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Enhancing Efficiency and Equity : Challenges and Reform Opportunities Facing Health and Pension Systems in the Western BalkansThis collection of papers explores the
 major challenges to the sustainability of health and pension
 system financing in the countries of the Western Balkans -
 Albania, Bosnia and Herzegovina, the Former Yugoslav
 Republic of Macedonia, Montenegro, Serbia, and the province
 of Kosovo. It focuses on how the incentives created by the
 different elements of the financing arrangements affect the
 behavior of providers and individuals, and the resulting
 inefficiencies in revenue collection and expenditure
 containment. The volume commences with an analysis of
 healthcare financing, exploring patterns of healthcare
 expenditure, and examining the key drivers of current
 healthcare expenditure and the most significant barriers to
 revenue generation. Subsequent chapters give special
 attention to provider payment mechanisms and the
 pharmaceutical sector. Equity considerations are highlighted
 in a chapter that explores the protection that is offered
 against the financial impact of health expenditures. With
 respect to the pension sector, the volume provides an
 overview of national pension systems and outlines the main
 challenges to achieving a sustainable balance between
 pension benefits and costs. The analyses of the health and
 pension reform process are placed within the context of the
 labor market challenges in the sub-region, especially as
 they relate to the ability to raise revenue for health and
 pensions through payroll contributions. All chapters
 conclude by identifying some reforms that countries in the
 sub-region could consider in order to enhance the efficiency
 and sustainability of their systems. Data are drawn from
 international databases, country institutions, and household surveys.
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Kosovo : Health Financing Reform StudyThe objective of this report is to present information on the different health financing reform options available to Kosovo, which can help the government to make informed policy decisions about financing reforms. The report focuses on the key insurance functions of revenue collection and management, risk pooling, and purchasing of health care, as well as the supportive regulatory and governance framework for health financing. Kosovo aims to reform health financing by moving toward a health insurance system. To implement the proposed single insurer as described in the health law, a draft law for health insurance was discussed in Parliament in 2004. The draft law envisioned the revenue sources for the future health insurance as follows: (i) 60 percent of Health Insurance Fund (HIF) revenue will be paid by the general budget; (ii) 13.5 percent will come from payroll contributions; (iii) 21 percent will come from direct payments by patients in the form of user fees; and (iv) 6.5 percent will come from patients' co-payments. Three years later, in April 2007, the Kosovo Parliament approved a health insurance law to introduce social health insurance (SHI) financed predominantly through payroll taxes, though it did not specify contribution levels. The revenue potential of such payroll funded insurance was estimated to be modest considering Kosovo's relatively small formal sector and employment rate. The Kosovo health system is predominantly tax funded. Government health spending is about 3 percent of gross domestic product (GDP) and 10 percent of general government expenditures. The ministry of economics and finance (MEF) transfer's health funds from the central budget to hospitals (51 percent), to municipalities in the form of an earmarked health grant for the provision of primary health care (PHC) services (26 percent), and to the ministry of health (MOH) for other services (22 percent) (MEF 2007).
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Expanding Health Coverage for Vulnerable Groups in IndiaIndia's health sector continues to be challenged by overall low levels of public financing, entrenched accountability issues in the public delivery system, and the persistent dominance of out-of-pocket spending. In this context, this case study describes three recent initiatives introduced by the central and state governments in India, aimed at addressing some of these challenges and improving the availability of and access to health services, particularly for the poor and vulnerable groups in the country. This includes two federal schemes introduced by the Government of India-the National Rural Health Mission (NRHM) of the Ministry of Health and Family Welfare and the Rashtriya Swasthya Bima Yojana (RSBY) of the Ministry of Labor and Employment-and the Rajiv Aarogyasri scheme launched by the state government of Andhra Pradesh. The three schemes discussed in this case study were designed and implemented by different agencies almost in parallel, over the same time period, and used different financing and delivery approaches. A discussion of the mechanics and operational features of these programs has been undertaken to unravel the underlying complexities, interactions, and interdependencies of these programs within the country's health system. The remainder of this case study on India's march toward universal health coverage focuses on three recent, prominent programs, and includes a discussion on the institutional structure of these programs and their interactions within the country's health system, their mechanisms for beneficiary targeting and enrolment, the benefits packages covered by them, accompanying innovations in public financial management, and their information environment. Annex one presents an overview of the health system and health financing in India, and annex two discusses the evolutionary context of India's Government sponsored health insurance schemes. The discussion of the mechanics and operational features of these programs has been undertaken to unravel the underlying complexities, interactions, and interdependencies within these programs. The case study also aims to contribute to the ongoing debate within the Indian health sector, with opinions divided between investments in traditional input-based health spending for publicly managed health facilities versus demand-side financing, purchasing of care, and involving private providers and intermediaries in delivering services financed by public money. The case study also aims to share how the lessons learned by one program can be applicable more widely within the Indian health system and beyond