1. Healthcare systems in LMICs DR. SONALI KUMARI SHAH JR(2018) SPH AND CM BPKIHS,DHARAN

2. Health system  “A health system comprises all the organizations, institutions, and resources that are devoted to producing health actions whose primary purpose is to improve health (WHO 2000). ”  This includes efforts to influence determinants of health as well as more direct health-improvement activities.  The health system delivers preventive, promotive, curative and rehabilitative interventions through a combination of public health actions and the pyramid of health care facilities that deliver personal health care — by both State and non-State actors.

3.  WHO framework describes health systems in terms of six core components or “building blocks”: (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance

5.  The six building blocks contribute to the strengthening of health systems in different ways.  Some cross-cutting components, such as leadership/governance and health information systems, provide the basis for the overall policy and regulation of all the other health system blocks.  Key input components to the health system include specifically, financing and the health workforce.  A third group, namely medical products and technologies and service delivery, reflects the immediate outputs of the health system, i.e. the availability and distribution of care.

8. Source:WHO, MBHSS, 2010

9.  In the broadest terms, there are four major healthcare models: o the Beveridge model, o the Bismarck model, o national health insurance, and o the out-of-pocket model.  While each model is distinct in and of itself, most countries don't adhere strictly to a single model; rather, most create their own hybrids that involve features of several.

10. The Beveridge model  Developed in 1948, by Sir William Beveridge in the United Kingdom, the Beveridge model is often centralized through the establishment of a national health service.  Essentially, the government acts as the single-payer, removing all competition in the market to keep costs low and standardize benefits.  Funded by taxes, there are no out-of-pocket fees for patients or any cost-sharing. Everyone who is a tax-paying citizen is guaranteed the same access to care, and nobody will ever receive a medical bill.

11.  There is also criticism around potential risk of overutilization and funding during a state of national emergency.  Whether it's a war or a health crisis, a government's ability to provide healthcare could be at risk as spending increases or public revenue decreases. It remains to be seen if this will be the case as a result of the COVID-19 pandemic.  Used by the United Kingdom, Spain, New Zealand, Cuba, Hong Kong, and the Veterans Health Administration in the U.S.

12. The Bismarck model  The Bismarck model was created near the end of the 19th century by Otto von Bismarck as a more decentralized form of healthcare.  Within the Bismarck model, employers and employees are responsible for funding their health insurance system through "sickness funds" created by payroll deductions.  Providers and hospitals are generally private, though insurers are public. In some instances, there is a single insurer (France, Korea) while multiple competing insurers in other countries, like Germany and the Czech Republic.

13.  Unlike the Beveridge model, the Bismarck model doesn't provide universal health coverage. It requires employment for health insurance, so it allocates its resources to those who contribute financially.  The primary criticism of the Bismarck model is how to provide care for those who are unable to work or can't afford contributions, including aging populations and the imbalance between retirees and employees.  Used by Germany, Belgium, Japan, Switzerland, the Netherlands, France, and some employer-based healthcare plans in the U.S.

14. The national health insurance model  The national health insurance model blends different aspects of both the Beveridge model and the Bismarck model.  First, like the Beveridge model, the government acts as the single-payer for medical procedures. However, like the Bismarck model, providers are private.  The national health insurance model is driven by private providers, but the payments come from a government-run insurance program that every citizen pays into.

15.  Essentially, the national health insurance model is universal insurance that doesn't make a profit or deny claims.  The primary criticism of the national health insurance model is the potential for long waiting lists and delays in treatment, which are considered a serious health policy issue.  Used by Canada, Taiwan, and South Korea, and similar to Medicare in the U.S.

16. The out-of-pocket model  The out-of-pocket model is the most common model in less-developed areas and countries where there aren't enough financial resources to create a medical system like the three models above.  In this model, patients must pay for their procedures out of pocket.  The reality is that the wealthy get professional medical care and the poor don't, unless they can somehow come up with enough money to pay for it.  Used by rural areas in India, China, Africa, South America, and uninsured or underinsured populations in the U.S.

17. GNI  GNI is the total amount of money earned by a nation's people and businesses. It is used to measure and track a nation's wealth from year to year. The number includes the nation's gross domestic product plus the income it receives from overseas sources.  GNI is an alternative to gross domestic product (GDP) as a means of measuring and tracking a nation's wealth and is considered a more accurate indicator for some nations.  It calculates income instead of output.

