Working towards Universal Health Coverage in East Asia and the Pacific

Highlights

• Countries in East Asia and the Pacific have committed to providing universal health coverage for their populations – so they can access quality health care when they need it without falling into financial hardship.
• To achieve better health outcomes, the World Bank is supporting countries by implementing projects that incorporate results-based financing based on indicators that incentivize the achievement of agreed health service goals.
• DLIs are increasing access to vaccines, improving nutrition, extending services to remote villages, and combating non-communicable diseases in Cambodia, Lao PDR, Indonesia, Samoa, and Papua New Guinea.

The World Bank is supporting countries across East Asia and the Pacific in their efforts to improve health services so that their citizens can get the health care they need without falling into financial hardship. Results-based financing based on Disbursement linked indicators (DLIs) are proving a valuable tool, helping maintain momentum towards universal health coverage (UHC) in the region.

Essentially, these indicators incentivize achieving agreed milestones by paying out funding only after tangible and verifiable results have been obtained. It’s not a tool for every project or environment, but careful and considered implementation has delivered significant results in Lao PDR, Cambodia, Indonesia, Samoa and Papua New Guinea.

Support for the initiatives discussed below is provided through the World Bank executed Advance UHC Multi-Donor Trust Fund, which includes significant contributions from the Australian Government’s Aid Program in collaboration with GAVI, Global Fund, and the Bill and Melinda Gates Foundation.

Lao PDR

Disbursement linked indicators (DLIs) effectively addressed the problem of inequity in Lao PDR’s immunization efforts by boosting vaccination rates in 50 lagging districts in 2019. A US$4 million grant from the Australian Government was pivotal in lifting immunization rates in the targeted districts by an average of 22% percent for measles-containing vaccine, and 30% for Pentavalent-3 vaccine (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type b) over the 2016–17 baseline.

Two DLIs have also helped drive increases in the number of children receiving integrated health outreach in remote villages. In 2019, almost 90,000 children regularly had their growth monitored and received counselling and more than 1,000 villages are now receiving regular integrated outreach. Subsequently, these indicators have been adopted as part of the Lao PDR’s national health information reporting platform. DLIs and their verification process have considerably improved overall data quality over the years.

Cambodia

DLIs are promoting integrated nutrition and immunization as part of the Cambodia Nutrition Project (CNP). The focus here is improving coordination between resources and systems and linking support for central level or special programs with that of frontline providers.

DLIs are also encouraging cross-agency collaboration. Targets align the timeframes and processes of community-based activities under one ministry with those under local governments governed by another ministry. For instance, three DLIs implemented by the Ministry of Interior (MOI) aim to build capacity at the subnational level, including performance assessment of local government administration. This is linked with a DLI for the National Center for Health Promotion at the Ministry of Health, to ensure community health workers in the same area are properly trained, supervised, and equipped at the same time that this support is provided to local governments.

Indonesia

In 2020-21, the US$750 million Indonesia Emergency Response to COVID-19 Program (co-financed by AIIB, KfW and DFAT) saw the first use of DLIs to combat the pandemic. Headline results include an additional 114,000 + isolation beds, over 11,000 critical care beds, testing capacity growing about 100-fold, and adequate personal protective equipment being distributed to health care facilities. A US$9.9 million grant from the Australian Government is co-financing three DLIs that will provide remote vaccine temperature monitoring devices, build capacity for vaccine delivery, and establish a system to monitor adverse reaction following vaccination.

Under the Indonesia—Supporting Primary Health Care Reform Program (I—SPHERE), the preparation of which was supported by the Advance UHC MDTF, DLIs were also successfully used to improve the quality of primary care delivery, helping community health centers across Indonesia to improve quality, community outreach and managerial performance standards.

Samoa

The first use of DLIs in the Pacific has been in Samoa where the government is addressing noncommunicable diseases (NCDs) through the Health System Strengthening Program.

“The increase in incidence of NCDs has highlighted the need to move away from the business as usual model and focus on accelerating results,” said Take Naseri, Director General of Samoa’s Ministry of Health. “By linking the disbursement of funding to achievement of results, the DLIs have provided us with an incentive to achieve the agreed results.”

The results they seek are to reduce the percentage of high-risk people diagnosed with NCDs at health facilities, increase the number of districts operating a community based NCD screening program, and develop health system capacity through annual plans and implementation review. The program has recently completed its first year of implementation and while verification has yet to be finalized, initial indications are that year 1 targets for four of the six DLIs have been fully achieved, while the other two will have been partially achieved.

Papua New Guinea

Though still early days, DLIs are also being used in Papua New Guinea as part of the US$30 million IMPACT Health Project. The project aims to increase the quality and availability of essential health care services by targeting bottlenecks to frontline health service delivery and strengthening newly established provincial health authorities. Initial targets focus on establishing the foundation for systems which will be scaled up and improved over the project lifetime. Early successes have been the National Department of Health’s endorsement of an integrated facility supervision checklist as a tool to improve quality and spur more consistent supervision, and the endorsement of a framework to measure health sector performance at the provincial level to better inform provincial health authority decision making.

The value of Disbursement Linked Indicators (DLIs)

DLIs are driving results in a variety of contexts across the East Asia and the Pacific. They are helping incentivize and accelerate results, sharpen focus on the best capacity development initiatives, improve monitoring and coordination, and streamline financing for local service delivery. It’s however, important to know their limitations and the most appropriate circumstances for their implementation. The World Bank is committed to systematic evidence-based learning and review mechanisms to further develop this understanding. Reflection, exchange and documentation of lessons learned take place regularly between key stakeholders and project teams. This has been instrumental in identifying bottlenecks and making adjustments over the life of the projects. The insights gained have helped shape a more nuanced approach to the use of DLIs, a valuable tool for progress towards universal health coverage.