GNHE » December 9, 2015

Daily Archives: December 9, 2015

Low-income countries South-East Asia

GNHE launches new UHC assessment for Nepal

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Shiva Adhikari, from the Patan Multiple Campus at Tribhuvan University and Health Economics Association in Nepal, has just written an assessment of his country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.


The author’s main conclusions are:

  • Nepal’s health financing and expenditure indicators are slightly better than those of the average low-income country, but out-of-pocket expenditure is still extremely high
  • This means that financial protection is not adequate for large numbers of people
  • Despite the provision of free essential services to the poor, geographic access to quality services is still pro-rich
  • There is growing pressure on the government of Nepal to expand the benefits covered under the free essential health package, as well as to expand coverage to all Nepalese
  • There is also growing pressure to increase government expenditure on health and improve the efficiency of the health system.
  • Proposals for new financing mechanisms, such as health insurance, are being debated.
  • Meeting these demands will be difficult for Nepal, given its low-income status.
  • In relation to expanding the fiscal space for health, a first consideration is economic growth, as higher growth rates would broaden the tax base and increase government revenue, especially if tax administration could be improved as well. Unfortunately, in recent years real GDP growth has been quite low.
  • Another option for government is to expand its domestic borrowing although there are arguments that this could affect the economy. Increasing donor funding, or international loans, also does not seem a very viable option, given that Nepal already receives considerable funding from these sources.
  • From a macro-fiscal perspective, therefore, the prospects of finding additional public resources for health are relatively low, unless health can increase its share of the government budget. Some consider that this would be difficult to argue for, as Nepal already spends a relatively large share of its budget on the health sector.
  • After analysing all these potential sources, a report produced by World Bank suggested that the only realistic option for Nepal is improving the efficiency of existing health expenditure.
  • However, more thinking may need to be done on how to increase tax-based financing – through widening the tax base, improving tax administration and ear-marking certain taxes – given the remaining problems with financial protection and inequities in access in Nepal.


Adhikari S. 2015. Universal health coverage assessment: Nepal. Global Network for Health Equity (GNHE). Available at:

Lower-middle-income countries South-East Asia

Achieving universal health coverage in Indonesia

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Trisnantoro, Marthias and Harbianto (from the Centre for Health Policy and Management, School of Medicine, Gadjah Mada University) in Indonesia, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.


The authors’ conclusions are:

  • The burden of health financing in Indonesia is mildly progressive
  • The distribution of utilisation is also mildly progressive, particularly for hospital inpatient care
  • Indonesia’s out-of-pocket payments are still at a very high rate because of user fees across the system and the large proportion of the population that remains uninsured
  • Catastrophic payments probably still burden many of the poor while utilisation by the poor is low relative to their need for health care
  • The complexity of the financial protection system has introduced distortions into funding flows and the provision of care
  • Risk pools have also been fragmented
  • To address these problems, the Indonesian government has initiated the implementation of its first universal health coverage program, National Health Insurance or BPJS
  • The intention is to unify all the old health schemes, creating one large risk pool
  • The coverage of the new scheme was almost 122 million people in 2012. The intention is to insure all 258 million Indonesians by 2019, including foreigners who work in the country for more than six months
  • The new scheme is funded through a mixture of government subsidies and premiums
  • There will be a nation-wide, single benefit package that is comprehensive, except for some limits and exclusions
  • The scheme will practise active purchasing with accredited providers (including capitation and Indonesian DRGs), negotiate with providers around cost control, and implement mechanisms to improve quality
  • Gate-keeping by primary care providers is an important strategy to improve health system efficiency
  • In conclusion, financial protection should be regarded as one aspect of universal health coverage and not the sole agenda for Indonesia. Intensive investment is required to ensure supply-side readiness, so that equitable health care utilization and health attainment can be achieved even in the currently under-developed regions of Indonesia.


Trisnantoro L, Marthias T, Harbianto D. 2014. Universal health coverage assessment: Indonesia. Global Network for Health Equity (GNHE). Available at: