In 2005, Vietnam’s legislature voted to develop a new health insurance system that would reduce most citizens’ out-of-pocket health-care costs and instructed the health ministry to take steps to make care more accessible, more affordable, and more effective—especially for those who lived in remote, mountainous regions. One of the challenges was how to manage scarce resources in order to constrain soaring costs. Another was how to coordinate with provinces and local governments (districts and communes)—which controlled much of the country’s health-care spending—in order to achieve national priorities, such as improved preventive care. During the next several years, the health ministry’s Department of Planning and Finance worked with those subnational units to improve the financial information system, hone strategies and plans, and align activities. By 2014, Vietnam’s government had more than tripled its per-capita health-care spending—to US$48.82 in 2014 from US$15.52 per capita in 2005, in current US dollars—a rate of growth that outpaced the average in both low-income and lower-middle-income countries. Although the ministry still struggled to keep patients’ costs down, the share of out-of-pocket spending fell to 45% in 2015 from 67% in 2005, according to government figures.

ISS staff members drafted this case study based on interviews conducted in Hanoi, Vietnam by Simon Engler and Huong Dang in May, June, and August 2018. Case published in May 2019. This case is part of an ISS series on linking health priorities to the budget process.

Ethiopia’s Federal Ministry of Health was struggling to meet its goals in 2014 despite impressive gains in the health of its citizens during the previous 20 years. A new minister and his leadership team reached out for ideas by engaging Ethiopia’s regions, districts, and communities—an essential step in a large and ethnically diverse society. They then developed an ambitious transformation program to help realize the government’s national aspirations for health care, including commitments made to achieving the Millennium Development Goals. To bring their vision to fruition, however, the minister and his team had to link priorities to the budget process and use the health budget as a management tool. The ministries of health and finance matched goals and targets to available resources and worked to create actionable plans. And health officials took steps to build cooperation and extend coordination at every level of government in Ethiopia’s federal system. Technical and capacity constraints—plus unexpected political upheaval beginning in late 2015—slowed implementation, but in 2018 a new administration was taking steps to address those challenges.

Gordon LaForge drafted this case study based on interviews conducted in Addis Ababa, Ethiopia, in October 2018. Case published January 2019.

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Following the peaceful Rose Revolution in November 2003, Georgia President Mikheil Saakashvili and State Minister for Reform Coordination Kakha Bendukidze sought to overhaul the country’s Soviet-style bureaucracy, which had become the target of public anger. Borrowing ideas from libertarian, free-market think tanks and the New Public Management model, Bendukidze recruited a staff, eliminated redundant functions in the executive arm of government, consolidated ministries and slashed the size of the civil service. Bendukidze’s vision of limited government complemented Saakashvili’s goal of eliminating corruption by reducing opportunities for bribe taking. Although Bendukidze was instrumental in developing many of the reform policies, his office left the implementation of reforms to individual ministries. This case chronicles the steps that the Georgian government took to reorganize and consolidate its operations, capitalizing on public support in order to make rapid and bold changes.

More than a decade after the 1994 genocide, Rwandan government ministries struggled to implement long-term plans or even meet mid-term targets. A skills shortage hindered projects at the district and local levels. In 2008, Charles Karake and Stella Mugabo, senior officials at the Human Resources and Institutional Development Agency, a government organization charged with improving national capacity, experimented with a management practice known as the Rapid Results Approach to enhance ministries’ ability to implement successful projects. Rapid Results encouraged officials to focus on small-scale projects that could be completed in a relatively brief time span, usually less than four months. This case shows how Rwanda’s Ministry of Local Government, under the direction of Protais Musoni, championed the technique to advance the goals of an anti-poverty program. A pilot program in Gashaki, an impoverished region in north Rwanda, improved the ability of local officials and leaders to help poor families raise their incomes. Although adoption of Rapid Results did not progress beyond the initial phase for a variety of reasons, public servants who participated in the program increased their ability to deliver services effectively and many of Gashaki’s residents improved their financial positions and quality of life within a surprisingly short period. However, critics noted the high cost of implementing Rapid Results and stressed that other factors also contributed to the positive results in Gashaki. This study considers the approach as an alternative to traditional methods of building capacity.

When Mohamed Abdel Salam El-Mahgoub became governor of Alexandria in 1997, he took charge of a storied Egyptian city on the verge of collapse. Garbage and trash lined streets that were clogged with traffic. Roads, highways, water and sanitation systems required urgent repair. Corrupt municipal employees exacted costly bribes for business licenses and building permits. The city’s economy had slowed, as investors, put off by the city’s fading infrastructure and poor services, took their money elsewhere. Alexandria’s fortunes began to turn at the beginning of a nine-year period that came to be called “the Mahgoub era.” Determined to restore the city’s greatness, Mahgoub encouraged citizen participation, formed alliances with key groups, and won public support via high-visibility projects.  He made government more business-friendly by tackling corruption that inflated the price of required documents, and he lured back investors with tax incentives and improved infrastructure. During his nine years in office, Mahgoub saw Alexandria’s economy bloom, fueled by construction projects and an improved business climate. Although some reforms lost momentum when Mahgoub was promoted to a cabinet position in 2006, his accomplishments as governor underscored the value of citizen participation in Egypt’s centralized government.