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Bismarck meets Beveridge on the Silk Road: Quand Bismarck rencontre Beveridge sur la Route de la soie: Bismarck y Beveridge en la Ruta de la Seda: Options for health financing reform are often portrayed as a choice between general taxation known as the Beveridge model and social health insurance known opciones de compra de quintiles the Bismarck model. Ten years of health financing reform in Kyrgyzstan, since the introduction of its compulsory health insurance fund inprovide an excellent example of why it is wrong to reduce health financing policy to a choice between the Beveridge and Bismarck models.

Rather than fragment the system according to the insurance status of the population, as many other low- and middle-income countries have done, the Kyrgyz reforms were guided by the objective of having a single system for the entire population. Key features include the role and gradual development of the compulsory health insurance fund as the single purchaser of health-care services for the entire population using output-based payment methods, the complete restructuring of pooling arrangements from the former decentralized budgetary structure to a single national pool, and the establishment of an explicit benefit package.

Central to the process was the transformation of the role of general budget revenues - the main source of public funding for health - from directly subsidizing the supply of services to subsidizing the purchase of services on behalf of the entire population by redirecting them into the health insurance fund.

Through their approach to health financing policy, and pooling in particular, the Kyrgyz health reformers demonstrated that different sources of funds can be used in an explicitly complementary manner to enable the creation of a unified, universal system. Policy choices in health financing, particularly for low-and middle-income countries, are often reduced to a decision on whether progress towards universal coverage can opciones de compra de quintiles be achieved through a social health insurance SHI system often labelled as the "Bismarck model" after the late 19th century German chancellor who enacted social legislation to insure workers against serious risks including health or a general tax-funded system often labelled as the "Beveridge model" after the designer of the British National Health Service.

Advocates of SHI have suggested that in low-income countries, insurance coverage can expand from the formal sector to the entire population, as it has done in many countries that followed the Bismarck model such as in western Europe, Japan and the Republic of Korea. Kyrgyzstan's experience with health financing reform since provides an example of how one low-income country introduced an SHI fund but did opciones de compra de quintiles suffer the potentially negative consequences for equity that had concerned critics.

The Kyrgyz experience illustrates the importance of thinking about health financing policy in functional terms 5,6 rather than in terms of historical models imported from western Europe. As with most of opciones de compra de quintiles countries of the former Soviet Union, Kyrgyzstan suffered an extreme fiscal contraction in the first half of the s.

It is estimated that bythe real level of government health spending in Kyrgyzstan was about half that of Behind this was not only the fall in public spending but also the rising costs of the inherited health system. The health system of the former Soviet Union was characterized by heavy reliance on physical infrastructure and specialization.

In the s, however, the decline in government revenues and the increase in prices made the large infrastructure unsustainable: Provider payment mechanisms were based on input-based norms formulated into strict line-item budgets reflecting historical patterns.

The more beds that a hospital had, the more staff positions it was allowed to have and the greater budget it received. There were 18 input categories used for budgeting such as personnel, drugs and utilities. Managers could not re-allocate across line-item categories if the need arose and so unspent resources were returned to the government budget.

In addition, the former Soviet Union health and health financing system was fragmented, with each level of government funding and managing its own decentralized health system. Excess capacity was particularly marked in urban centres, where both city and provincial oblast facilities existed. It was in this challenging context that health financing reforms were introduced. Late inthe government announced that a law to introduce a new mandatory health insurance fund MHIF was to become effective in The strategy developed in response was called the "joint systems approach", whereby the MHIF and the oblast health departments would use a common system for information and accounting.

A critically important technical step for the future transition to a universal system was the establishment of a single hospital information system for all patients regardless of their insurance status. Another important decision was made by the management of the MHIF: The payment mechanism was different, however: The payroll tax rate was set at this low level for several reasons: Hence, the health insurance contribution was designed as a complementary revenue source.

The insured population included employees, pensioners and those in receipt of social benefits. Inchildren aged less than 16 were added to the insured category, funded by a direct transfer from the central state budget.

The Single Payer System. While the MHIF made substantial progress in developing its information and payment systems, the previous health financing system co-existed opciones de compra de quintiles it, with opciones de compra de quintiles level of government allocating budgets to its own facilities on the basis of historical norms.

Hence, while the bit of extra money provided considerable relief at the margin for providers and patients particularly in the case of medicines, for which MHIF payments became the main source of fundingthe underlying structural fragmentation problems of the system were not addressed. This began to change inhowever, following a government decision the previous year to eliminate the oblast level of several ministries, including health.

Faced with the possibility that the oblast government administrations would simply distribute budgets to the providers in each region, the Minister of Health advocated instead that the state budget for health in each oblast be administered by the oblast branch of the MHIF. This was agreed, and the Kyrgyz Single Payer System was initiated in in two oblasts.

This reform reached nationwide implementation by and has completely transformed the health financing system. Funding and population coverage arrangements under the Single Payer System are shown in Fig. The package includes formal co-payments for referral care, with the level of co-payment linked to a patient's insurance or exemption status. The insured population is entitled to reduced co-payments and an additional outpatient drug benefit.

The reformed system is an attempt to recapture the universal health care system that existed under the former Soviet Union. The radical changes in the fiscal context meant that major reform of the financing system was needed to address the underlying efficiency problems and move towards both formalization and reduction of the out-of-pocket payment burden.

National pooling of funds. A further reform was introduced in Pooling of funds at the central level allowed the MHIF to initiate the process of equalizing allocations for the state guaranteed benefit package by oblast. The government used incremental funds to increase funding in previously underfunded areas, rather than to redistribute directly from the better-off regions, in order to avoid losing political support from opciones de compra de quintiles better-off regions.

This became possible as funding trends began to reverse with a strong government commitment to increase health expenditures, reflected in a rise from 2. The impact of centralized pooling was immediate. The funding gap between the capital city of Bishkek and other oblasts reduced in all cases except one. In addition, key findings from a household survey analysis are that financial barriers to care have steadily reduced since andand out-of-pocket costs have declined, particularly for the two poorest quintiles.

Equity in both utilization and financing has improved. In addition, the share of patients making informal payments was significantly reduced for all categories of patient expenditures.

The Single Payer System addressed many of the underlying problems in the health system. The pooling of budget funds at oblast level and later at the national level gradually reduced fragmentation in the system and created an enabling environment for restructuring and re-allocation of resources according to needs rather than infrastructure. The break with norm-based budget allocation reduced the persistence of facility managers to hold onto infrastructure opciones de compra de quintiles the introduction of case-based payment at the hospital level shifted the incentives so that providers became interested in increasing productivity and reducing fixed costs.

Changing the payment mechanisms was challenging. Although resource allocation within the health sector across facilities was now based on the number of cases, oblast finance departments continued to set budgets based on historical norms, often interpreting a reduction in infrastructure as a opciones de compra de quintiles in need. Initially, this led to a reduction in the health budget of reforming oblastsrequiring political interventions to overcome the resistance of budget departments to redefine their interpretation of need.

In addition, the much slower pace of overall public finance reform created a conflict between the new provider payment mechanisms and the old-style public reporting processes which remained based on line-items. This overall budgeting and reporting system threatened the efficiency enhancing incentives and limited the extent of the still quite substantial gains from these.

This issue is only now being resolved with a shift in the overall budgeting process for the health sector from an input to an output basis i. Extensive quantitative 12,18,19 and qualitative 20 research shows that the reforms also were largely opciones de compra de quintiles in replacing informal payments with formal co-payments and reducing patient financial burden, particularly for medicines and medical supplies, despite the fact that the total level of public spending on health did not increase very much during the period when the Single Payer System was extended nationwide.

There remains a long way to go, however, opciones de compra de quintiles available public financing still leaves a substantial level of private cost-sharing for the package.

Further improvement in financial protection remains an ongoing challenge for health financing reforms. Factors for successful reform.

Several factors explain why Kyrgyzstan has implemented such far-reaching reforms although its pre-reform health system did not differ significantly from that of other countries in the former Soviet Union. First, the fiscal imperative to reform and squeeze internal resources was great, opciones de compra de quintiles real public expenditures on health reduced by half between and In countries where the fiscal contraction was less severe or where there were realistic opportunities for eventual substantial opciones de compra de quintiles growth driven by raw material exports e.

Kazkakhstan, the Russian Federation and Uzbekistangovernments could afford delaying efficiency enhancing reforms for a longer time. Second, many elements thought to be important for successful reform implementation were in place for much of the ten-year reform period. Despite occasional wavering, there was high-level political attention and support for the chosen path of health financing reform.

There has been opciones de compra de quintiles and continuous leadership in the health sector pushing forward the reform agenda and forging political support.

