2018年-世界发展银行全球_Challenges_on_the_Path_to_Universal_Health_Coverage___The_Experience_of_Azerbaijan_44页_1mb

Summary of "Challenges on the Path to Universal Health Coverage: The Experience of Azerbaijan"

Core Content

This document provides an in-depth analysis of Azerbaijan's experience in advancing Universal Health Coverage (UHC), highlighting the progress made and the ongoing challenges. The study is part of the World Bank's Universal Health Coverage Study Series, which aims to share knowledge on pro-poor reforms that support UHC in developing countries. The case study focuses on the financial and institutional reforms implemented in Azerbaijan and evaluates their effectiveness in improving access to health services and financial protection for the poor.

Main Objectives

• To assess how the poor have fared as a result of recent efforts toward UHC in Azerbaijan.
• To provide an overview of the government's planned additional reforms, particularly the introduction of a Mandatory Social Health Insurance (MSHI) scheme.
• To highlight the challenges in implementing these reforms in the context of a difficult economic and fiscal situation.

Key Findings

Health System Overview

• Azerbaijan's health system continues to follow the Soviet Semashko model, characterized by centralized planning, public ownership of facilities, and input-based fund allocation.
• The system has not established a clear provider-purchaser split, which affects efficiency and accountability.

Financing Trends

• Public health expenditure increased significantly over the last 15 years, from 2000 to 2015.
• In 2015, per capita public health expenditure was about 74 manats, which was six times higher in real terms than in 2000.
• Despite the increase, public expenditure on health remained low as a percentage of total health expenditure (about 34% according to national data, but only 20% according to WHO data).
• Azerbaijan had the lowest public health expenditure as a percentage of total government expenditure among ex-USSR countries in 2014 (20% vs. 10.5% in Turkey and 15.3% in the EU).

Health Utilization and Coverage

• Health care utilization rates have increased, but the majority of the increase was among the highest income groups.
• There was a slight decrease in outpatient care utilization among the poor.
• Key maternal and child health services have seen some improvement due to state national programs.
• The utilization of services for NCDs remains low, reflecting inadequate coverage and underfunding.

Financial Protection

• Out-of-pocket (OOP) health expenditure remains high, with 12.5% of household consumption spent on health in 2015.
• Catastrophic health expenditure was reported by 23% of households in 2015, with 16% of households spending more than 30% of total consumption on health.
• The incidence of catastrophic health expenditure increased between 2008 and 2015, but the poor saw a reduction in this rate.

Challenges and Reforms

• The introduction of the MSHI scheme is seen as a key reform to improve financial protection and access to quality health services.
• The MSHI scheme is expected to increase revenue collection and promote structural changes in the health system.
• However, the scheme faces challenges, including:
  • Difficulty in collecting revenue from non-poor informal sector workers.
  • Limited revenue potential due to a low payroll tax rate (2–4%).
  • The need for a comprehensive and sustainable benefits package.
  • The necessity of a mechanism for beneficiary identification and resource pooling.

Recommendations

• Strengthen the prioritization and efficiency of health resource allocation.
• Expand the list of drugs and services provided at no cost to the population, especially focusing on prevention.
• Improve the performance of the public delivery network, particularly primary health care (PHC).
• Consider alternative revenue sources such as tobacco taxation.
• Reform the organizational structure and functioning of the health system to enhance provider autonomy and service delivery.

Key Information

• Health Outcomes: Azerbaijan has seen significant improvements in maternal and infant mortality, and life expectancy has increased by nearly eight years between 1990 and 2015.
• Economic Context: The country has a strong economic performance, driven by natural resource-based growth, which has led to increased public health expenditure.
• Double Burden of Disease: Azerbaijan faces a dual burden of communicable diseases and noncommunicable diseases (NCDs), with NCDs increasingly affecting population health.
• Current System Weaknesses: The system is heavily biased toward hospital care, underfunding PHC. There is also a lack of clarity in the criteria for including drugs in the free list, and significant inefficiencies in resource utilization.
• MSHI Pilot: The MSHI scheme is currently being piloted, with the goal of improving financial protection and access to care. It may require a shift from line-item budgets to output-based payments and the establishment of a single purchasing agency.

Pending Agenda

• Reform of Health Financing: To ensure the MSHI scheme is effective, additional revenue sources and more efficient resource allocation are needed.
• Strengthening Primary Health Care: PHC needs more funding and development to become the first point of contact for health services.
• Improving Service Delivery: Enhancing the performance of the public health delivery network and ensuring provider autonomy are crucial for success.
• Expanding Coverage for NCDs: Prevention and early detection of NCDs should be prioritized, especially since these diseases are more effectively managed in PHC settings.
• Efficiency Gains: Reducing input costs and improving allocative efficiency can help generate fiscal space for health.

Conclusion

Azerbaijan has made important strides in improving health coverage and financial protection for its population, particularly through increased public expenditure and targeted state national programs. However, the system still faces significant challenges in ensuring equitable access, reducing catastrophic health expenditure, and improving the efficiency of service delivery. The introduction of the MSHI scheme presents an opportunity for structural reform, but its success depends on addressing these challenges through improved resource management, expanded coverage, and better organization of the health delivery network.