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Strengthening health financing systems in the Eastern Mediterranean Region towards universal health coverage: health financing atlas 2018

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Health financing atlas 2018

Strengthening health financing systems in the Eastern Mediterranean Region towards universal health coverage

Health financing atlas 2018

Strengthening health financing systems in the Eastern Mediterranean Region towards universal health coverage

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WHO Library Cataloguing in Publication Data

Names: World Health Organization. Regional Office for the Eastern Mediterranean

Title: Strengthening health financing systems in the Eastern Mediterranean Region towards universal health coverage: health

financing atlas 2018 / World Health Organization. Regional Office for the Eastern Mediterranean

Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2019

Identifier: ISBN: 978-92-9274-495-3 (pbk.) ISBN: 978-92-9274-496-0 (online)

Subjects: Universal Health Insurance - economics | Healthcare Financing | Health Policy | Eastern Mediterranean Region

Classification: NLM W 125

This publication was originally published under ISBN: 978-92-9022-256-9, 978-92-9022-257-6

Contents

Foreword ............................................................................................................................................................................................................5

Acknowledgements ....................................................................................................................................................................................6

Key messages ................................................................................................................................................................................................7

Eastern Mediterranean Region health expenditure dashboard .....................................................................................8

Introduction .....................................................................................................................................................................................................9

Chapter 1: Overview of health financing in the Eastern Mediterranean Region .................................................................. 10

Chapter 2: Analytical framework ............................................................................................................................................................ 15

Chapter 3: Health financing systems: country profiles ..................................................................................................................17

1. Afghanistan ........................................................................................................................................................................................... 18

2. Bahrain ................................................................................................................................................................................................... 22

3. Djibouti ................................................................................................................................................................................................... 26

4. Egypt .......................................................................................................................................................................................................30

5. Islamic Republic of Iran ..................................................................................................................................................................... 34

6. Iraq ...........................................................................................................................................................................................................38

7. Jordan ..................................................................................................................................................................................................... 42

8. Kuwait .....................................................................................................................................................................................................46

9. Lebanon .................................................................................................................................................................................................50

10. Libya ........................................................................................................................................................................................................56

11. Morocco ..................................................................................................................................................................................................60

12. Occupied Palestinian territory .......................................................................................................................................................64

13. Oman .......................................................................................................................................................................................................68

14. Pakistan ................................................................................................................................................................................................. 72

15. Qatar ....................................................................................................................................................................................................... 78

16. Saudi Arabia ......................................................................................................................................................................................... 82

17. Somalia ...................................................................................................................................................................................................86

18. Sudan ......................................................................................................................................................................................................88

19. Syrian Arab Republic .........................................................................................................................................................................94

20. Tunisia ....................................................................................................................................................................................................98

21. United Arab Emirates ......................................................................................................................................................................102

22. Yemen ................................................................................................................................................................................................... 106

Chapter 4: Conclusion ...............................................................................................................................................................................110

Foreword

I feel particularly privileged to have started my term as WHO Regional Director for the Eastern Mediterranean in 2018. It is a very special year for the Organization, marking both the 70th anniversary of WHO and the 40th anniversary of the Alma-Ata Declaration. Seventy years ago, the world realized that there was a need for an international custodian of people’s health, and 30 years later global policy-makers joined forces once again to define the most cost-effective approach for achieving health for all – resilient health systems based on the principles of primary health care.

In 2015, world leaders made another audacious commitment by adopting the Sustainable Development Goals, including universal health coverage as one of the targets as a means to promote health and well-being and ensure that no one is left behind.

In its Thirteenth General Programme of Work, WHO identified universal health coverage as a main focus of its work with Member States and set a target of 1 billion more people benefiting from universal health coverage by 2023. Accordingly, universal health coverage was identified as the top priority for all health system endeavours in the Roadmap of WHO’s work for the Eastern Mediterranean Region 2017–2021, and a technical paper presented at the 65th session of the WHO Regional Committee for the Eastern Mediterranean provided an estimate of the regional contribution to this global target.

The Regional Office for the Eastern Mediterranean has developed the Framework for action on advancing universal health coverage in the Eastern Mediterranean Region. The Framework provides a set of key actions for countries and their development partners to achieve progress across all three dimensions of universal health coverage: service coverage, population coverage and financial protection. I was very pleased to witness the signing of the UHC2030 International Health Partnership Global Compact and the endorsement of the Salalah Declaration on Universal Health Coverage 2018 by countries of the Region at a ministerial meeting on “The road to universal health coverage in the Eastern Mediterranean Region” in Oman in September 2018. The Declaration calls on heads of state, governments and policy-makers to progress towards universal health coverage by enhancing access to promotive, preventive, curative, rehabilitative and palliative health services, and providing adequate financial protection for all of these services.

Health financing plays an essential role in ensuring progress towards universal health coverage. The Eastern Mediterranean Region health financing atlas 2018 presents an analysis of health financing systems in the Region in order that countries can learn from the experiences of others in reforming and transforming their health financing systems to enhance performance. I hope that this initiative contributes to the efforts exerted by all Member States and their development partners in the Region to reform their health financing systems to achieve the goal of universal health coverage.

Dr Ahmed Al-Mandhari WHO Regional Director for the Eastern Mediterranean

Acknowledgements

This report was produced by the Health Economics and Financing Programme in the Department of Health System Development at the WHO Regional Office for the Eastern Mediterranean. The authors of the report are Awad Mataria (WHO Regional Office for the Eastern Mediterranean), Callum Brindley (WHO headquarters), and Nevine Elnahass (WHO Regional Office for the Eastern Mediterranean).

We are grateful for the contributions of numerous individuals for their support in making this report possible and improving the quality of information used in the analysis. We wish in particular to thank officials at the ministries of health of all 22 countries of the Eastern Mediterranean Region for their strong support.

Special thanks are due to Mahmoud Farag and Ilker Dastan (WHO Regional Office for the Eastern Mediterranean) for their substantial technical contribution to the report.

We would also like to acknowledge the technical input of the following individuals from WHO headquarters: Hélène Barroy, Elina Dale, Justine Hsu, Matthew Jowett, Inke Mathauer, and Ke Xu.

We also gratefully acknowledge the contribution of Ala Alwan (University of Washington), Eduardo Banzon (Asian Development Bank), Sameen Siddiqi (Aga Khan University), Ahmed Al-Mandhari (WHO Regional Director for the Eastern Mediterranean), Zafar Mirza (WHO Regional Office for the Eastern Mediterranean), and Agnes Soucat (WHO headquarters) in the preparation of this report.

We would like to thank the Department for International Development of the United Kingdom, the European Commission, the Government of Japan, the Government of France, and the Grand Duchy of Luxembourg for their funding support for WHO’s health financing work, which has played a critical role in enabling us to undertake several of the country assessments that were used in the analysis.

Key messages

Investment in health is insufficient compared with global trends.

Public spending on health is low despite sufficient fiscal space because it is not a high enough priority.

The population is not fully covered by equitable and efficient prepayment arrangements.

Low public spending on health and a lack of financial protection are leading to high out-of-pocket health payments.

High out-of-pocket health payments are causing a high degree of financial hardship and significant impoverishment.

Eastern Mediterranean Region health expenditure dashboard

12 120

562

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653 116Population (000s)

Average current health expenditure as % of GDP

Average current health expenditure per capita (US$)

Average GDP per capita (US$)

Public/compulsory health insurance (domestic general government health expenditure as % of current health expenditure)

Voluntary health insurance (voluntary health insurance as % of current health expenditure]

Aid/external resources (external resources as % of current health expenditure)

Out-of-pocket health payments (out-of-pocket health payments as % of current health expenditure)

Other (Other as % of current health expenditure)

0 20 40 60 80 100

2000

2005

2010

2015

2000 2005 2010 2015

100

200

300

400

500

600

C ur re nt

he al th

ex p en

di tu re

p er

ca p ita

(U S$

)

C ur re nt

he al th

ex p en

di tu re

as %

of G D P

Pakistan 2.7%

Qatar 3.2%

Iraq 3.4%

United Arab Emirates 3.5%

Oman 3.8%Kuwait

4.0%

Egypt 4.2%

Djibouti 4.4%

Bahrain 5.2%

Morocco 5.5%

Saudi Arabia 5.8%

Yemen 6.0%

Jordan 6.3%

Sudan 6.3%

Tunis ia 6.7%

Lebanon 7.4%

Islamic Republic of Iran 7.6%

Afghanistan 10.3%

High income Upper -middle income Lower-middle income Low income

Tunis ia 13.6%

Sudan 18.1%

Pakistan 3.7%Morocco

7.7%

Egypt 4.2%

Djibouti 4.1%

Lebanon 14.3%

Jordan 12.4%

Islamic Republic of Iran 22.6%

Saudi Arabia 10.1%

Qatar 6.6%

Oman 6.7%

Kuwait 6.2%

Bahrain 9.5%

United Arab Emirates 8.0%

High income

Upper -middle income

Lower-middle income

Low income

2000 2002 2004 2006 2008 2010 2012 2014

Public expenditure on health from domestic sources as % of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure)

Public expenditure on health from domestic sources as % of GDP (domestic general government health expenditure as % of GDP)

Current health expenditure as a percentage of GDP, by country, 2015

Structure of current health expenditure by financing source, 2000–2015

Current health expenditure per capita and as a percentage of GDP, 2000–2015

Selected macroeconomic, demographic and health expenditure indicators, 2015

Public expenditure on health from domestic sources as a percentage of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure), by country, 2015

Public expenditure on health from domestic sources as a percentage of total public expenditure and as a percentage of GDP

Note: regional averages are unweighted.

