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Lessons for Hospital AutonomyThe Government of Vietnam sees hospital
 autonomy policy as important and consistent with current
 development trends in Vietnam. It is based on government
 policies as laid out in government Decree on financial
 autonomy of revenue-generating public service entities; and
 to 2006, it is replaced by decree on professional,
 organizational, human resource management and financial
 autonomy of revenue-generating and state budget-financed
 public service entities. These policies apply to public
 service entities in all sectors, including the health sector
 and hospitals. This policy is an important element of public
 administration reform in Vietnam, helping service entities
 survive and develop under the socialist-oriented market
 mechanism. It aims to help hospitals in fulfilling assigned
 professional tasks by allowing them to restructure their
 organization and staffing. The government has also allowed
 public service entities to mobilize private capital and
 joint ventures to organize activities and services
 responding to social and people's needs. This study
 will show that since the implementation of decrees, a number
 of improvements have been demonstrated within hospitals with
 respect to physical facilities, service provision, medical
 techniques, service quality and staff incomes, thus creating
 stability and satisfaction among hospital workers. But it
 also describes the international evidence that
 implementation of hospital autonomy comes with a risk of
 unintended outcomes driven by powerful financial incentives
 from the market place to increase revenue. These include
 supply induced demand, cost escalation, inappropriate care.
 There are some indications that such risks may be emerging
 in Vietnam as well, although these would need further
 research. Fortunately, there is also international evidence
 about policies that can mitigate such risks, and these are
 also described in this report. This report will inspire
 further studies and encourage policymakers to think about
 continuous improvement of policies.
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The Long March to Universal Coverage : Lessons from ChinaThe march to Universal Health Coverage (UHC) in China is unparalleled. Since the establishment of the State Council Medical Reform team in 2006,4 the basic objective of China's health reforms has been to provide the whole nation with basic medical and health care, while ensuring equal access to, and affordability of, health services. The Chinese government announced the national three-year reform plan in 2009, after which the country has made remarkable progress toward achieving nearly universal health coverage. The recent health reform initiatives under the 12th Five-Year Plan (2011-2015) continue to center on five areas. Building on recent experience, more effort is directed toward a structural change of the health system and building an environment that will facilitate policy implementation. This includes optimizing resource distribution, encouraging hospital competition, strengthening regulation and accountability, and enhancing human resources and information technology. While China has successfully extended the breadth of Health Coverage to the Poor (HCP), its scope (the comprehensiveness of services covered) and depth (the degree of financial risk protection) appear to be insufficient. Hospital admissions have increased significantly; suggesting improved access, up to 50 percent of current admissions may be amenable to more cost-effective outpatient care. Thus, it is critical to look into problems beyond the HCP program design, such as institutional arrangements, intergovernmental transfers, and supply constraints. This case study concludes with a discussion of the impacts of HCP and the needed next steps to advance HCP as an intermediate objective to the country's longer-term goals of equitable access and high quality of services.
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Who pays? Out-of-Pocket Health Spending and Equity Implications in the Middle East and North AfricaEnsuring affordable, effective health care and financial protection against the adverse effects of household out-of-pocket (OOP) health expenditures represents an important policy objective in most countries, yet relatively little evidence exists regarding patterns and implications of household health expenditures in the Middle East and North Africa (MENA) region. This paper examines the scope of out-of-pocket expenditures and their implications on living standards and policy reforms in six MENA countries including Yemen, the West Bank and Gaza, Egypt, Iran, Tunisia, and Lebanon. Results show that OOP payments represent a relatively high share of total national health care financing at 49 percent on average in the MENA region as of 2006. Households pay an average of 6 percent of their total household expenditure on health. Most of this OOP is spent on medications, doctor visits and diagnostic services. Lower-income and rural households generally face greater financial risk; yet this is reversed where private health services are utilized and paid for more frequently by higher-income groups. 7 to 13 percent of households face particularly high OOP payments, or catastrophic expenditures equal to at least 10 percent of household spending. Poverty rates tend to increase by up to 20 percent after health care spending is accounted for. Results are discussed in light of ongoing policy efforts to strengthen social protection for health care.