18. World Bank  The World Bank assigns the world’s economies to four income groups— 1) low, 2) lower-middle, 3) upper-middle, 4) and high-income countries.  The classifications are updated each year on July 1 and are based on GNI per capita in current USD of the previous year (i.e. 2019 in this case).

19. The new thresholds (to be compared with GNI per capita in current USD) are as follows

23. Global health spending in transition The health sector continues to expand faster than the economy.  Between 2000 and 2017, global health spending in real terms grew by 3.9% a year while the economy grew 3.0% a year.  Middle income countries are rapidly converging towards higher levels of spending. In those countries, health spending rose 6.3% a year between 2000 and 2017 while the economy rose by 5.9% a year. Health spending in low income countries rose 7.8% a year.

24.  Across low income countries, the average health spending was only US$ 41 a person in 2017, compared with US$ 2,937 in high income countries – a difference of more than 70 times.  High income countries account for about 80% of global spending, but the middle income country share increased from 13% to 19% of global spending between 2000 and 2017.  Public spending represents about 60% of global spending on health and grew at 4.3% a year between 2000 and 2017. This growth has been decelerating in recent years, from 4.9% a year growth in 2000–2010 to 3.4% in 2010–2017.

25.  Total out-of pocket spending more than doubled in low and middle income countries from 2000 to 2017 and increased 46% in high income countries.  Donor funding represents 0.2 % of health spending globally. It continues to be an important source in low income countries at 27% of health spending and 3% in lower middle income countries.

28. South Asia’s economic  South Asia’s economic outlook is grim The region is set to plunge in 2020 into its worst-ever recession as the devastating impacts of COVID-19 on South Asian economies linger on, taking a disproportionate toll on informal workers and pushing millions of South Asians into extreme poverty.  According to the latest South Asia Economic Focus Beaten or Broken? regional growth is expected to contract by 7.7 percent in 2020, after topping 6 percent annually in the past five years. Beaten or Broken?

30. India  India’s economy, the region’s largest, is expected to contract by 9.6 percent in the fiscal year that started in March 2020.  Regional growth is projected to rebound to 4.5 percent in 2021.  Factoring in population growth, however, income-per-capita in the region will remain 6 percent below 2019 estimates, indicating that the expected rebound will not offset the lasting economic damage caused by the pandemic.

31. India  In India, the hospitals and clinics are run by government, charitable trusts and by private organizations.  The public clinics in rural areas are called Primary Health Centers(PHCs).  Public healthcare is free for all and entirely funded through taxes.  Major hospitals are located in district headquarters or major cities.  Apart from the modern system of medicine, traditional and indigenous medicinal systems likeAyurvedic and Unani systems are in practice throughout the country.

32.  The modern system of medicine is regulated by the Medical Council of India, whereas the alternative systems recognised by Government of India are regulated by the Department of AYUSH(an acronym for Ayurveda,Yoga,Unani,Sidha and Homeopathy) under the Ministry of Health, Government of India.  PHCs are non-existent in most places, due to poor pay and scarcity of resources.  Patients generally prefer private health clinics.

33.  Ayushman Bharat Pradhan Mantri Jan Arogya Yojana ( PM-JAY, of the Government of India to provide free access to healthcare for 40% of people in the country.  The program is a centrally sponsored and is jointly funded by both the federal government and the states.  PM-JAY offers service to 50 crore (500 million) people and is the world's largest government sponsored healthcare program.  The program is a poverty alleviation programme as its users are people with low income in India.

34.  These days some of the major corporate hospitals are attracting patients from neighboring countries such as Pakistan, countries in the Middle East and some European countries by providing quality treatment at low cost.PakistanMiddle EastEuropean  In 2005, India spent 5% of GDP on health care, or US$36 per capita. Of that, approximately 19% was government expenditure.

36. Pakistan  TheUnited Nations estimates that in 2003 Pakistan's HIV prevalence rate was 0.1 percent among those 15–49, with an estimated 4,900 deaths from acquired immune deficiency syndrome (AIDS).  AIDS is a major health concern, and both the government and religious community are engaging in efforts to reduce its spread.  In 2003 there were 68 physicians for every 100,000 persons in Pakistan.

37.  According to 2002 government statistics, there were 12,501 health institutions nationwide, including 4,590 dispensaries,906 hospitals with a total of 80,665 hospital beds, and 550 rural health centers with a total of 8,840 beds.  According to the World Health Organisation, Pakistan's total health expenditures amounted to 3.9 percent of gross domestic product (GDP)in 2001, and per capita health expenditures were US$16.  The government provided 24.4 percent of total health expenditures, with the remainder being entirely private, out-of-pocket expenses.