Source: Eastern Mediterranean regional health expenditure dashboard. Annex to: Xu K, Soucat A, Kutzin J, et al. New perspectives on global health spending for universal health coverage. Geneva: World Health Organization; 2018 (WHO/HIS/HGF/HFWorkingPaper/18.2). Licence: CC BY-NC-SA 3.0 IG0 (http://www.who.int/health_financing/topics/ resource-tracking/new-perspectives/en/, accessed 9 September 2018).

Introduction

More than 150 world leaders adopted the United Nations 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs) in September 2015.1 For health, this means action on 13 interrelated targets to achieve SDG 3: “Ensure healthy lives and promote well-being for all at all ages”, and in particular, the achievement of SDG Target 3.8: “Achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”.2 Although formulated as one target among 12 others, universal health coverage has been identified as WHO’s top priority, with all roads leading towards its achievement.3

As defined in the World Health Report 2010,4 universal health coverage has three dimensions: population coverage, service coverage and financial protection. Countries have been working to strengthen their health systems to progress towards universal health coverage by implementing reforms that contribute to three ultimate universal health coverage goals: reducing the gap between utilization and need; improving quality; and enhancing financial protection.5 All health system components, that is, governance, service delivery, financing, health workforce, medicines and technologies, and information, are closely interrelated in contributing to the fulfillment of the above universal health coverage goals.

In particular, health financing systems have proved to be essential in ensuring effective progress towards universal health coverage, as they impact three intermediate universal health coverage objectives, namely, efficiency, equity and transparency, and thereby ultimately contribute to the achievement of the three elements of universal health coverage cited in SDG Target 3.8.

Health financing systems need to be designed to:

(a) raise sufficient and sustainable financial resources for health, which are equitably, effectively and sustainably mobilized;

(b) pool and manage collected financial resources to guarantee equity in financing and utilization with adequate financial protection for all; and

(c) use financial resources to provide the right incentives for providers and users alike to facilitate efficiency and enhance financial sustainability.

These objectives are facilitated by three health financing functions: revenue raising; pooling; and purchasing. In addition, special attention is given to benefit design – defining what to deliver under universal health coverage and subsequently identifying the resources needed, their management arrangements and utilization modalities, have been proposed as an effective approach to expand universal health coverage as part of the “progressive universalism” approach.6

The health financing atlas 2018 presents an analysis of the health financing systems in the 22 countries of WHO’s Eastern Mediterranean Region. Chapter 1 provides an overall summary of the health financing situation in the Region; Chapter 2 describes the analytical approach used to conduct the country-specific analysis based on nine elements; Chapter 3 describes the Region’s health financing systems country by country; and Chapter 4 concludes with general observations on the current situation and ways forward to improve the performance of health financing systems in the Region in the pursuit of universal health coverage.

1 Resolution A/RES70/21. Transforming our world: the 2030 Agenda for Sustainable Development. Agenda items 15 and 116. 2 Mirza Z. Sustainable Development Agenda 2030 thrives on health. Eastern Mediterranean Health Journal. 2017;22(10):711–712. 3 Ghebreyesus TA. All roads lead to universal health coverage. The Lancet. 2017;5(9): e839–e840. 4 The world health report. Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010 (http://www.who.int/whr/2010/en/, accessed 12 July 2018). 5 Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization. 2013;91:602–611. 6 Jamison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Binagwaho A et al. (2013). Global health 2035: a world converging within a generation. The Lancet. 2013;382(9908):1898–1955.

Overview of health financing in the Eastern Mediterranean Region

Chapter 1

The WHO Eastern Mediterranean Region consists of 21 Member States plus occupied Palestinian territory. It has a population of more than 653 million living in countries at various socioeconomic levels. Health system performance and population health outcomes vary considerably between countries of the Region. Inequities in health, acute and chronic emergencies, rising exposure to health risks, increasing health care costs and low levels of access to quality health care represent the main challenges facing health systems and people’s health in the Region.

The Region is a low investor in health. In 2015, current health expenditure in the Region exceeded US$ 145 billion – barely 2% of global current health spending for almost 9% of the world’s population. Average per capita current health expenditure in 2015 reached US$ 562,7 with huge disparities between and within countries. Current health expenditure as a share of gross domestic product (GDP) was 5.35% in 2015, almost half that observed globally (close to 10%). Fig. 1 describes the evolution of per capita current health expenditure in the Region from 2000 to 2015 – in absolute amounts and as a percentage of GDP.

The level of current health expenditure varies considerably between countries; for example, Pakistan, home to almost 30% of the population of the Region, spent only US$ 38 per person on health in 2015, while Qatar, a country of 2.4 million people, spent more than US$ 2000 per person on health in the same year. As a percentage of GDP, Afghanistan spent 10.3% of its GDP as current health expenditure in 2015, while Pakistan spent only 2.7%; both are low-income countries. Fig. 2 shows current health expenditure as a percentage of GDP in 18 countries of the Region for which this information is available.

12 120

562

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653 116Population (000s)

Average current health expenditure as % of GDP

Average current health expenditure per capita (US$)

Average GDP per capita (US$)

Public/compulsory health insurance (domestic general government health expenditure as % of current health expenditure)

Voluntary health insurance (voluntary health insurance as % of current health expenditure]

Aid/external resources (external resources as % of current health expenditure)

Out-of-pocket health payments (out-of-pocket health payments as % of current health expenditure)

Other (Other as % of current health expenditure)

0 20 40 60 80 100

2000

2005

2010

2015

2000 2005 2010 2015

100

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400

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C ur re nt

he al th

ex p en

di tu re

p er

ca p ita

(U S$

)

C ur re nt

he al th

ex p en

di tu re

as %

of G D P

Pakistan 2.7%

Qatar 3.2%

Iraq 3.4%

United Arab Emirates 3.5%

Oman 3.8%Kuwait

4.0%

Egypt 4.2%

Djibouti 4.4%

Bahrain 5.2%

Morocco 5.5%

Saudi Arabia 5.8%

Yemen 6.0%

Jordan 6.3%

Sudan 6.3%

Tunis ia 6.7%

Lebanon 7.4%

Islamic Republic of Iran 7.6%

Afghanistan 10.3%

High income Upper -middle income Lower-middle income Low income

Tunis ia 13.6%

Sudan 18.1%

Pakistan 3.7%Morocco

7.7%

Egypt 4.2%

Djibouti 4.1%

Lebanon 14.3%

Jordan 12.4%

Islamic Republic of Iran 22.6%

Saudi Arabia 10.1%

Qatar 6.6%

Oman 6.7%

Kuwait 6.2%

Bahrain 9.5%

United Arab Emirates 8.0%

High income

Upper -middle income

Lower-middle income

Low income

2000 2002 2004 2006 2008 2010 2012 2014

Public expenditure on health from domestic sources as % of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure)

Public expenditure on health from domestic sources as % of GDP (domestic general government health expenditure as % of GDP)

Current health expenditure as a percentage of GDP, by country, 2015

Structure of current health expenditure by financing source, 2000–2015

Current health expenditure per capita and as a percentage of GDP, 2000–2015

Selected macroeconomic, demographic and health expenditure indicators, 2015

Public expenditure on health from domestic sources as a percentage of total public expenditure and as a percentage of GDP

Fig. 1. Current health expenditure per capita and as a percentage of GDP, 2000–2015

7 Note: all regional averages are unweighted.

Source: Eastern Mediterranean regional health expenditure dashboard. Annex to: Xu K, Soucat A, Kutzin J, et al. New perspectives on global health spending for universal health coverage. Geneva: World Health Organization; 2018 (WHO/HIS/HGF/HFWorkingPaper/18.2). Licence: CC BY-NC-SA 3.0 IG0 (http://www.who.int/health_ financing/topics/resource-tracking/new-perspectives/en/, accessed 9 September 2018).