Extensive capacity building has led to the development of qualified mid-level staff in the Ministry of Health and MHIF ensuring sustainability of the reforms. The institutional features of the MHIF have also been important to make the system work efficiently and in a transparent manner: Finally, development partners have worked in a coordinated manner supporting the government's health sector strategy.

The Kyrgyz reforms provide an excellent example of why health financing policy should not be reduced to a simplistic choice between the Beveridge and Bismarck models.

In a low-income setting where much of the population opciones de compra de quintiles not employed in the formal sector, payroll taxes will not be a major source of funds. However, it is possible to create a universal health financing system by transforming the role of opciones de compra de quintiles funding from directly subsidizing provision to subsidizing the purchase of services on behalf of the entire population. In other words, universality was designed into the system from the beginning rather than hoping that insurance coverage would simply expand over time.

Even in contexts where there are severe limitations on the choice of sources of funds, reforms that reduce fragmentation in pooling, shift from input- to output-based payment methods, specify benefit entitlements more transparently and develop capacity in a purchasing agency can lead to improvements in health system performance.

By approaching health financing policy from a functional perspective, the Kyrgyz health reformers have demonstrated that it is not necessary to choose between Beveridge and Bismarck; well-defined policy can enable their complementary co-existence in opciones de compra de quintiles unified, universal health system. Shaw P, Griffin C. Financing health care in sub-Saharan Africa through user fees and insurance.

The World Bank; The German perspective on the importance of social dialogue in the extension of coverage: Holst J, Brandrup-Lukanow A, eds. Extending social protection in health. Health opciones de compra de quintiles for the formal sector in Africa: When social health insurance goes wrong: Soc Policy Adm ; A descriptive framework for country-level analysis of health care financing arrangements. The revenue decline in the countries of the former Soviet Union.

International Monetary Fund; Kutzin J, Cashin C. European observatory on health opciones de compra de quintiles systems:

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List entries are alphabetical by title and contain the title, abstrsct, language, filesize , and then the filename which is hyperlinked and will open in a new browser window. Most files are PDFs. In addition to the Mexico City-based council, we are also bringing together a group of businesses in Tijuana, Mexico, in a less formalized structure to address HIV in the workplace. The business councils have become an effective mechanism for exchanging information across the business community; encouraging members to adopt policies and leverage resources for HIV programs; and fostering linkages and partnerships among the government, civil society, and private sectors.

Key recommendations for improving policy implementation included ensuring that policies are responsive to the most at-risk populations, strengthening leadership capacity of the multisectoral AIDS councils, and increasing implementers' access to information about available funding sources. The council has 26 member organizations, reaching about , employees. Members have adopted HIV and anti-discrimination workplace policies. As a result, the organizations were able to carry out a successful advocacy campaign to halt a proposed measure that would have criminalized transmission of HIV.

Shortly thereafter, HIV-specific wording was removed from the proposed legislation. As part of this larger effort, the Health Policy Initiative works with policymakers in Central America to identify opportunities for improving regional cooperation as individual governments assume more responsibility for procuring high-quality contraceptives. This Spanish-language brief outlines related policy considerations for collaboration among El Salvador, Guatemala, and Honduras.

Their Role in Latin America and the Caribbean Contraceptive security exists when all individuals are able to choose, obtain, and use high-quality contraceptives when they need them. This report summarizes portions of four case studies about the innovative regional strategies that LAC countries have been implementing since to achieve contraceptive security.

In numerous countries, locally formed contraceptive security committees have been spearheading and coordinating these CS efforts, generally operating at a technical level. The objective of this study was to analyze the experience of six committees and assess their role in working to achieve contraceptive security. According to the results of the analysis, these committees played a key role in making progress toward contraceptive security. Several other LAC countries made significant political and legislative progress without establishing CS committees.

Contraceptive security exists when all persons have access to high-quality contraceptives and condoms whenever they need them. The framework aims to help policymakers and advocates engage the poor throughout the policymaking process and integrate pro-poor strategies into health policies and plans.

The six components of the framework are E - engage the poor, Q - quantify the level of inequalities, U - understand barriers to access, I - integrate equity, T - target resources and efforts to the poor, and Y - yield public-private partnerships for equity.

Additional briefs in this series focus on how stakeholders can use each component to help design policies, programs, and financing mechanisms to better meet the needs of the poor and other underserved groups. This brief is the poster format. Engage and Empower the Poor Poverty is a multidimensional concept that has evolved over time.

