Summary of Outputs
                      Health Financing Sustainability in Maldives (p163776)

The following outputs are attached.

•   Mission Report, July 2017. A situation analysis of the pharmaceutical sector, including reform
    options, following visit by Lead Health Specialist/Global Solutions Lead. The note identifies the main
    cost drivers in the pharmaceutical sector, and identifies policy options including drug price
    harmonization, co-payments for non-preferred medicines, expanding e-prescription systems, and
    streamlining the essential medicines list. Drug price harmonization became a prior action in the
    Development Policy Financing (DPF) operation. As of October 2018, technical groundwork was
    completed but gazetting was pending.

•   Summary of options for cost containment of medicines and medical consumables, November
    2017. A further analysis of reform options to reduce pharmaceutical expenditures, highlighting
    additional options such as purchasing from an international wholesaler, simplifying drug
    registration, enforcing generic consumption, and reducing unnecessary consumption.

•   Concept note and agenda, India health insurance forum event, New Delhi, November 2017.
    Maldives was the only invited international observer for this event, which brought together
    practitioners from almost 20 Indian government health insurance schemes to discuss operational
    challenges and good practices. About 80 percent of Maldives overseas hospital claims are from
    India, and most seek care in the state of Kerala. The event was attended by two managers from
    Aasandha/NSPA. A side-meeting with the Kerala insurance scheme managers was arranged.

•   Sample insurance Third Party Administrator (TPA) contract from India, February 2018 (not
    attached). This 44-page document was shared with Aasandha to inform its own transition towards
    using a TPA to manage its overseas (Indian) medical costs. This was related to a prior action under
    the Development Policy Financing (DPF) operation. An RfP was issued earlier in 2018 but there are
    plans to re-issue to achieve a larger pool of candidates.

•   Report: Reducing the expenditure on drugs and consumables in the Government of Maldives
    (April 2018). Report drafted by consultant/expert from Tamil Nadu on procurement reform options
    to reduce drug expenditures by State Trading Organization (STO), Ministry of Health, and
    Aasandha/NSPA. Key topics include STO purchasing arrangements, margins, and inventory
    management, implementing standard treatment guidelines (STGs), and supply chain management.

•   Health Sector Spending Review (Presentation to Ministry of Finance and Treasury and NSPA),
    August 2018. Analysis of spending trends, global benchmarking, efficiency indicators, and policy
    options. The findings were cited extensively in November 2018 budget. The study highlighted the
    Indira Gandhi Memorial Hospital (IGMH) and the new Dharumavantha wing as the key driver of
    health spending in recent years. Aasandha costs have stabilized, especially for overseas care, but
    drug spending remains a key challenge to ensure sustainability. The PPT includes analysis of sources
    of inefficiency, especially related to drug prices and over-use of hospitals instead of primary care.
•   Equity and financial protection in Maldives: Findings from household survey. Presentation of
    results from analysis of Household Income and Expenditure Survey (HIES). The findings show that
    outpatient and inpatient utilization is relatively equal across socioeconomic groups, while out-of-
    pocket spending is higher among better off households, and concentrated mainly on outpatient
    care. A significant share of OOP is incurred abroad, although fewer than 10% of households incur
    such spending. Overall, the HIES results suggest a significant decline in the average share of
    household budgets that is used to cover health expenses. Standard indicators of financial
    protection, such as the incidence of catastrophic and impoverishing health care expenses, are also
    presented.