12 120

562

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653 116Population (000s)

Average current health expenditure as % of GDP

Average current health expenditure per capita (US$)

Average GDP per capita (US$)

Public/compulsory health insurance (domestic general government health expenditure as % of current health expenditure)

Voluntary health insurance (voluntary health insurance as % of current health expenditure]

Aid/external resources (external resources as % of current health expenditure)

Out-of-pocket health payments (out-of-pocket health payments as % of current health expenditure)

Other (Other as % of current health expenditure)

0 20 40 60 80 100

2000

2005

2010

2015

2000 2005 2010 2015

100

200

300

400

500

600

C ur re nt

he al th

ex p en

di tu re

p er

ca p ita

(U S$

)

C ur re nt

he al th

ex p en

di tu re

as %

of G D P

Pakistan 2.7%

Qatar 3.2%

Iraq 3.4%

United Arab Emirates 3.5%

Oman 3.8%Kuwait

4.0%

Egypt 4.2%

Djibouti 4.4%

Bahrain 5.2%

Morocco 5.5%

Saudi Arabia 5.8%

Yemen 6.0%

Jordan 6.3%

Sudan 6.3%

Tunis ia 6.7%

Lebanon 7.4%

Islamic Republic of Iran 7.6%

Afghanistan 10.3%

High income Upper -middle income Lower-middle income Low income

Tunis ia 13.6%

Sudan 18.1%

Pakistan 3.7%Morocco

7.7%

Egypt 4.2%

Djibouti 4.1%

Lebanon 14.3%

Jordan 12.4%

Islamic Republic of Iran 22.6%

Saudi Arabia 10.1%

Qatar 6.6%

Oman 6.7%

Kuwait 6.2%

Bahrain 9.5%

United Arab Emirates 8.0%

High income

Upper -middle income

Lower-middle income

Low income

2000 2002 2004 2006 2008 2010 2012 2014

Public expenditure on health from domestic sources as % of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure)

Public expenditure on health from domestic sources as % of GDP (domestic general government health expenditure as % of GDP)

Current health expenditure as a percentage of GDP, by country, 2015

Structure of current health expenditure by financing source, 2000–2015

Current health expenditure per capita and as a percentage of GDP, 2000–2015

Selected macroeconomic, demographic and health expenditure indicators, 2015

Public expenditure on health from domestic sources as a percentage of total public expenditure and as a percentage of GDP

12 120

562

5 .35

653 116Population (000s)

Average current health expenditure as % of GDP

Average current health expenditure per capita (US$)

Average GDP per capita (US$)

Public/compulsory health insurance (domestic general government health expenditure as % of current health expenditure)

Voluntary health insurance (voluntary health insurance as % of current health expenditure]

Aid/external resources (external resources as % of current health expenditure)

Out-of-pocket health payments (out-of-pocket health payments as % of current health expenditure)

Other (Other as % of current health expenditure)

0 20 40 60 80 100

2000

2005

2010

2015

2000 2005 2010 2015

100

200

300

400

500

600

C ur re nt

he al th

ex p en

di tu re

p er

ca p ita

(U S$

)

C ur re nt

he al th

ex p en

di tu re

as %

of G D P

Pakistan 2.7%

Qatar 3.2%

Iraq 3.4%

United Arab Emirates 3.5%

Oman 3.8%Kuwait

4.0%

Egypt 4.2%

Djibouti 4.4%

Bahrain 5.2%

Morocco 5.5%

Saudi Arabia 5.8%

Yemen 6.0%

Jordan 6.3%

Sudan 6.3%

Tunis ia 6.7%

Lebanon 7.4%

Islamic Republic of Iran 7.6%

Afghanistan 10.3%

High income Upper -middle income Lower-middle income Low income

Tunis ia 13.6%

Sudan 18.1%

Pakistan 3.7%Morocco

7.7%

Egypt 4.2%

Djibouti 4.1%

Lebanon 14.3%

Jordan 12.4%

Islamic Republic of Iran 22.6%

Saudi Arabia 10.1%

Qatar 6.6%

Oman 6.7%

Kuwait 6.2%

Bahrain 9.5%

United Arab Emirates 8.0%

High income

Upper -middle income

Lower-middle income

Low income

2000 2002 2004 2006 2008 2010 2012 2014

Public expenditure on health from domestic sources as % of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure)

Public expenditure on health from domestic sources as % of GDP (domestic general government health expenditure as % of GDP)

Current health expenditure as a percentage of GDP, by country, 2015

Structure of current health expenditure by financing source, 2000–2015

Current health expenditure per capita and as a percentage of GDP, 2000–2015

Selected macroeconomic, demographic and health expenditure indicators, 2015

Public expenditure on health from domestic sources as a percentage of total public expenditure and as a percentage of GDP

Source: Eastern Mediterranean regional health expenditure dashboard. Annex to: Xu K, Soucat A, Kutzin J, et al. New perspectives on global health spending for universal health coverage. Geneva: World Health Organization; 2018 (WHO/HIS/ HGF/HFWorkingPaper/18.2). Licence: CC BY-NC-SA 3.0 IG0 (http://www.who.int/health_financing/topics/resource-tracking/ new-perspectives/en/, accessed 9 September 2018).

The Region exhibits low public spending on health. Evidence from global best practices demonstrates that public spending is a prerequisite for progress to be made towards universal health coverage. Fig. 3 summarizes the structure of current health expenditure in the Region by financing source. It demonstrates consistently low public spending on health as a share of current health expenditure, which oscillated at around 50% between 2000 and 2015. In some low- and middle-income countries, the share of public spending in current health expenditure is as low as 20%. Public spending on health in the Region constituted only 2.5% of GDP in 2015, compared to a global average of 3.5%, as shown in Fig. 4.

Fig. 2. Current health expenditure as a percentage of GDP, by country, 2015

Fig. 3. Structure of current health expenditure by financing source, 2000–2015

Source: Eastern Mediterranean regional health expenditure dashboard. Annex to: Xu K, Soucat A, Kutzin J, et al. New perspectives on global health spending for universal health coverage. Geneva: World Health Organization; 2018 (WHO/HIS/HGF/HFWorkingPaper/18.2). Licence: CC BY-NC-SA 3.0 IG0 (http://www.who.int/health_ financing/topics/resource-tracking/new-perspectives/en/, accessed 9 September 2018).

Fig. 4. Share of public spending on health as a percentage of GDP, 2015

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PublicSpending on Health in EMR Year: 2015

Abbreviat ions: Domest ic government health expenditure (GGHE-D) . Gross domest ic product (GDP) . Note: Expenditure excludes capital investments. Macroeconomicdata such as GDP and GGE taken from internat ional sources including IMF andWorld Bank. Averages are unweighted. Source: WHOGlobal Health Expenditure Database. For more informat ion visit ht tps://bit .ly/2sdLJDW or contact nha@who.int

Global average

Eastern Mediterranean Region average

Abbreviations: GGHE-D = domestic general government health expenditure. GDP = gross domestic product. Note: Expenditure excludes capital investments. Macroeconomic data such as GDP and GGE are taken from international sources including the International Monetary Fund and the World Bank. Source: WHO global health expenditure database. For more information visit https://bit.ly/2sdLJDW or contact nha@who.int

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30%

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60%

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Eastern Mediterranean Region average

Fiscal Space in EMR Year: 2015

Abbreviat ions: General government expenditure (GGE) . Gross domest icproduct (GDP) . Note: Expenditure excludes capital investments. Macroeconomicdata such as GDP and GGE taken from internat ional sources including IMF andWorld Bank. Averages are unweighted. Source: WHOGlobal Health Expenditure Database. For more informat ion visit ht tps://bit .ly/2sdLJDW or contact nha@who.int

Abbreviations: GGE = general government expenditure. GDP = gross domestic product. Note: Expenditure excludes capital investments. Macroeconomic data such as GDP and GGE are taken from international sources including the International Monetary Fund and the World Bank. Source: WHO global health expenditure database. For more information visit https://bit.ly/2sdLJDW or contact nha@who.int

Low public spending on health is primarily due to the low priority given to the health sector. Available information shows that public spending on health in the Region as a share of total public spending is on average one percentage point lower (9%) than the global average (10%) (Fig. 6), with wide discrepancies between countries of different income levels. Fig. 7 shows the low level of public investment in health in all low-income countries as well as several lower-middle income countries. The picture related to this indicator in high-income countries is mixed due to the significantly high GDP and general government expenditure levels in some of these countries.

Fig. 5. Share of general government expenditure as a percentage of GDP (“fiscal space”), 2015

Low public spending on health, despite high fiscal space. Public spending on health in the Region is low despite the general availability of public resources, as demonstrated by the level of fiscal space in the Region. Fig. 5 shows how the regional average fiscal space was equivalent to the global average of 35% in 2015, with a large number of countries even having a much higher fiscal space than the global average. Nevertheless, in some countries, especially those affected by acute and chronic conflict, the level of fiscal space was extraordinarily low – 2% in Somalia and 16% in the Syrian Arab Republic.