38.  Pakistan has launched the Prime Minister's National Health Insurance Programme (PMNHIP), which aims to provide health insurance to poor families in 23 provinces.  Through the scheme, they will be given health cards covering them for up to Rs50,000 (US$477) of treatment in public or private hospitals, including emergencies, maternity care, post-hospital treatment and even transportation costs. In addition, they will be covered for up to Rs300,000 to cover treatment for seven particularly expensive diseases: diabetes, cardiovascular diseases, cancer, kidney and liver diseases, HIV and Hepatitis complications, burns and road accidents.

39. Sri Lanka  Sri Lanka has a universal health care system that extends free healthcare to all citizens, which has been a national priority.  OPD facilities are readily available in public (general) hospitals situated in major towns and cities, with laboratory and radiology facilities common in most.  But most illnesses can be treated in teaching hospitals in Colombo, Colombo South, Colombo North, Kandy/Peradeniya, Galle (Karapitiya Hospital) and Jaffna.

40.  All doctors and nurses in the government hospitals are qualified and trained, with some of the most experienced staff working at the teaching hospitals.  For emergencies, especially accidents, it is highly recommended to go directly to general hospital accident services as they are equipped with the staff and facilities to handle emergencies.  Despite low levels of health expenditures, Sri Lanka's health indicators are comparable to more developed countries in the region. The public healthcare system also has long waiting lists for specialized care and advanced procedures. As a result, reliance on private care is increased.

41.  Agrahara is a mandatory social health insurance scheme providing coverage mostly for inpatient care for the public sector employees in Sri Lanka.  “Sri Lanka’s health service is one of the best not only in Asia but in the world, WHO Director-General Dr. Tedros Adhanom Ghebreyesus said on 10 th April 2018.  Dr. Ghebreyesus had stated that the reason behind the high quality of Sri Lanka’s health service is because it is freely available. Sri Lanka’s political leadership gives a clear guidance to the Sri Lankan Health Service.”

43. Bhutan  The Ministry of Health has provided universal health care in Bhutan since the 1970s.  Health care infrastructure and services are planned and developed through Five Years Plan (FYP) of the Ministry of Health.  Second democratically appointed Health Minister, Lyonpo Tandin Wangchuk, is the head of the Ministry of Health.  Barring one private health clinic in the capital of Thimphu, there are no private physicians or clinics. There are more than 30 hospitals across Bhutan.

44.  While free universal healthcare guarantees that everyone receives the same standard of treatment, it is also disadvantageous at times as the doctors are overworked, and there is a lack of medicines and specialists that can make treating complicated illnesses, cancer and neurosurgery in Bhutan a problem.  Patients need to be transported to India and Thailand for better medical facilities.  At remote locations of Bhutan, even accessing basic health services is not easy.

45. bhutan

46. Bangladesh  The health care are designated to meet the health needs of the community through the use of available knowledge and resources. The services provided should be comprehensive and community based.

47.  Health care delivery system in Bangladesh based on PHC concept has got various Level of service delivery:Bangladesh  Home and community level.  Union level,  Union sub centre (USC) or Health and family welfare centre; This is the first health facility level.  Thana level, Thana Health Complex (THC): This is the first referral level.  District Hospital: This is the secondary referral level.  National Level: This is the tertiary referral level.

48.  A) Primary level health care is delivered though USC or HFWC with one in each union domiciliary level, integrated health and family planning services through field workers for every 3000–4000 population and 31 bed capacities in hospitals.  B) The secondary level health care is provided through 500 bed capacities in district hospital. Facilities provide specialist services in internal medicine, general surgery, gynecology, paediatrics and obstetrics, eye clinical, pathology, blood transfusion and public health laboratories.pathologyblood transfusion

49.  C) Tertiary Level health care is available at the medical college hospital, public health and medical institutes and other specialist hospitals at the national level where a mass wide range of specialised as well as better laboratory facilities are available. . WHO Bangladesh Bhutan India Nepal Pakistan Srilanka Population (000) 164689 771 1380004 29136 220892 21413 CHE (% of GDP) 5-8% 2.34 3.06 3.54 5.84 3.20 3.76 OOPE (% of CHE) 73.87 13.16 62.67 50.80 56.24 50.65 Physicians per 1000 people 1 per 1000 0.5 0.4 0.8 0.9 1.0 0.9 Hospital Beds per 1000 people 5 per 1000 0.8 1.7 0.5 0.3 0.6 4.2 UHC index 48 62 55 48 45 66

