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Assessing Fiscal Space for Health in NepalNepal has seen impressive improvements
 in health outcomes and has done well both in its rate of
 progress and relative to its income level. Infant mortality
 has been declining over the past five decades to 38.6 per
 1,000 live births in 2009. Similarly, maternal mortality has
 decreased to 380 per 100,000 live births in 2008. Life
 expectancy has been steadily increasing to 67 years in 2009.
 The rate of progress is better than those witnessed by
 neighboring countries. But challenges remain in addressing
 inequality, high and increasing out of pocket payments.
 Geographic and income-related inequalities in population
 health outcomes remain large and are increasing. For
 example, not only is the decline in infant mortality not
 uniform, some regions have seen an increase. The policy
 response to these challenges has been to expand free care
 services and pilot protection mechanism against the
 financial risk of ill health. There is growing demand to
 expand the package as well as the coverage of existing free
 essential health care to all Nepalese; to introduce new
 programs such as health insurance, and other similar
 initiatives This note identifies efficiency gains as the
 main potential source of additional fiscal space. The
 analysis presented herein indicates that improvement in
 health system efficiency i.e., getting more value for money
 is by far the most plausible option for realizing additional
 fiscal space for health in Nepal. As the note demonstrates,
 the prospects for additional resources for health from all
 other possible sources from conducive macroeconomic
 conditions, re-prioritization of health, external resources,
 and other health-sector specific sources is limited in
 Nepal. On the other hand, there are many indications of
 systemic inefficiencies in the health system of the country
 and the challenge would be to focus on identifying and
 implementing appropriate interventions to improve the
 situation and reduce waste. The note highlights some
 specific areas, such as those related to provider payments,
 drug procurement mechanisms, and hospital and district grant
 allocations whereby significant improvements in obtaining
 better value for money can be realized.
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Rapid Assessment of the Effect of the Economic Crisis on Health Spending in MongoliaThis rapid assessment examines the
 effect of Mongolia's economic crisis on government
 health budgets and health expenditure, household
 out-of-pocket spending and donor health commitments. This
 study was part of a larger assessment conducted in four
 countries on the effects of the economic crisis on health
 spending. A standardized approach was developed for all
 country case studies and consisted of a desk review of
 internationally-available literature and databases,
 extensive in-country review of data and documents available
 in government and donor offices, and semi-structured
 interviews with government staff, health providers and
 development partners. This assessment in Mongolia reveals a
 substantial reduction in the government health budget: the
 2009 national health budget was significantly lower than the
 previous year's, and then was further reduced by 10
 percent in a subsequent budget amendment. At national level,
 budget cuts were concentrated in investment line items.
 Among recurrent line items, the pharmaceutical budget was
 hardhit, but salaries were largely preserved, and there were
 no retrenchments. Similar patterns were observed at
 sub-national level for hospital budgets, which depend on the
 central allocations, but not for primary care facilities,
 which are funded on a capitation basis. Compared to other
 sectors, the health sector was relatively protected during
 the economic crisis and the share of health in the total
 government budget was higher after the budget amendment than
 before. To protect households from the effects of the
 economic crisis on health spending, the government undertook
 specific policy measures to expand health insurance coverage
 to vulnerable groups. Donor commitments to the health sector
 during the crisis largely tracked previously planned commitments.
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Tajikistan : Review of Public Expenditures on HealthThis policy note is part of the World
 Bank's Programmatic Public Expenditure Review (PER)
 work program for FY2012-2014. The PER consists of a series
 of fiscal policy notes, which aim at providing the
 Government of Tajikistan with recommendations to strengthen
 budgetary processes and analysis. This policy note, the
 second in the series, examines public expenditures on health
 in Tajikistan. After an introductory section, the note
 describes the institutional and administrative structure of
 the health sector. Section 3 presents health outcomes and
 health care utilization indicators. Section 4 describes
 health financing in Tajikistan and presents the main options
 to expand fiscal space for health. Section 5 reviews the
 health financing and organizational reforms implemented in
 Tajikistan. Section 6 provides the main conclusions: 1)
 despite progress, health sector outcomes are mixed in
 Tajikistan and utilization pattern of health services is
 characterized by significant inequalities; 2) public
 spending on health is relatively low and skewed towards
 hospitals rather than outpatient care; 3) the hospital
 sector is characterized by oversupply of beds, avoidable
 inpatient admissions, low occupancy rates, and excessive
 average length of stay; 4) an increase in public health
 expenditures since 2000 was largely driven by the expanding
 wage bill, while other expenditures had been compressed; 5)
 public health expenditures show a regressive incidence, with
 the distribution of inpatient care more pro-rich than
 outpatient care; 6) the large reliance on out-of-pocket
 produces a high incidence of catastrophic spending; 7) a
 number of health financing and organizational reforms have
 been initiated since 2000, but the scope and coverage is
 still limited; and 8) the overall prospect for increasing
 fiscal space for health in Tajikistan are positive, with
 rationalization of both the overall budget and the public
 health delivery system.