Abbreviations: GGHE-D = domestic general government health expenditure.GGE = general government expenditure. Note: Expenditure excludes capital investments. Macroeconomic data such as GDP and GGE are taken from international sources including the International Monetary Fund and the World Bank. Source: WHO global health expenditure database. For more information visit https://bit.ly/2sdLJDW or contact nha@who.int

Fig. 6. Share of public spending on health as a percentage of total public spending (health prioritization), 2015

Low public spending on health has resulted in a high share of out-of-pocket payment in total current health expenditure in the Region. This low public spending on health has been observed between 2000 and 2015, with the regional average varying between 2% and 3% of GDP and between 6.5 and 8.5% of total public spending (Fig. 8). The share of out-of-pocket payment in the Region oscillated at around 40% of total current health expenditure between 2000 and 2015, compared to a global average of 32% in 2015 (Fig. 9).

Fig. 7. Public expenditure on health from domestic sources as a percentage of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure), by country, 2015

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10%

12%

14%

16%

18%

20%

22% G G H E -D

% G G E

Health Prior it izat ion in EMR Year: 2015

Abbreviat ions: Domest ic government health expenditure (GGHE-D) . General government expenditure (GGE) . Note: Expenditure excludes capital investments. Macroeconomicdata such as GDP and GGE taken from internat ional sources including IMF andWorld Bank. Averages are unweighted. Source: WHOGlobal Health Expenditure Database. For more informat ion visit ht tps://bit .ly/2sdLJDW or contact nha@who.int

Global average

Eastern Mediterranean Region average

12 120

562

5 .35

653 116Population (000s)

Average current health expenditure as % of GDP

Average current health expenditure per capita (US$)

Average GDP per capita (US$)

Public/compulsory health insurance (domestic general government health expenditure as % of current health expenditure)

Voluntary health insurance (voluntary health insurance as % of current health expenditure]

Aid/external resources (external resources as % of current health expenditure)

Out-of-pocket health payments (out-of-pocket health payments as % of current health expenditure)

Other (Other as % of current health expenditure)

0 20 40 60 80 100

2000

2005

2010

2015

2000 2005 2010 2015

100

200

300

400

500

600

C ur re nt

he al th

ex p en

di tu re

p er

ca p ita

(U S$

)

C ur re nt

he al th

ex p en

di tu re

as %

of G D P

Pakistan 2.7%

Qatar 3.2%

Iraq 3.4%

United Arab Emirates 3.5%

Oman 3.8%Kuwait

4.0%

Egypt 4.2%

Djibouti 4.4%

Bahrain 5.2%

Morocco 5.5%

Saudi Arabia 5.8%

Yemen 6.0%

Jordan 6.3%

Sudan 6.3%

Tunis ia 6.7%

Lebanon 7.4%

Islamic Republic of Iran 7.6%

Afghanistan 10.3%

High income Upper -middle income Lower-middle income Low income

Tunis ia 13.6%

Sudan 18.1%

Pakistan 3.7%Morocco

7.7%

Egypt 4.2%

Djibouti 4.1%

Lebanon 14.3%

Jordan 12.4%

Islamic Republic of Iran 22.6%

Saudi Arabia 10.1%

Qatar 6.6%

Oman 6.7%

Kuwait 6.2%

Bahrain 9.5%

United Arab Emirates 8.0%

High income

Upper -middle income

Lower-middle income

Low income

2000 2002 2004 2006 2008 2010 2012 2014

Public expenditure on health from domestic sources as % of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure)

Public expenditure on health from domestic sources as % of GDP (domestic general government health expenditure as % of GDP)

Current health expenditure as a percentage of GDP, by country, 2015

Structure of current health expenditure by financing source, 2000–2015

Current health expenditure per capita and as a percentage of GDP, 2000–2015

Selected macroeconomic, demographic and health expenditure indicators, 2015

Public expenditure on health from domestic sources as a percentage of total public expenditure and as a percentage of GDP

Abbreviations: GGHE-D = domestic general government health expenditure. GGE = general government expenditure. Note: Expenditure excludes capital investments. Macroeconomic data such as GDP and GGE are taken from international sources including the International Monetary Fund and the World Bank. Source: WHO global health expenditure database. For more information visit https://bit.ly/2sdLJDW or contact nha@who.int

12 120

562

5 .35

653 116Population (000s)

Average current health expenditure as % of GDP

Average current health expenditure per capita (US$)

Average GDP per capita (US$)

Public/compulsory health insurance (domestic general government health expenditure as % of current health expenditure)

Voluntary health insurance (voluntary health insurance as % of current health expenditure]

Aid/external resources (external resources as % of current health expenditure)

Out-of-pocket health payments (out-of-pocket health payments as % of current health expenditure)

Other (Other as % of current health expenditure)

0 20 40 60 80 100

2000

2005

2010

2015

2000 2005 2010 2015

100

200

300

400

500

600

C ur re nt

he al th

ex p en

di tu re

p er

ca p ita

(U S$

)

C ur re nt

he al th

ex p en

di tu re

as %

of G D P

Pakistan 2.7%

Qatar 3.2%

Iraq 3.4%

United Arab Emirates 3.5%

Oman 3.8%Kuwait

4.0%

Egypt 4.2%

Djibouti 4.4%

Bahrain 5.2%

Morocco 5.5%

Saudi Arabia 5.8%

Yemen 6.0%

Jordan 6.3%

Sudan 6.3%

Tunis ia 6.7%

Lebanon 7.4%

Islamic Republic of Iran 7.6%

Afghanistan 10.3%

High income Upper -middle income Lower-middle income Low income

Tunis ia 13.6%

Sudan 18.1%

Pakistan 3.7%Morocco

7.7%

Egypt 4.2%

Djibouti 4.1%

Lebanon 14.3%

Jordan 12.4%

Islamic Republic of Iran 22.6%

Saudi Arabia 10.1%

Qatar 6.6%

Oman 6.7%

Kuwait 6.2%

Bahrain 9.5%

United Arab Emirates 8.0%

High income

Upper -middle income

Lower-middle income

Low income

2000 2002 2004 2006 2008 2010 2012 2014

Public expenditure on health from domestic sources as % of total public expenditure (domestic general government health expenditure as a percentage of general government expenditure)

Public expenditure on health from domestic sources as % of GDP (domestic general government health expenditure as % of GDP)

Current health expenditure as a percentage of GDP, by country, 2015

Structure of current health expenditure by financing source, 2000–2015

Current health expenditure per capita and as a percentage of GDP, 2000–2015

Selected macroeconomic, demographic and health expenditure indicators, 2015

Public expenditure on health from domestic sources as a percentage of total public expenditure and as a percentage of GDP

Abbreviations: OOPS = out-of-pocket spending. CHE = current health expenditure. Note: Expenditure excludes capital investments. Macroeconomic data such as GDP and GGE are taken from international sources including the International Monetary Fund and the World Bank. Source: WHO global health expenditure database. For more information visit https://bit.ly/2sdLJDW or contact nha@who.int

Li b ya

S om

al ia

S yr ia n A ra b

R ep

ub lic

Q at ar

O m an

K uw

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S au

d iA

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U ni te d A ra b

E m ira

te s

D jib

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B ah

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Jo rd an

Le b an

Is la m ic

R ep

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Tu ni si a

M or oc

E gy

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S ud

P ak

is ta n

Ir aq

A fg ha

ni st an

Y em

10%

20%

30%

40%

50%

60%

70%

80%

O O P S % C H E

Global average

Eastern Mediterranean Region average

Out of Pocket Spending in EMR Year: 2015

Abbreviat ions: Out-of-pocket spending (OOPS) . Current health expenditure (CHE) . Note: Expenditure excludes capital investments. Macroeconomicdata such as GDP and GGE taken from internat ional sources including IMF andWorld Bank. Averages are unweighted. Source: WHOGlobal Health Expenditure Database. For more informat ion visit ht tps://bit .ly/2sdLJDW or contact nha@who.int

Fig. 9. Share of out-of-pocket payment as a percentage of total current health expenditure, 2015

High out-of-pocket payment can result in high levels of financial hardship. Region-wide, in 2015 an estimated 55.5 million people faced financial hardship, while an estimated 7.7 million people were pushed into poverty due to high out-of-pocket payments.

Fig. 8. Public expenditure on health from domestic sources as a percentage of total public expenditure and as a percentage of GDP

Chapter 2 Analytical framework

The framework shown in Fig. 10 has been developed to link health financing systems and their three functions – revenue raising, pooling and purchasing – with the intermediate objectives and ultimate goals of universal health coverage. It also places health financing systems within the other components/functions of health systems.8

Source: Kutzin J, Witter S, Jowett M, Bayarsaikhan D. Developing a national health financing strategy: a reference guide. Geneva: World Health Organization; 2017. (Health Financing Guidance No 3) Licence: CC BY-NC-SA 3.0 IGO (http://apps.who.int/iris/bitstream/10665/254757/1/9789241512107-eng.pdf, accessed 10 September 2018).