In addition to measures of socioeconomic status such as income, assets, and educational attainment , emerging definitions of poverty recognize that poverty also results in isolation, voicelessness, and vulnerability. This brief explores ways to engage the poor throughout the policy process, using illustrative examples from Guatemala, Kenya, Vietnam, and India.

Thus, the second component of the EQUITY Framework involves quantifying the level of inequalities in health service access and health status. Techniques such as quintile analyses and mapping of poverty or most-at-risk populations can help to identify the areas and groups most in need of health services. To illustrate an approach for quantifying inequalities, this brief summarizes a study that examined reproductive and maternal health indicators by relative wealth and place of residence in 16 countries.

Target Resources and Efforts to the Poor Experience has shown that health interventions will not reach the poorest, most at-risk groups without appropriate planning, targeting, and oversight.

Targeting may involve implementing pro-poor financing mechanisms such as vouchers, health insurance or bringing services closer to the poor such as through community-based health workers or mobile health clinics. This brief presents examples from Jharkhand, India, and Guatemala on targeting policies and programs to the poor, indigenous populations, and other underserved groups. Barriers are often rooted in a variety of sources, including policy, resource, operational, and sociocultural issues.

Understanding these diverse issues will enable policymakers and program managers to design policy and strategies that are more responsive to the needs of the poor and other vulnerable groups. This brief explores barriers to family planning and reproductive health services in Guatemala and Kenya. To meet the needs of the poor, countries must make the best use of all available public, private, donor, and NGO resources.

The purpose of the review was to assess the advances and challenges in implementing the NSP and to identify areas to be strengthened to foster achievement of the plan's goals. This brief summarizes the key findings from the assessment. Through dissemination of the findings and dialogue, in-country partners have explored possible solutions to the challenges identified in the assessment.

Contraceptive Security" Spanish The other public provider of services is the social security institute that provides health services to those in the formal employment sector. The private sector comprised of pharmacies, private providers, and non-governmental organizations also plays an important role. As demand for FP services increases, there needs to be a shift in how the public and private sectors respond.

Promoting partnerships between the public and private sectors is a strategy for ensuring that unmet needs for services and contraceptives is satisfied, particularly among vulnerable populations in rural and remote regions. The framework involves a multi-part process: The project's activity in Peru to promote public-private partnerships was carried out from to Most-at-risk populations are also playing a stronger role in HIV advocacy and policy dialogue.

As a result, men who have sex with men, transgenders, and women are gaining greater access to HIV prevention, treatment, and care. Task Order 1 of the USAID Health Policy Initiative conducted a policy review and situational analysis to explore operational barriers to PEP for those who have experienced sexual violence in Mexico and designed materials to increase demand for PEP services and improve their delivery through existing channels. The Health Policy Initiative worked with healthcare providers and local- and national-level decisionmakers to identify barriers to PEP.

Unfortunately, due to political and budgetary limitations imposed by Mexico's response to the H1N1 epidemic, these materials were not piloted or disseminated as originally planned because ARVs for PEP were not available. The methodology and specific project results are presented in complementary documents.

Previous studies in Bolivia have demonstrated that many cultural, economic, and social factors influence women's decision to use contraception or visit facilities for other RH services Camacho et al.

The assessment increased knowledge about how GBV prevents women's full access to services. This assessment draws on both quantitative and qualitative methods. It outlines a workshop consisting of 15 activities that aim to build the capacity of HIV policy facilitators within organizations. The guide can be used to train employees who are assigned to monitor, develop, and implement HIV workplace policies. The guide identifies various obstacles that could impede progress and provides guidance on how to engage management on these issues.

This brief summarizes key findings from the assessment. The purpose of the review was to assess the advances and challenges in implementing the policy and to identify areas to be strengthened to foster achievement of the policy's goals.

The main objective of the Phase 1 process is to create dialogue and knowledge exchange among participants to learn of their reality in the context of gender-based violence. It addresses the role of fostering critical consciousness of power and gender inequality—and links to GBV—from within the community.

This knowledge based on the local context informs the development of a flexible model that guides the participants in the elimination of existing barriers to addressing and preventing GBV. It also facilitates discussion to try to understand how this issue is addressed by members of the community and institutions and local government.

