2015年-世界发展银行全球_Assessing_Fiscal_Space_for_Health_in_Nepal_50页_1mb

Summary of "ASSESSING FISCAL SPACE FOR HEALTH IN NEPAL"

Core Content

This discussion paper explores the concept of fiscal space for health in Nepal, with a focus on identifying potential sources of additional resources to support the expansion of health services and the introduction of financial protection mechanisms. The paper highlights that despite significant progress in health outcomes, challenges such as inequality, high out-of-pocket (OOP) payments, and inefficiencies in the health system remain. The main conclusion is that efficiency gains are the most viable source of fiscal space for health in Nepal.

Main Viewpoints

• Health Outcomes: Nepal has made substantial improvements in health outcomes over the past few decades. Life expectancy increased from 38 years in 1960 to 67 years in 2009, and infant mortality decreased from 197 per 1,000 live births in 1960 to 39 per 1,000 live births in 2009. These improvements are better than regional neighbors and are consistent with Nepal's income level.

• Challenges: Persistent challenges include geographic and income-related inequalities in health outcomes, high levels of OOP payments (around 50% of total health spending in 2009), and issues related to the quality and responsiveness of the health system. Malnutrition remains a significant problem, with nearly 50% of children under five being malnourished.

• Policy Response: There is a growing demand to expand free essential health care (EHCS) to all Nepalese and introduce social health insurance. The expansion of EHCS has led to increased pressure on government budgets, as it requires higher compensatory spending.

• Fiscal Space: The paper defines fiscal space as the ability to increase public health spending without compromising the government's long-term financial sustainability. It emphasizes that fiscal space must be assessed within the broader macroeconomic context and without crowding out other essential expenditures.

• Key Sources of Fiscal Space:

  • Economic Growth: Limited potential due to relatively weak growth.
  • Domestic Mobilization: Limited scope for increasing domestic resources.
  • Re-prioritization: Possible, but constrained by existing expenditure envelopes.
  • Taxation on Health-Related Goods: Can be mobilized, though not a major source.
  • External Resources: Contribution from donors has declined and remains limited.
  • Efficiency Gains: Identified as the most promising source of additional fiscal space.

Key Information

Efficiency Gains

• Importance: Efficiency gains are highlighted as the most significant source of additional fiscal space. Improving the value for money in health spending is essential for sustainable expansion.
• Areas for Improvement:
  • Provider Payments: Reforming payment systems to align with performance.
  • Drug Procurement: Addressing stock-outs and inefficiencies in procurement.
  • Grant Allocations: Improving the distribution and use of grants for hospitals and districts.
  • Health Worker Absenteeism: Reducing waste and improving service delivery.
  • Equipment Procurement and Maintenance: Enhancing the utilization of existing resources.

Potential Reforms

• Per Diem System: A simple and immediate way to reform provider payments, though it may lead to behavioral changes by providers.
• Case-Based Payments: More complex but could be a long-term solution, requiring data collection and monitoring systems.
• Stewardship Role of the Ministry: The Ministry of Health should refocus its role to ensure better stewardship of the health sector, emphasizing equity, financial protection, and quality over service delivery mechanisms.

Data and Trends

• Health Expenditure Trends: Total health expenditure in Nepal increased over the years, with government spending rising from 5% to 7% of total government expenditure between 2000/01 and 2006/07.
• Public vs. Private Spending: Public spending accounts for around 36% of total health expenditure, while private spending dominates (64%), largely from OOP payments.
• Out-of-Pocket Payments: Remain high at about 50% of total health expenditure in 2009, contributing to poverty and financial risk.

Future Work

• District-Level Analysis: Further research is planned to understand district-level drivers of efficiency and to identify best practices from high-performing districts.
• Stakeholder Engagement: Consultations with stakeholders are being considered to inform future analyses and policy development.

Conclusion

The paper concludes that while Nepal has made progress in health outcomes, the expansion of health services and the introduction of financial protection mechanisms require additional resources. Efficiency gains, particularly through performance-based financing and better governance, are the most feasible way to achieve this. The Ministry of Health must rethink its role in stewardship and focus on maximizing the value of current spending to support long-term health goals.