Fig. 10. Health financing within the context of universal health coverage (UHC)

Accordingly, the health financing atlas 2018 is built on an analytical framework consisting of nine elements that was used to describe the health financing systems in the 22 countries of the Region. The nine elements comprise: the overall macroeconomic picture and the health financing system architecture; health financing governance; the three health financing functions (revenue raising, pooling and purchasing) as well as benefit design; and finally, the three dimensions of universal health coverage (population coverage, service coverage and financial protection).

The universal health coverage index of coverage of essential health services is used to describe the status of service coverage in various countries. It is a single indicator that is computed based on tracer indicators (some of which are proxies of service coverage) to monitor coverage of essential health services. Tracer interventions include: reproductive, maternal, newborn and child health; infectious diseases; noncommunicable diseases; and service capacity and access. Service coverage is typically measured on a scale of 0 to 100%, with 100% as the target, and

8 Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization. 2013; 91:602–611.

Creating resources

Revenue raising

Equity in resource distribution

E�ciency

Transparency & accountability

Utilization relative to need

Health financing within the overall health system

UHC intermediate objectives

Final coverage goals

Financial protection & equity in finance

Quality

Pooling

Purchasing

Service delivery

St ew

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/ G ov

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nc e

/ O ve

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Be ne

fit s

therefore the universal health coverage service coverage index is presented on a scale of 0 to 100. For more details, including a list of current values of the universal health coverage index of coverage of essential health services by country, see Tracking universal health coverage: 2017 global monitoring report. Geneva: World Health Organization and International Bank for Reconstruction and Development/The World Bank; 2017. Licence: CC BY-NC-SA 3.0 IGO (http://www.who.int/healthinfo/universal_health_coverage/report/2017/en/).

To map each country’s health financing system, an exhaustive set of questions and issues related to each of the above nine elements was considered. This was supplemented by a presentation of the time trends of selected indicators and scatter plots of others describing the evolution of health spending in each country over the 15-year period between 2000 and 2015, and comparing the current status in each country vis-à-vis others falling within the same income group.

Descriptive information was collected from a number of sources including published and grey literature, and discussed with key informants and specialized units within regional ministries of health for endorsement. For comparison purposes, all health expenditure data were extracted from the WHO Global Health Expenditure Database unless they were unavailable for the specific country or the specific indicator, in which case national sources were sought.

Health financing systems: country profiles

Chapter 3

1. Afghanistan

1. Macroeconomics Persistent insecurity has resulted in slow economic recovery in Afghanistan. Economic growth is mainly driven by the agriculture sector. In 2016, Afghanistan’s GDP was US$ 19.5 billion, with a GDP per capita of US$ 562, which is slightly below the average for low-income countries (US$ 612). In 2015, general government expenditure reached US$ 5.205 billion, constituting 26.7% of GDP. The poverty rate at the national poverty line increased from 36% in 2011/2012 to 39% in 2013/2014.

2. Health financing architecture The Ministry of Public Health is the main steward of the health system. It sets health care financing policies and standards, including defining the Basic Package of Health Services and Essential Package of Hospital Services. Under the System Enhancement for Health Action in Transition Project, resources allocated for the Basic Package of Health Services and the Essential Package of Hospital Services (on- and off-budget) come under one umbrella through the Afghanistan Reconstruction Trust Fund platform, covering the entire country and allowing harmonization in intervention design and implementation arrangements across the provinces. A Grant Contracting and Management Unit under the Ministry of Public Health contracts out health services to nongovernmental organizations in 31 provinces while retaining responsibility for service delivery in the remaining three provinces through a contracting-in modality.

3. Revenue raising Health services are primarily financed by three donors: the World Bank, the European Union (EU) and the United States Agency for International Development (USAID). Current health expenditure as a share of GDP has changed little between 2006 and 2015. In 2015, per capita current health expenditure stood at US$ 60, representing 10.3% of GDP – of which public spending from domestic sources constituted 47% and external assistance around 16%. The proportion of public spending on health from domestic sources in total public spending, which reflects prioritization of the sector, remained stable between 2013 and 2015 at an average of 2% – around US$ 3.1 per capita. As Afghanistan transitions from humanitarian to development aid, it faces significant challenges in developing a health financing system which does not heavily rely on external support.

4. Pooling Prepayment is limited, leading to weak capacity to redistribute resources across different population groups. Nevertheless, the health financing system in Afghanistan performs well with regard to pooling. There is a national- level pool – the Grant Contracting and Management Unit – where domestic government resources and on-budget external assistance are combined and managed by the Ministry of Public Health. A certain level of fragmentation exists due to the way health services are organized, with a number of health facilities – mainly hospitals – being directly supported through bilateral donors or managed by other government ministries, for example, the Ministry of Defense, the Ministry of Interior, and the Ministry of Higher Education.

5. Purchasing The Grant Contracting and Management Unit under the Ministry of Public Health contracts out health services to nongovernmental organizations in 31 provinces (contracting-out) and retains the responsibility for service delivery in the remaining three provinces (contracting-in). Providers under the contracting-in modality submit quarterly requests for funds to the Ministry of Public Health based on their work plans. Providers under the contracting-out approach receive their funding on a performance-based lump-sum basis. Further developments are taking place under the Sehatmandi Project (2018–2021) of the World Bank, whereby the Basic Package of Health Services and the Essential Package of Hospital Services contracts are being modified to increase the focus on achieving results. The contracts will have two parts: (a) a fee-for-service component with service providers paid a fixed tariff for certain services and (b) a lump-sum component to cover overheads and services that are hard to quantify or define precisely, for example for emergency preparedness or for participating in national immunization days. The Sehatmandi Project has also considered the harmonization of staffing and salary payment rules across various nongovernmental organizations in order to simplify financial flows.

9 Tracking universal health coverage: 2017 global monitoring report. World Health Organization and International Bank for Reconstruction and Development/The World Bank; 2017 (https://www.who.int/healthinfo/universal_health_coverage/report/2017/en/, accessed 11 February 2019).

6. Benefits design There are two main health service packages in the country: the Basic Package of Health Services and the Essential Package of Hospital Services, both forming the bedrock of the Afghan health care system. Under the Basic Package of Health Services, all Afghan citizens have a right to receive services at five standard types of health facilities: health posts, sub-health centres, basic health centres offering outpatient care, comprehensive health centres and district hospitals. The Basic Package of Health Services has seven key elements: maternal and newborn care, child health and immunization, public nutrition, communicable disease treatment and control, mental health, disability and rehabilitation services, and the regular supply of essential medicines. The Essential Package of Hospital Services establishes a standard services package for each hospital level; provides staffing guidelines for hospitals; and promotes a referral system to integrate Basic Package of Health Services facilities with hospitals and the essential medicines list. It is mandated that all hospitals providing the Essential Package of Hospital Services should have four clinical functions: medicine, surgery, paediatrics, and obstetrics and gynaecology.

7. Population coverage Public health services are free of charge for all, according to the Afghan constitution and health law. However, gaps in coverage remain due to a number of barriers, including availability of services, affordability, and in some cases, acceptability. The volatile security situation in the country, particularly in rural areas, is also a barrier. According to the 2010 Afghanistan Living Conditions Survey, 57% of the population have access to health services within an hour’s walk. A similar survey conducted in 2016–2017 found that 86.7% of the population can access health services within two hours, using any means of transportation.

8. Service coverage Coverage by needed health services has been increasing over the past decade. However, this coverage varies according to wealth, education level and geographic area. According to the 2015 Afghanistan Living Conditions Survey, PENTA3 vaccine coverage among children aged between 12 and 23 months reached 86%, while antenatal care coverage stood at 61%, and skilled birth attendance reached 58%. The current universal health coverage service coverage index value for the country is 34, which is among the lowest in the world.9 Although 90% of the population live in rural areas, health workforce density in urban areas is higher than that in rural areas. Moreover, health care staff in urban areas are better qualified than those in rural areas, which adversely affects equity in service utilization. With the increasing role of the private health sector in service provision, issues of whether and how services can be purchased from private for-profit providers using public funds are yet to be resolved.

9. Financial protection The level of out-of-pocket expenditure on health in Afghanistan is high, reaching 78% of current health expenditure in 2015 – making it significantly higher than the average for low- and lower middle-income countries (40%). In 2015, 4.8% of the population faced catastrophic out-of-pocket expenditures on health at the 10% of household total consumption or income threshold.