The methodology is developed based on participatory methods used or adapted in Bolivia and facilitates community-based self-diagnosis, design of subsequent research and collection of evidence, and development of the intervention. The main objective is to analyze the implications of the research conducted in Phase 1 and agree on priority actions in each locality to contribute to GBV prevention and response in various settings home, school, community, health services, police, municipal government, indigenous councils.

The process gives priority to the sexual and reproductive health sector and other key sectors identified by the community. The process allows for completion and shared appraisal of the current situation experienced by communities in relation to GBV, providing vital and critical foundations for understanding the context of this reality.

Finally, it provides exercises to build bridges that can lead to future situations free of GBV, proposing critical routes for institutional and political responses. During the past decade, governments and donors have been working together to put in place sustainable mechanisms to ensure continuous supplies of contraceptives. Major progress has been achieved on many fronts, including transitioning from donor to country financing, better matching of public subsidies to those most in need, obtaining lower contraceptive prices, and establishing the institutional capacity for countries to manage their own contraceptive security CS.

This approach, initiated at the national level, has been replicated in various departamentos. Indigenous women's networks have played a key role in decentralizing the approach and monitoring family planning, reproductive health, and maternal health programs in communities.

Guidelines for Latin American and Caribbean Countries This paper presents some case studies of and guidelines for strengthening the policy environment for family planning FP in Latin American countries undergoing decentralization. The intended audiences are policymakers, program planners, and specialists in government and civil society organizations, including nongovernmental organizations working in family planning.

The guidelines draw on literature on the decentralization of health systems in Latin America and on research findings garnered through key informant interviews in Bolivia and Mexico. Guidelines for Latin American and Caribbean Countries. Lessons Learned from Latin America and the Caribbean In upcoming years, countries in the Latin America and Caribbean Region will see a gradual decline in donations and technical assistance toward ensuring contraceptive security CS , which is when people are able to choose, obtain, and use high-quality contraceptives whenever they need them.

In light of this trend, governments throughout the region are faced with ensuring the provision of family planning services, including a continuous supply of contraceptives. Several countries, including Bolivia, the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Paraguay, and Peru, have begun to explore ways to finance and efficiently procure contraceptives for their target populations.

This report analyzes the legal and regulatory framework in each of the nine focus countries that may aff ect future procurement of contraceptive commodities, as well as the current policy environments of fi ve USAID? Additionally, this report presents country specific pricing data for contraceptives, providing a comparative analysis of how diff erent procurement policies affect price as well as the large variation in price found among international suppliers.

Next, the report illustrates lessons learned from all 14 countries to help improve procurement processes, streamline regulations, and prepare for the eventual phaseout of donations and technical assistance. Careful consideration of these lessons, especially experiences from the five graduated countries, can help governments prepare to effi ciently procure their own contraceptives in the long run.

Finally, taking into account analyses presented in this report and the various levels of effi ciency and procurement capacity of each of the nine focus countries, the final section presents a series of recommendations and outlines different options that each county may implement to improve access to contraceptives and realize potentially signifi cant cost-savings. It has created devastating effects on the economy and markets, threatening the security and prosperity of the global society.

For companies operating in regions of high HIV rates, such as Mexico, the consequences on their productivity and profitability will be even greater. Examining Microfinance and Sustainable Livelihood Approaches This literature and program review focused on the current and future role of microfinance and sustainable livelihood strategies in reducing adolescent girls' vulnerability to HIV infection in developing countries, particularly in sub-Saharan Africa.

Part 1 of the review focuses on youth-centered programs to prevent HIV infection among vulnerable female adolescents—including microfinance and sustainable livelihood programs. Part 2 analyzes the relationship between microfinance and HIV prevention in the general population, with a focus on women and the oldest adolescents in the target group. Adapting the traditional microfinance model to meet the needs of this sub-group could prove to benefit not only these adolescents but also the microfinance industry.

It highlights key approaches and activities and provides an extensive list of resources. It contains all the resources, as well as supplemental materials. A companion CD-ROM is available, which contains all the listed resources as well as supplemental materials. Targeting Resources and Efforts to the Poor: It focuses on pro-poor strategies that increased access to family planning for the poor and indigenous populations in Peru.

It provides guidance on how to foster equitable resource allocation. Examples include equity-based allocation formulas and decentralized decisionmaking.

Analysis and Implementation Advocacy in the Avances de Paz Project Gender-based violence GBV is increasingly recognized as both a public health and human rights issue that affects the majority of the world's women. Bolivia has a long history of high prevalence of GBV—particularly intimate partner violence.