50. Bangladesh Accn to WHO

51. Philippines  In 2000 the Philippines had about 95,000 physicians, or about 1 per 800 people.Philippinesphysicians  In 2001 there were about 1,700 hospitals, of which about 40 percent were government-run and 60 percent private, with a total of about 85,000 beds, or about one bed per 900 people.hospitals  The leading causes of morbidity as of 2002 were diarrhea, bronchitis, pneumonia, influenza, hypertension, tuberculosis, heart disease, malaria, chickenpox, and measles. diarrheabronchitispneumoniainfluenzahypertensiontuberculosisheart diseasemalariachickenpoxmeasles

52.  Cardiovascular diseases account for more than 25 percent of all deaths. Cardiovascular diseases  According to official estimates, 1,965 cases of human immunodeficiency virus (HIV) were reported in 2003, of which 636 had developed acquired immune deficiency syndrome (AIDS). Other estimates state that there may have been as many as 9,400 people living with HIV/AIDS in 2001.human immunodeficiency virusacquired immune deficiency syndrome

53. Myanmmar  The general state of healthcare in Myanmar (also known as Burma ) is poor. healthcareMyanmar  Healthcare in Myanmar is consistently ranked among the lowest in the world.  In 2015, in congruence with a new democratic government, a series of healthcare reforms were enacted.  In 2017, the reformed government spent 5.2% of GDP on healthcare expenditures.  Health indicators have begun to improve as spending continues to increase.

54.  Patients continue to pay the majority of healthcare costs out of pocket.  Although, out of pocket costs were reduced from 85% to 62% from 2014 to 2015. They continue to drop annually.  The global average of healthcare costs paid out of pocket is 32%. Both public and private hospitals are understaffed due to a national shortage of doctors and nurses.  Public hospitals lack many of the basic facilities and equipment. WHO consistently ranks Myanmar among the worst nations in healthcare.

56. Timor-letse  Government expenditure on health was US$150 per person in 2006. There were only two hospitals and 14 village healthcare facilities in 1974. By 1994, there were 11 hospitals and 330 healthcare centres.  Sergio Lobo, a surgeon is the Health Minister. He says that “Many of the health-related issues are outside the competence of the Minister of Health.” Since independence the country has established a medical school, a nursing school, and a midwifery school. There is no MRI scanner in the country.

59.  Health care services in Nepal are provided by both public and private sectors and are generally regarded as failing to meet international standards.international standards  In 2002, government funding for healthcare was approximately US$2.30 per person. Approximately 70% of health expenditure came from out-of- pocket contributions.  Government allocation for health care was approximately 5.8% of the budget in 2009. In 2012, the Nepalese government launched a pilot program for universal health insurance in five districts of the country.

60.  As of 2014, Nepal's total expenditure on health per capita was US$137.  There are 102 Hospitals in Nepal according to the data up to 2011.

61. Ghana  In Ghana, most health care is provided by the government, but hospitals and clinics run by religious groups also play an important role. Some for- profit clinics exist, but they provide less than 2% of health services.Ghana  Health care is very variable through the country. The major urban centres are well served, but rural areas often have no modern health care. Patients in these areas either rely on traditional medicine or travel great distances for care.  In 2005, Ghana spent 6.2% of GDP on health care, or US$30 per capita. Of that, approximately 34% was government expenditure.

62.  Apart from allocations from tax revenue, the Ghanaian health system is financed by direct out-of-pocket (OOP) payments (accounting for nearly half of all health care expenditure) and health insurance (composing of premiums and payroll deductions

63. Zimbabwe  Zimbabwe now has one of the lowest life expectancies on Earth – 44 for men and 43 for women, down from 60 in 1990.  The rapid drop has been ascribed mainly to the HIV/AIDS pandemic.  Infant Mortality Rate has risen from 59 per thousand in the late 1990s to 123 per 1000 by 2004.  The health system has more or less collapsed: By the end of November 2008, three of Zimbabwe's four major hospitals had shut down, along with the Zimbabwe Medical School and the fourth major hospital had two wards and no working.

64.  Due to hyperinflation, those hospitals still open are not able to obtain basic drugs and medicines. hyperinflationmedicines  The ongoing political and economic crisis also contributed to the emigration of the doctors and people with medical knowledge.emigration  In August 2008, large areas of Zimbabwe were struck by the ongoing cholera epidemiccholeraepidemi

65. Algeria  When Algeria gained its independence from France in 1962, there were only around 300 doctors across the whole country and no proper system of healthcare.  Over the next few decades, great progress was made in building up the health sector, with the training of doctors and the creation of many health facilities.  Today, Algeria has an established network of hospitals (including university hospitals), clinics, medical centres and small health units or dispensaries.