Health expenditure profile Health expenditure profi le

Afghanistan

Revenue sources

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

2 0 1 3

2 0 1 4

2 0 1 5

20%

40%

60%

80%

100%

Other

Aid

Out-of-pocket spending

Voluntary health insurance

Domestic public

Year

2000 2005 2010 2015

GDP per capita (US$)

CHE per capita (US$)

GGHE-D%CHE

OOPS%CHE

GGHE-D%GDP

GGE%GDP

GGHE-D%GGE

Population 33 736 496

0.5

584

28 803 168

0.5

527

25 070 798

0.5

373

20 093 756

Current health expenditure (CHE per capita US$ and CHE%GDP)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

C H E % G D P (b lu e lin e)

C H E p er

ca p ita

(U S $)

(g re en

b ar s)

Public expenditure and health pr ior it izat ion (GGHE-D%GDP and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

G G H E -D

% G D P (b lu e lin e)

G G H E -D

% G G E (y el lo w

b ar s)

Public expenditure and out -of-pocket spending (GGHE-D%GDPand OOPS%CHE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

G G H E -D

% G D P (b lu e lin e)

20%

40%

60%

80%

O O P S % C H E (r ed

b ar s)

Aid and health pr ior it izat ion (EXT per capita US$ and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

A id

p er

ca p ita

(U S $)

(g re en

lin e)

5% G G H E -D

% G G E (y el lo w

b ar s)

Abbreviations: Domesticgeneral government health expenditure = GGHE-D. Current health expenditure = CHE. General government expenditure = GGE. Out-of-pocket spending = OOPS. External resources = EXT. Gross domesticproduct = GDP. Note: Expenditure excludes capital investments. Macroeconomicdata such as GDP and GGE taken from international sources including the International Monetary Fund and the World Bank Source: WHO Global Health Expenditure Database. For more information visit https://bit.ly/2sdLJDW or contact nha@ who.int

Health expenditure profi le Afghanistan

Revenue sources

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

2 0 1 3

2 0 1 4

2 0 1 5

20%

40%

60%

80%

100%

Other

Aid

Out-of-pocket spending

Voluntary health insurance

Domestic public

Year

2000 2005 2010 2015

GDP per capita (US$)

CHE per capita (US$)

GGHE-D%CHE

OOPS%CHE

GGHE-D%GDP

GGE%GDP

GGHE-D%GGE

Population 33 736 496

0.5

584

28 803 168

0.5

527

25 070 798

0.5

373

20 093 756

Current health expenditure (CHE per capita US$ and CHE%GDP)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

C H E % G D P (b lu e lin e)

C H E p er

ca p ita

(U S $)

(g re en

b ar s)

Public expenditure and health pr ior it izat ion (GGHE-D%GDP and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

G G H E -D

% G D P (b lu e lin e)

G G H E -D

% G G E (y el lo w

b ar s)

Public expenditure and out -of-pocket spending (GGHE-D%GDPand OOPS%CHE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

G G H E -D

% G D P (b lu e lin e)

20%

40%

60%

80%

O O P S % C H E (r ed

b ar s)

Aid and health pr ior it izat ion (EXT per capita US$ and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

A id

p er

ca p ita

(U S $)

(g re en

lin e)

G G H E -D

% G G E (y el lo w

b ar s)

Health expenditure profi le Afghanistan

Revenue sources

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

2 0 1 3

2 0 1 4

2 0 1 5

20%

40%

60%

80%

100%

Other

Aid

Out-of-pocket spending

Voluntary health insurance

Domestic public

Year

2000 2005 2010 2015

GDP per capita (US$)

CHE per capita (US$)

GGHE-D%CHE

OOPS%CHE

GGHE-D%GDP

GGE%GDP

GGHE-D%GGE

Population 33 736 496

0.5

584

28 803 168

0.5

527

25 070 798

0.5

373

20 093 756

Current health expenditure (CHE per capita US$ and CHE%GDP)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

C H E % G D P (b lu e lin e)

C H E p er

ca p ita

(U S $)

(g re en

b ar s)

Public expenditure and health pr ior it izat ion (GGHE-D%GDP and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15 0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

G G H E -D

% G D P (b lu e lin e)

G G H E -D

% G G E (y el lo w

b ar s)

Public expenditure and out -of-pocket spending (GGHE-D%GDPand OOPS%CHE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

G G H E -D

% G D P (b lu e lin e)

20%

40%

60%

80%

O O P S % C H E (r ed

b ar s)

Aid and health pr ior it izat ion (EXT per capita US$ and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

A id

p er

ca p ita

(U S $)

(g re en

lin e)

G G H E -D

% G G E (y el lo w

b ar s)

Fig. 1.1. Key health financing and expenditure indicators, 2000–2015

Fig. 1.3. Current health expenditure (CHE per capita [US$] and CHE as a percentage of GDP)

Fig. 1.5. Public expenditure and out-of-pocket spending (GGHE-D as a percentage of GDP and OOPS as a

percentage of CHE)

Fig. 1.2. Revenue sources

Fig. 1.4. Public expenditure and health prioritization (GGHE-D as a percentage of GDP and GGHE-D as

a percentage of GGE)

Fig. 1.6. Aid and health prioritization (EXT per capita [US$] and GGHE-D as a

percentage of GGE)

Afghanistan

Abbreviations: CHE = current health expenditure. GGHE-D = domestic general government health expenditure. EXT = external resources. GGE = general government expenditure. GDP = gross domestic product. OOPS = out-of-pocket spending. Note: Expenditure excludes capital investments. Macroeconomic data such as GDP and GGE are taken from international sources including the International Monetary Fund and the World Bank. Source: WHO global health expenditure database. For more information visit https://bit.ly/2sdLJDW or contact nha@who.int

Health expenditure profi le Afghanistan

Current health expenditure as %GDPand per capita US$

10 100 1000 10000

CHE per capita (US$)

0.0%

5.0%

10.0%

15.0%

20.0%

C H E % G D P

Government health expenditure as%GDP and per capita US$

100 1000 10000 100000

GDP per capita (US$)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

G G H E -D

% G D P

Fiscal space and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

20%

40%

60%

80%

100%

G G E % G D P

Health pr ior it izat ion and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

10%

20%

30%

G G H E -D

% G G E

OOPS%CHE and GGHE-D%GDP

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

GGHE-D%GDP

20%

40%

60%

80%

O O P S % C H E

EXT%CHE and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

20%

40%

60%

80%

E X T%

C H E

Abbreviat ions: Domest ic general government health expenditure = GGHE-D. Current health expenditure = CHE. General government expenditure = GGE. Out-of-pocket spending = OOPS. External resources = EXT. Gross domest ic product = GDP. Note: Expenditure excludes capital investments. Macroeconomicdata such as GDPand GGE taken from internat ional sources including the Internat ional Monetary Fund and the World Bank Source: WHOGlobal Health Expenditure Database. For more informat ion visit ht tps://bit .ly/2sdLJDW or contact nha@who.int

Health expenditure profi le Afghanistan

Current health expenditure as %GDPand per capita US$

10 100 1000 10000

CHE per capita (US$)

0.0%

5.0%

10.0%

15.0%

20.0%

C H E % G D P

Government health expenditure as%GDP and per capita US$

100 1000 10000 100000

GDP per capita (US$)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

G G H E -D

% G D P

Fiscal space and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

20%

40%

60%

80%

100%

G G E % G D P

Health pr ior it izat ion and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

10%

20%

30%

G G H E -D

% G G E

OOPS%CHE and GGHE-D%GDP

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

GGHE-D%GDP

20%

40%

60%

80%

O O P S % C H E

EXT%CHE and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

20%

40%

60%

80%

E X T%

C H E

Abbreviat ions: Domest ic general government health expenditure = GGHE-D. Current health expenditure = CHE. General government expenditure = GGE. Out-of-pocket spending = OOPS. External resources = EXT. Gross domest ic product = GDP. Note: Expenditure excludes capital investments. Macroeconomicdata such as GDPand GGE taken from internat ional sources including the Internat ional Monetary Fund and the World Bank Source: WHOGlobal Health Expenditure Database. For more informat ion visit ht tps://bit .ly/2sdLJDW or contact nha@who.int

Health expenditure profi le Afghanistan

Current health expenditure as %GDPand per capita US$

10 100 1000 10000

CHE per capita (US$)

0.0%

5.0%

10.0%

15.0%

20.0%

C H E % G D P

Government health expenditure as%GDP and per capita US$

100 1000 10000 100000

GDP per capita (US$)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

G G H E -D

% G D P

Fiscal space and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

20%

40%

60%

80%

100%

G G E % G D P

Health pr ior it izat ion and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

10%

20%

30%

G G H E -D

% G G E

OOPS%CHE and GGHE-D%GDP

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

GGHE-D%GDP

20%

40%

60%

80%

O O P S % C H E

EXT%CHE and GDPper capita US$

100 1000 10000 100000

GDP per capita (US$)

20%

40%

60%

80%

E X T%

C H E

Abbreviat ions: Domest ic general government health expenditure = GGHE-D. Current health expenditure = CHE. General government expenditure = GGE. Out-of-pocket spending = OOPS. External resources = EXT. Gross domest ic product = GDP. Note: Expenditure excludes capital investments. Macroeconomicdata such as GDPand GGE taken from internat ional sources including the Internat ional Monetary Fund and the World Bank Source: WHOGlobal Health Expenditure Database. For more informat ion visit ht tps://bit .ly/2sdLJDW or contact nha@who.int

Fig. 1.7. Current health expenditure as a percentage of GDP and per capita (US$)

Fig. 1.9. Fiscal space and GDP per capita (US$)

Fig. 1.11. OOPS as a percentage of CHE and GGHE-D as a percentage of GDP

Fig. 1.10. Health prioritization and GDP per capita (US$)

Fig. 1.12. EXT as a percentage of CHE and GDP per capita (US$)

Fig. 1.8. Government health expenditure as a percentage of GDP and per capita (US$)

country being profiled

other country in the Eastern Mediterranean Region

country not in the Eastern Mediterranean Region

1. Macroeconomics Bahrain is a high-income country. In 2015, GDP was US$ 31.7 billion, constituting a GDP per capita of US$ 23 080. Recent economic growth has been moderate, with GDP growth decreasing from 3.5% in 2013 to 3.4% in 2014, mainly due to the sharp reduction in global oil prices. Oil revenue constitutes around 85% of government revenues. International reserves continue to fall, putting pressure on the country’s exchange rate. General government expenditure reached US$ 11.4 billion in 2015, constituting 35.9% of GDP. The poverty rate in Bahrain is not known, and the country does not suffer from extreme poverty as defined by the United Nations (UN). However, it is estimated that around 12.2% of Bahrainis live on less than US$ 5 per day, with considerable differences in wealth noticeable among the poorest neighbourhoods.

