This paper takes up three major organizational forms of hospital autonomy reforms – autonomization, corporatization, and public-private partnerships – and the underlying components necessary for their successful implementation. International examples of hospital autonomy reforms in both OECD and emerging market countries serve as a foundation for analyzing potential opportunities, as well as pitfalls, of autonomy reforms in different contexts.

The paper concludes with an evaluation of the possible application of public hospital autonomy reforms in India. A brief overview of existing autonomy reforms in non-hospital settings is followed by recommendations for the Indian government on the applicability of specific models to the Indian public health sector.

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Government-Sponsored Health Insurance in India: Building Blocks for Achieving UHC or Trojan Horse

This presentation explores the role of state and central government health insurance schemes in achieving universal health coverage in India. It provides an overview of the main features and impacts thus far of multiple new state-sponsored insurance programs, as well as challenges. Finally, it takes a forward-looking approach and considers the role of these health insurance schemes in the broader public and private health care landscape in India. 

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Pay for Performance and Hospital Quality Within the Affordable Care Act

This presentation examines the new generation of Pay for Performance initiatives included in the U.S. Affordable Care Act (ACA) and provides lessons for countries considering similar health care payment reforms. It lists measures and outcomes used to gauge performance under the ACA, and the payment schemes employed to link pay to these measures. While highlighting various improvements arising from the adoption of Pay for Performance, such as lower costs and reduced readmission rates, the presentation also discusses emerging challenges.

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Patient Flow Analysis: Innovation for OECD & Emerging Market Hospitals

This presentation provides a basic introduction to Patient Flow Analysis (PFA) and its applications and relevance to hospitals in emerging markets. Specific international examples highlight the benefits of PFA for hospitals, including increased patient and staff satisfaction, greater patient throughput, reduced costs, and less chaotic hospital environments. The presentation concludes with an overview of Aceso Global’s ongoing work in Mexico on this topic, including specific metrics and measures used to perform PFA, and potential challenges that can arise when attempting to implement patient flow management changes. 

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Sustainability of Global Fund Supported Programs: Brazil Country Case Study

This report summarizes the policies, programs and levels of investment in malaria, tuberculosis and HIV/AIDS in Brazil, linking these to broader Brazilian health care initiatives and to both general and specific investments. It provides the background necessary to understanding the contribution of the Global Fund, and the country’s transition away from that support once funding for malaria and tuberculosis ended. Brazil’s strong commitment to health, early establishment of excellence, its depth of technical expertise, and its ability to implement complex health programs has translated into a level of independence that relies on outside support for only part of its agenda. That in turn facilitates adapting to declining external transfers, and an understanding that transition means establishing functioning and funded institutions."

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Holistic Approaches to People-Centered Care: New Models for Service Delivery Built on Strong Primary Health Care

This product examines current challenges in health care service delivery and introduces a new delivery approach: People Centered Integrated Care (PCIC). Emerging evidence suggests that this new approach generates better patient compliance, patient satisfaction, access, quality, and efficiency, with fewer unnecessary hospitalizations and admissions. The product showcases a World Bank study on PCIC initiatives and highlights lessons learned from implementation across the globe.

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Aceso Global CTO Authors World Bank Call to Action for Chinese Health Care System

A new World Bank report, issued in collaboration with the Government of China and the World Health Organization, urges adopting “People Centered Integrated Care” in China as a way to reduce costs and place primary care at the heart of the country’s health system. Aceso Global CTO Gerard La Forgia led the study from its inception and joined Aceso Global just prior to the conclusion of the report. The World Bank released the report’s 200-page Policy Summary on July 22, 2016.

 
 
 

Over the past three decades, China has made significant improvements in health, including in child and maternal mortality. Also, Chinese citizens theoretically enjoy Universal Health Coverage. Yet, in the years ahead rising costs could limit further improvements in the Chinese health system. An aging population and a shift in the disease burden to non-communicable diseases such as cancer, cardiovascular disease and diabetes will place new strains on an already costly system. Current healthcare costs are growing unsustainably, and are projected to reach 9.1 percent of GDP by 2035. The People Centered Integrated Care model suggested in the report provides a potential means to making the system more effective while also containing cost escalation.

The existing Chinese system over invests in expensive hospitals and specialty care, while increasingly neglecting primary care service. Rising patient dissatisfaction with the quality of primary care has driven many Chinese to visit hospitals at the first sign of illness. Not only is this an inefficient use of expensive hospital resources, but it has also led to a decline in the number of health professionals seeking work in the primary care sector. This vicious cycle only further weakens the quality of the primary care system. In response to these challenges, the report recommends placing primary care at the core of an integrated health system to reduce costs and free up hospitals for more complex care needs, while simultaneously altering incentive systems so that hospitals and clinics are rewarded for quality of care rather than the volume of services provided. Finally, the report encourages greater private sector involvement to harness private sector efficiency for public healthcare. 

The challenges faced by China—from rising health costs, to an aging population, to a shifting disease burden away from communicable diseases—are not unique. OECD countries are already facing these issues, and Emerging Market countries will experience similar trends over the next decade and will be confronted with the need to rein in costs while expanding service equity and quality. Policymakers can consult the report for lessons as a step to solving these challenges. 

 

Find the report, Healthy China: Deepening Health Reform in China: Building High-Quality and Value-Based Service Delivery, here.

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Who is Paying for Health Care in Eastern Europe and Central Asia?

This paper analyzes informal payments in Eastern European and Central Asian (ECA) public healthcare systems. Informal payments comprise any purchase of health services outside of formal payment channels and therefore escape reporting and regulation measures. These payments, which are highly prevalent across the region, impede access, decrease equity and ferment systemic corruption. As a result, patients either consume less health care or sell personal assets to pay for treatment. This paper highlights the policy implications of informal payments and explores potential solutions to this problem.

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Governance and Corruption in Public Health Care Systems

This paper examines the relationship between governance and health care delivery, defines indicators for governance and corruption, and summarizes country and cross-country evidence using these indicators. The components of governance and corruption examined include perceptions of corruption and performance, management challenges in public health systems, staff absenteeism, informal payments, and misuse of public funds. Concluding that governance plays an important role in the performance of health services, this paper provides policy options for promoting better governance. 

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Governance in Health Care Delivery: Raising Performance

This 2009 paper argues that good governance is central to raising performance in health care delivery. It provides a definition for good governance in health and a framework for thinking about governance issues as a way of improving performance in the health sector. The paper was co-authored by Maureen Lewis and Gunilla Pettersson and published as: Governance in Health Care Delivery: Raising Performance, World Bank Policy Research Working Paper Number 5074. 

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