66.  While equipment and medicines may not always be the latest available, staffing levels are high and the country has one of the best healthcare systems in Africa.  Access to health care is enhanced by the requirement that doctors and dentists work in public health for at least five years.  The government provides universal healthcare.

69. Most efficient Healthcare systems During COVID Era Source: Bloomberg

70. Thialand  Healthcare in Thailand is overseen by the Ministry of Public Health(MOPH), along with several other non-ministerial government agencies.  Universal Health Coverage is provided through three programs: 1. the civil service welfare system for civil servants and their families, 2. Social Security for private employees, 3. and the universal coverage scheme, introduced in 2002, which is available to all other Thai nationals.  According to the World Bank, under Thailand’s health schemes, 99.5 percent of the population have health protection coverage.World Bank

71.  As of 2019, Thailand's population of 68 million is served by 927 government hospitals and 363 private hospitals with 9,768 government health centres plus 25,615 private clinics.

72. FINANCIAL PROTECTION  FINANCIAL PROTECTION Financial protection is measured through two indicators: (1) impoverishment, and (2) catastrophic health expenditure.  Impoverishment: 0% people* are being pushed into poverty (at $1.90 level) because of out-of-pocket health spending.  Catastrophic expenditure on health: 2.2% of people spent more than 10% of their household's total expenditure on health care

73.  The system, known as the 3Ms, comprises the following programs: 1. MediShield Life: a universal basic health care insurance, is mandatory for citizens and permanent residents and provides lifelong protection against large hospital bills and select costly outpatient treatments. 2. MediSave: a national medical savings scheme, helps cover out-of- pocket payments. Personal and employer salary contributions (8%–10.5%, depending on age) to MediSave accounts are mandatory for all working citizens and permanent residents.

74. 3. MediFund: is the government’s safety net for needy Singaporeans who cannot cover their out-of-pocket expenses, even with MediSave.

76. Singapore  Singapore has achieved universal health coverage through a mixed financing system.  The country’s public statutory insurance system, MediShield Life, covers large bills arising from hospital care and certain outpatient treatments.  Singapore’s health care financing system is underpinned by the belief that all stakeholders share responsibility for attaining sustainable universal health coverage. Singapore has a multipayer health care financing framework, where a single treatment episode might be covered by multiple schemes and payers, often overlapping.

77. References  Sherry Glied, Peter C Smith. “The Oxford Handbook of Health Economics.”  https://blogs.worldbank.org/opendata/new-world-bank-country-classifications- income-level-2020-2021 https://blogs.worldbank.org/opendata/new-world-bank-country-classifications- income-level-2020-2021  https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world- bank-country-and-lending-groups https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world- bank-country-and-lending-groups  https://www.investopedia.com/terms/g/gross-national-income-gni.asp https://www.investopedia.com/terms/g/gross-national-income-gni.asp  https://www.verawholehealth.com/blog/ https://www.verawholehealth.com/blog/  https://www.who.int/southeastasia/health-topics/health-data-and-health- information-systems https://www.who.int/southeastasia/health-topics/health-data-and-health- information-systems  https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

78.  https://www.bloomberg.com/news/articles/2020-12-18/asia-trounces-u-s- in-health-efficiency-index-amid-pandemic https://www.bloomberg.com/news/articles/2020-12-18/asia-trounces-u-s- in-health-efficiency-index-amid-pandemic  https://www.intechopen.com/books/healthcare-access-regional- overviews/making-universal-health-coverage-effective-in-low-and-middle- income-countries-a-blueprint-for-health https://www.intechopen.com/books/healthcare-access-regional- overviews/making-universal-health-coverage-effective-in-low-and-middle- income-countries-a-blueprint-for-health  https://www.who.int/news/item/16-09-2020-launch-of-the-2020-global- action-plan-for-healthy-lives-and-well-being-for-all-progress-report https://www.who.int/news/item/16-09-2020-launch-of-the-2020-global- action-plan-for-healthy-lives-and-well-being-for-all-progress-report  https://equityhealthj.biomedcentral.com/articles/10.1186/1475-9276-10-26 https://equityhealthj.biomedcentral.com/articles/10.1186/1475-9276-10-26  https://srilanka.factcrescendo.com/english/fact-check-statement-made- by-who-dg-shared-out-of-context/