2. Health financing architecture The Bahraini health financing system consists of a mix of public and private financing agents, but is predominantly governed by the public sector, which includes the Ministry of Health, the Bahrain Defense Force and the Ministry of Education. Private insurance companies and households represent the main private financing agents. A Supreme Council of Health was established in 2012. It consists of 12 members including the Minister of Health, who serves as the vice chairperson. The Supreme Council of Health is responsible for developing the National Health Strategy and ensuring its implementation, and is at present overseeing a major health sector reform programme in Bahrain. The Ministry of Health is responsible for planning and provision of health services. In 2014, the Supreme Council of Health developed a social health insurance law. The law establishes: (a) the National Health Insurance Fund, Daman, to be jointly responsible for pooling health funds and purchasing health services alongside private insurance companies; (b) an independent Health Information and Knowledge Management Agency to monitor quality and prices; and (c) a National Health Regulatory Authority, which is responsible for the licensing of health professionals and facilities as well as monitoring insurance companies. Under the new reform programme, the Ministry of Health will be mainly responsible for the provision of health services in public facilities, with other private providers also contributing to the provision of these services.

3. Revenue raising General government revenues constitute the main source of revenue for the health system, primarily through budget allocation from the Ministry of Finance. In 2015, current health expenditure reached US$ 1190 per capita, represented 5.16% of GDP. Private health expenditure is relatively low at US$ 402 per capita in 2015. Although Bahrain has the lowest general government expenditure of all member countries of the Gulf Cooperation Council, its general government health expenditure is one of highest in the Region, amounting to US$ 788 per capita and constituting 9.5% of general government expenditure. Some indirect contributions come from neighbouring countries within overall support to Bahrain’s government. The Labour Market Regulatory Agency is responsible for collecting fees for basic health care for all expatriate employees in all establishments, on behalf of the Ministry of Health. Under the new social health insurance law, health financing sources will be expanded by collecting contributions from the government on behalf of citizens and from employers on behalf of employees (citizens and expatriates), and heads of households are expected to pay contributions on behalf of their domestic workers.

4. Pooling Bahrain has a pluralistic segmented health system with multiple pooling arrangements. Within the public sector, there are currently several detached pooling funds: public, parastatal and private. The Ministry of Health acts as the main pooling agent. Domestic general government health expenditure as a share of current health expenditure reached 66.2% in 2015. Other pooling arrangements include 81 charity funds, 12 private health insurers, the Bahrain Defense Force, the Ministry of the Interior and private employers. In addition, the General Organization for Social Security and the General Organization for Pension Funds each pool funds separately to cover work-related injuries. Voluntary health insurance accounted for 8.7% of current health expenditure in 2015. Under the recently enacted health insurance law, there are two main mandatory coverage arrangements: the National Health Insurance Fund, Daman, pooling citizens’ contributions and those of expatriates working in small companies (with fewer than 50

2. Bahrain

employees); and private insurance companies covering expatriates working in larger companies or for those who opt out of Daman. Premiums paid for expatriates are risk-rated, with annual ceilings revised each year.

5. Purchasing Under the current health system arrangement, the Ministry of Health is the main purchaser and provider of health services. Purchasing primarily happens from state-owned facilities, using direct budget transfer based on line-item payments, which curbs efficiency and performance improvement. The health workforce employed by the Ministry of Health are paid through salaries. In addition, a fee-for-service system is used for limited private practices and private hospitals and clinics. The new social health insurance law currently underway plans to separate purchasing from provision, and would mean that the Ministry of Health would no longer be responsible for service provision. The main purchasers of services are expected to be Daman and private health insurance companies. The government plans to pay for hospitals using diagnosis-related groups, and for primary health care using capitation, in order to allow for financial and management autonomy.

6. Benefits design A comprehensive package of health services is provided free of charge for all nationals, and is subsidized for expatriates. The package does not explicitly exclude any promotive, preventive, curative or rehabilitative services. At present, expatriates are covered for primary health care services only, while those with private health insurance are entitled to primary health care, secondary care for acute and chronic conditions, diagnostics and physiotherapy. The new social health insurance law provides a mandatory benefit package for citizens and expatriates, focusing mainly on primary, preventive and emergency care, essential medications available on the primary health care list, and diagnostics. The benefit package provided for nationals is, however, more comprehensive than the one available to expatriates. Insured individuals are allowed to supplement their basic package with specialized or optional packages.

7. Population coverage Around half of the population of Bahrain are expatriates. All Bahraini citizens enjoy a constitutional right to comprehensive health services. Health services are also heavily subsidized for expatriates living in Bahrain. Coverage for expatriates has developed since 1976. In 2014, all companies were mandated to provide health care for all their employees through private health insurance or social health insurance without discrimination. Currently, 41.8% of expatriates are covered by social health insurance, 3.8% by private health insurance, and 54.4% are in the process of enrolment. Domestic workers are charged for services, but under the new law, these workers are to be covered by a mandatory basic health care package.

8. Service coverage Health care is provided by the Ministry of Health, the Bahrain Defense Force, university hospitals and private providers. Since 1960, the Government of Bahrain has provided comprehensive health care for all citizens and residents via a network of primary health care centres, clinics, and secondary and tertiary care facilities. The government dominates health care provision. Primary health care services are based on a family and community health care approach through 27 health care centres. Curative care is provided through 2046 public hospitals and 452 private hospitals. Private sector health provision is growing fast, and it is hoped that it will play a major role in health care provision in the future. In 2012, the numbers of physicians and nurses per 10 000 population were 27.2 and 51.4 respectively. In 2015, the universal health coverage service coverage index value for the country was 72, which is among the highest in the world.10

9. Financial protection At present, health care is provided free of charge for all Bahrainis. However, it is estimated that out-of-pocket payments constituted 25.1% of current health expenditure in 2015. Under the new social health insurance law, citizens will be required to pay some user fees for some services provided by the complementary package, and to co-pay for services under the optional package, while expatriates will be expected to cost-share for services provided by the complementary and optional benefit packages. At present, no estimates are available for the two financial protection indicators.

10 Tracking universal health coverage: 2017 global monitoring report. World Health Organization and International Bank for Reconstruction and Development/The World Bank; 2017 (https://www.who.int/healthinfo/universal_health_coverage/report/2017/en/, accessed 11 February 2019).

Health expenditure profile

Fig. 2.6. Aid and health prioritization (EXT per capita [US$] and GGHE-D as a

percentage of GGE)

Fig. 2.5. Public expenditure and out-of-pocket spending (GGHE-D as a percentage of GDP and OOPS as a

percentage of CHE)

Fig. 2.4. Public expenditure and health prioritization (GGHE-D as a percentage of GDP and GGHE-D as

a percentage of GGE)

Fig. 2.3. Current health expenditure (CHE per capita [US$] and CHE as a percentage of GDP)

Fig. 2.2. Revenue sourcesFig. 2.1. Key health financing and expenditure indicators, 2000–2015

Health expenditure profi le Bahrain

Revenue sources

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

2 0 1 3

2 0 1 4

2 0 1 5

20%

40%

60%

80%

100%

Other

Aid

Out-of-pocket spending

Voluntary health insurance

Domestic public

Year

2000 2005 2010 2015

GDP per capita (US$)

CHE per capita (US$)

GGHE-D%CHE

OOPS%CHE

GGHE-D%GDP

GGE%GDP

GGHE-D%GGE

Population 1 371 855

3.4

1 190

23 081

1 240 862

2.4

689

20 956

889 168

2.1

662

22 315

664 614

2.4

795

23 214

Current health expenditure (CHE per capita US$ and CHE%GDP)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

C H E % G D P (b lu e lin e)

200

400

600

800

1000

1200

C H E p er

ca p ita

(U S $)

