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4.6. Learnings from the case studies
From the case studies, a number of themes emerge that can inform our thinking about health sector
reforms aimed at expanding health service access for the poor and reaching the target of universal
health coverage in countries. These themes relate to the design and implementation of health sector
reforms, the issue of health insurance as a way of reducing out-of-pocket health expenditure, the
involvement of the private sector, information management systems, and nature of health priorities in
past and future.
With respect to reforms, a thorough understanding of the level of health and access to health services,
and barriers to good health is essential to design reform with high impact at a large scale. A good
example is Turkey, where structured steps for understanding the own context and learning from other
countries’ experiences was undertaken in the formof extensive literature reviews, and field visits were
undertaken. Furthermore, monitoring and communicating progress at each step has been essential, as
have long-term engagement, dedication and leadership.
The importance of political leadership has also been observed in Indonesia, where domestic political
concerns were usually the main drivers for all subsequent improvements in the health system (and
not external pressures or triggers. This experience is very different in Uganda, where donor support
does not always meet government priorities. In addition, gaining and maintaining voter support has
been essential, e.g. in Indonesia, at district level, the ability to provide successful local health service
model has become an important vote catcher for local leaders. Similarly, Turkey prioritized
‘emergencies’ in their list of reforms in order to keep voters and politicians onboard for subsequent
reforms that would take more time.
The importance of community-based primary health care to reach poor people is a common theme
across the case studies. Especially Indonesia has made good progress in several health indicators
including maternal and child health (although there are still gaps) by strengthening community-based
services and out-reach and vertical, integrated programming; and Turkey’s family medicine
programme is seen as a very strong contributor to health outcome improvements as well. Locating
highly-skilled health personnel to provide service in rural and remote areas has been proven a
challenge; however, with the ‘right’, context-specific policies and incentives this can be achieved as
seen in both cases. For example, Indonesia offered flexible, short-term contracts to attract health
workers and in particular specialists to remote, rural areas; and Turkey made very positive
experiences with abolishing dual service and incentivising remote work.
Related to the importance of community based primary health care is the role it can play in tackling
new health challenges, such as NCDs, which are on the increase globally. These new challenges will be
most effectively tackled at the primary care level through regular screening of the targeted population,
as global experience demonstrates.
Health insurance is an essential part of achieving universal health care as it helps reduce out-of-pocket
expenditures which are a major barrier to access to health globally. However, implementing insurance
cover for all has its challenges – particularly where informal workers, people without ID cards,
indigenous people and people living in very remote areas easily ‘fall off the system’. These experiences
are clearly made in Indonesia and Uganda. Furthermore, the design of eligibility criteria can prove
challenging as seen in Tunisia where some population groups are too poor to afford out-of-pocket
health expenditures but not poor enough to receive state support.
The private sector can be a great support in addressing shortcomings in health service supply and thus
make health services more inclusive. For example, realizing the considerable gaps and shortcomings
in public health service delivery (e.g. lack of human resources and physical infrastructure, huge
regional disparities in service coverage), the government of Indonesia hast started to actively