Despite recent progress in access to health services, 800 million people spend more than the 10 percent threshold of their household budget on health, and almost 100 million are pushed into extreme poverty each year because out-of-pocket health payments.

This week, as the world marks International Universal Health Coverage Day, hundreds of millions of people around the world cannot access quality health services without suffering financial hardship. Despite recent progress in access to health services, 800 million people spend more than the 10 percent threshold of their household budget on health, and almost 100 million are pushed into extreme poverty each year because out-of-pocket health payments, according to a 2017 World Bank and World Health Organization joint report.

Since 2014, the World Bank Group has been part of a global coalition of leading health and development organizations that have committed to work together to ensure everyone, everywhere, can access quality health services when needed without being forced into poverty. 

A recent IEG evaluation looked at the World Bank’s support to health services during the last decade and suggests four areas where governments and institutions like the World Bank can do more to support progress towards Universal Health Coverage (UHC).

1. Improving the measurement of the quality and distributional effects of health services: Evidence on the contribution to Universal Health Coverage requires solid Monitoring and Evaluation frameworks, with particular regard to quality and equity dimensions.

Substantial time, effort, and capacity is required to establish a Monitoring and Evaluation (M&E) system – including audits, verification of co-responsibilities, and feedback loops – all of which is central to effective program implementation, supervision and accountability. While the World Bank’s health services portfolio shows greater emphasis over time on improving the quality of health services, it still exhibits limited monitoring of all the relevant aspects of the enhanced quality – structure, process, and outcomes – with the exception of those projects supporting Performance Based Financing interventions. IFC projects usually monitor even more narrow aspects of structural quality. Following the Twin Goals of increasing shared prosperity and reducing poverty, the health services portfolio targets vulnerable populations to benefit from project interventions. Yet projects’ M&E rarely measure the distributional impact of the investments comparing results for beneficiaries and for nonbeneficiaries.

2. Supporting a balanced approach to achieving UHC: Conditional Cash Transfers and Performance Based Financing can create financial incentives that help achieve better results in access, quality, and the strengthening of health systems.

Performance Based Financing (PBF) programs play an important role in contributing to achieve Universal Health Coverage, as they focus on a defined package of health services, the expansion of health service coverage, and increasing access to good-quality health services. The part of the World Bank’s portfolio with PBF interventions shows better results in access to and quality of health services, and present stronger monitoring and evaluation frameworks, including the measurement of different dimensions of quality. There is an opportunity to expand these good practices to the entire health services portfolio. On the demand side, projects supporting incentives to stimulate the uptake of health services through Conditional Cash Transfers also outperform the evaluation portfolio in improving access, health outcomes, and in strengthening the health system. These findings should encourage the World Bank to continue and deepen its emphasis on a balanced approach that comprises relevant demand-side, system wide and supply-side interventions, while fostering the participation of beneficiaries to enhance accountability, fight corruption, and ensure that services benefit the poor.

3. Strengthening interactions between the public and the private sector for health care: Private provision with public financing can play a key role in making health services available for the poor, but important bottlenecks have to be addressed to effectively contribute to Universal Health Coverage.

This evaluation found that hospitals and specialty chains supported by IFC investments had difficulties to attract public financing and continued to rely primarily on out-of-pocket payments mainly due to mismatch of public and private expectations, limitation of public resources and inadequate regulation.  More specific health system challenges include inadequate referral systems resulting in overflow of demand and unexpected fiscal pressures on government, delays in government payment, inadequate calculation of government contribution, delays in matching human resources availability with infrastructure, limited accountability function and government capacity to manage and understand the role of the private sector.

The Health in Africa (HIA) initiative, a joint World Bank and IFC effort to better integrate public-private interactions, has been supporting governments to strengthen regulations, processes of public and private health facilities, and accreditations of private health facilities. However, successful examples have so far been found only in Ghana and Kenya.  The inadequate integration of private investments with public financing reduces the potential to expand coverage among the poor and the contribution to universal health coverage.

4. Ensuring the sustainability of financial incentives: Financial incentives to health providers need to be integrated within the health system to ensure long-term sustainability and avoid distortions.

A  2014 IEG evaluation of World Bank Group support to health financing found that the limited integration of incentive schemes with other health financing functions (for example, purchasing) and with the broader public financing context creates sustainability risks and potential distortions. The health services evaluation, in addition, stresses the opportunity to improve the integration of monitoring and verification systems for Performance Based Financing within the overall national health information systems to improve the long-term sustainability of PBF pilots.

To learn more about the World Bank’s recent achievements and challenges in supporting Health Services, read IEG’s recent evaluation.