(g re en

b ar s)

Public expenditure and health pr ior it izat ion (GGHE-D%GDP and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15 0.0%

1.0%

2.0%

3.0%

G G H E -D

% G D P (b lu e lin e)

10%

G G H E -D

% G G E (y el lo w

b ar s)

Publicexpenditure and out-of-pocket spending (GGHE-D%GDP and OOPS%CHE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

G G H E -D

% G D P (b lu e lin e)

10%

15%

20%

25%

O O P S % C H E (r ed

b ar s)

Aid and health prioritization (EXT per capita US$ and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

A id

p er

ca p ita

(U S $)

(g re en

lin e)

10%

G G H E -D

% G G E (y el lo w

b ar s)

Health expenditure profi le Bahrain

Revenue sources

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

2 0 1 3

2 0 1 4

2 0 1 5

20%

40%

60%

80%

100%

Other

Aid

Out-of-pocket spending

Voluntary health insurance

Domestic public

Year

2000 2005 2010 2015

GDP per capita (US$)

CHE per capita (US$)

GGHE-D%CHE

OOPS%CHE

GGHE-D%GDP

GGE%GDP

GGHE-D%GGE

Population 1 371 855

3.4

1 190

23 081

1 240 862

2.4

689

20 956

889 168

2.1

662

22 315

664 614

2.4

795

23 214

Current health expenditure (CHE per capita US$ and CHE%GDP)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

C H E % G D P (b lu e lin e)

200

400

600

800

1000

1200

C H E p er

ca p ita

(U S $)

(g re en

b ar s)

Public expenditure and health pr ior it izat ion (GGHE-D%GDP and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

1.0%

2.0%

3.0%

G G H E -D

% G D P (b lu e lin e)

10%

G G H E -D

% G G E (y el lo w

b ar s)

Publicexpenditure and out-of-pocket spending (GGHE-D%GDP and OOPS%CHE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

G G H E -D

% G D P (b lu e lin e)

10%

15%

20%

25%

O O P S % C H E (r ed

b ar s)

Aid and health prioritization (EXT per capita US$ and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

A id

p er

ca p ita

(U S $)

(g re en

lin e)

10% G G H E -D

% G G E (y el lo w

b ar s)

Health expenditure profi le Bahrain

Revenue sources

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

2 0 1 3

2 0 1 4

2 0 1 5

20%

40%

60%

80%

100%

Other

Aid

Out-of-pocket spending

Voluntary health insurance

Domestic public

Year

2000 2005 2010 2015

GDP per capita (US$)

CHE per capita (US$)

GGHE-D%CHE

OOPS%CHE

GGHE-D%GDP

GGE%GDP

GGHE-D%GGE

Population 1 371 855

3.4

1 190

23 081

1 240 862

2.4

689

20 956

889 168

2.1

662

22 315

664 614

2.4

795

23 214

Current health expenditure (CHE per capita US$ and CHE%GDP)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

C H E % G D P (b lu e lin e)

200

400

600

800

1000

1200

C H E p er

ca p ita

(U S $)

(g re en

b ar s)

Public expenditure and health pr ior it izat ion (GGHE-D%GDP and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

1.0%

2.0%

3.0%

G G H E -D

% G D P (b lu e lin e)

10%

G G H E -D

% G G E (y el lo w

b ar s)

Publicexpenditure and out-of-pocket spending (GGHE-D%GDP and OOPS%CHE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

G G H E -D

% G D P (b lu e lin e)

10%

15%

20%

25%

O O P S % C H E (r ed

b ar s)

Aid and health prioritization (EXT per capita US$ and GGHE-D%GGE)

2 0 00

2 0 01

2 0 02

2 0 03

2 0 04

2 0 05

2 0 06

2 0 07

2 0 08

2 0 09

2 0 10

2 0 11

2 0 12

2 0 13

2 0 14

2 0 15

A id

p er

ca p ita

(U S $)

(g re en

lin e)

10%

G G H E -D

% G G E (y el lo w

b ar s)

Bahrain

country being profiled

other country in the Eastern Mediterranean Region

country not in the Eastern Mediterranean Region

Fig. 2.8. Government health expenditure as a percentage of GDP and per capita (US$)

Fig. 2.10. Health prioritization and GDP per capita (US$)

Fig. 2.12. EXT as a percentage of CHE and GDP per capita (US$)

Fig. 2.7. Current health expenditure as a percentage of GDP and per capita (US$)

Fig. 2.9. Fiscal space and GDP per capita (US$)

Fig. 2.11. OOPS as a percentage of CHE and GGHE-D as a percentage of GDP

Health expenditure profi le Bahrain

Current health expenditure as %GDPand per capita US$

10 100 1000 10000

CHE per capita (US$)

0.0%

5.0%

10.0%

15.0%

20.0%

C H E % G D P

Government health expenditure as%GDP and per capita US$

100 1000 10000 100000

GDPper capita (US$)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

G G H E -D

% G D P

Fiscal space and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

20%

40%

60%

80%

100%

G G E % G D P

Health pr ior it izat ion and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

10%

20%

30%

G G H E -D

% G G E

OOPS%CHE and GGHE-D%GDP

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

GGHE-D%GDP

20%

40%

60%

80%

O O P S % C H E

EXT%CHE and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

20%

40%

60%

80%

E X T%

C H E

Health expenditure profi le Bahrain

Current health expenditure as %GDPand per capita US$

10 100 1000 10000

CHE per capita (US$)

0.0%

5.0%

10.0%

15.0%

20.0%

C H E % G D P

Government health expenditure as%GDP and per capita US$

100 1000 10000 100000

GDPper capita (US$)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

G G H E -D

% G D P

Fiscal space and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

20%

40%

60%

80%

100%

G G E % G D P

Health pr ior it izat ion and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

10%

20%

30%

G G H E -D

% G G E

OOPS%CHE and GGHE-D%GDP

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

GGHE-D%GDP

20%

40%

60%

80%

O O P S % C H E

EXT%CHE and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

20%

40%

60%

80%

E X T%

C H E

Health expenditure profi le Bahrain

Current health expenditure as %GDPand per capita US$

10 100 1000 10000

CHE per capita (US$)

0.0%

5.0%

10.0%

15.0%

20.0%

C H E % G D P

Government health expenditure as%GDP and per capita US$

100 1000 10000 100000

GDPper capita (US$)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

G G H E -D

% G D P

Fiscal space and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

20%

40%

60%

80%

100%

G G E % G D P

Health pr ior it izat ion and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

10%

20%

30%

G G H E -D

% G G E

OOPS%CHE and GGHE-D%GDP

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

GGHE-D%GDP

20%

40%

60%

80%

O O P S % C H E

EXT%CHE and GDPper capita US$

100 1000 10000 100000

GDPper capita (US$)

20%

40%

60%

80%

E X T%

C H E

11 Djibouti’s Economic Outlook – October 2017. Washington, DC: The World Bank; 11 October 2017 (http://www.worldbank.org/en/country/djibouti/ publication/djibouti-economic-outlook-october-2017, accessed 22 July 2018). 12 Law No. 24/AN/14/7 of 5 February 2014, available at http://www.droit-afrique.com/upload/doc/djibouti/Djibouti-Loi-2014-24-assurance-maladie- universelle.pdf, accessed 22 July 2018.

3. Djibouti

1. Macroeconomics Djibouti is a small lower middle-income country of 992 635 inhabitants in 2016, with more than 40% of the population living below the poverty line and 23% living in extreme poverty. Djibouti’s economy depends on foreign financing, foreign direct investment, and rents from foreign countries’ military bases and port services. GDP increased from US$ 1.10 billion in 2010 to US$ 1.72 billion in 2015, resulting in a GDP per capita of US$ 1862 in 2015. GDP growth of 7.1% is projected for 2017. Economic growth is mainly driven by port activities, transportation services and construction. Foreign direct investment contributed 9.1% of GDP in 2016, up from 7.2% in 2015, as a result of industrial development in the new free zone and activities related to the new railway between Djibouti and Ethiopia. General government expenditure increased from US$ 411 million in 2010 to US$ 1.017 billion in 2015, representing an increase in its share of GDP from 37.4% to 59.1%. Although fiscal and external positions are improving gradually, risks of debt and fiscal sustainability remain.11 Job creation is another challenge, with unemployment reaching 39% in 2016.

2. Health financing architecture Despite significant progress in implementing the National Health Development Plan (2013–2017), the health system in Djibouti continues to face many challenges, especially in ensuring sustainable health financing, but equally in human resources, medical products and technologies, and health information systems. Various health sector reforms aimed at pro-poor policies have been pursued. In 2008, the National Social Security Fund was established under the Ministry of Labour and Administrative Reform as a public administrative institution with legal status and financial autonomy, by merging two public instituti

Key facts

Organisation World Health Organization (WHO)

Document type Publications

Adoption date March 18, 2019

Source World Health Organization