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Capacity building for Universal Health Coverage - reflections from WHO’s 2nd Advanced Course on Health Care Financing for UHC In Low and Middle Income Countries

6/30/2015

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Kurfi Abubakar Muhammed (Principal Manager, Standards and Quality Assurance, Nigerian National Health Insurance Scheme) shares with us his feelings and experience after the course he attended a few weeks ago in Barcelona. This course is organised once a year. The next edition is foreseen around June 2016.

From 8 to 12 June 2015, I had the opportunity to attend the 2nd Advanced Course on Health Care Financing for UHC in low and middle income countries (LMICs) organized by WHO. The course is part of the WHO capacity building efforts aimed at developing the technical expertise of health care professionals working on health financing in LMICs. The 5-day program took place in Barcelona, Spain, with 55 participants working across 25 different countries. The main goal of the course is to bring participants to a common understanding of health financing and UHC; it also aims to share with the participants a common understanding of WHO’s health financing policy framework, and more generally, WHO’s approach to health policy. Empirical illustrations are also provided of how countries are doing in terms of the objectives of health financing policy for UHC, among others. There are plenty of LMICs in Africa, and many have not yet made much progress with respect to the attainment of UHC. Hence the relevance of this course to experts from countries like mine, Nigeria. We were not disappointed.

But first a few words on the setting. Even though I have never been a big fan of Barcelona’s football team, I have to admit I was excited to be visiting the town just 2 days after the team won the Champions League in Europe. Who knows, I could possibly catch up with all the celebrations?  But besides the expectations of going to a Barcelona in a no doubt jubilant mood, one thing kept nagging at the back of my mind. Why choose Spain, of all places, to teach people from all over the world about health care financing or UHC? What lessons are there for LMICs from the land of Catalonia with respect to health care financing? I was therefore relieved when I heard upon arrival that the choice of the venue was more out of convenience and historical reasons rather than for any academic purpose [1].   


Overview of the course

I found the course to be a comprehensive review of all the determinants of UHC in LMICs. Discussions related, among others, to fiscal space and the issue of sustainability tradeoffs - participants were made to further appreciate the concept of “fiscal space” and the key aspects of the macroeconomic and fiscal environment that will determine the potential government health resource envelope as it relates to financing healthcare.  Another major issue that was discussed concerned revenue raising as it relates to financing healthcare; it highlighted the different categories of revenues, specific objectives for revenue raising policy, and the options available to policy makers. Linking revenue mobilization with pooling reforms in order to minimize risk in health insurance was also discussed; here we were made aware of why expanding risk pooling is an objective for UHC-oriented reforms; we also learnt to determine the desirable and undesirable features of pooling arrangements for the effectiveness of risk pooling (redistributive capacity). Then came the issue of strategic purchasing in health insurance which aims to show the challenges of allocation of pooled funds to providers for the delivery of services. We learnt to appreciate more the purchasing function and how it can be leveraged to achieve health system objectives.  The pros and cons of the various payment options in health insurance were discussed as well as potential adverse incentives and unintended consequences of different provider payment systems and ways of combining different payment mechanisms.

Political economy of UHC

One of the main highlights of the course for me was the lecture on the political economy of universal health coverage by Rob Yates. In the lecture Rob emphasized the political dimension to the whole discussion on UHC, and how this relates to the economic and technical aspects of the debate towards UHC. Key lessons from the political economy concerns that have emerged and shaped how various nations have achieved UHC were shared, such as prioritization in the government budget for health, and how macroeconomic growth has been important in enabling countries to expand coverage and provide better financial protection for their citizens. Efficient allocation, reallocation as well as redistribution of scarce resources have also been shown to be  effective strategies towards making more money available for health. What struck me, as a Nigerian, was how Thailand, a country with a similar GDP as ours, has been able to utilize removal of subsidies on fuel to finance health universal healthcare for its populace. Key to this however is strong political leadership with the capability to manage major social, political and economic changes towards mobilizing adequate resources to finance healthcare, and at the same time set up prudent and accountable expenditure management systems and policies that will ensure the expansion of coverage and provide benefits to the whole populace. I believe that the massive grass roots support for a new administration in Nigeria, the pedigree of the new president as someone whose word is his bond, and his knack for accountability and distaste for corruption can all serve as veritable templates upon which Nigeria can build its own foundation towards the attainment of UHC. 

 Reaching persons in the informal sector: re-thinking the policy options 

It is well known that 70-80% of Nigerians pay for health care out of pocket. This absence of financial protection has tilted most Nigerians into poverty, due mainly to low insurance penetration, which is a measure of the relationship between premiums earned and the nation’s GDP, put at less than 6 percent. This gross inability of Nigeria as a country to provide health insurance to most of its citizens, especially those in the informal sector, at least till now, made me appreciate very much the lecture delivered by Joseph Kutzin of the WHO health financing unit. In the lecture he discussed the thorny issue of how to ensure that persons without regular salaried employment (the “informal sector”) are able to obtain the health services they need, with financial protection. He also showed how to apply a functional approach to a major health financing challenge, demonstrating the importance of this way of thinking and of taking a comprehensive view. Overall emphasis was on the value of re-framing the challenge away from “how do we get the informal sector to contribute” and towards “how do we ensure financial access and financial protection for everyone” irrespective of their employment status.  As a firm believer and defender of Community Based Health Insurance as a path towards UHC, I began to see reasons why this may not be the best option for LMICs.  Rather, for Nigeria to cover its informal sector with health insurance, it needs to devise more innovative financing options and block existing leakages in the management of finances in the country. In addition, health insurance needs to be made compulsory while utilizing the revenue from taxes, petroleum subsidies and other deductions to subsidize contributions for the poor.

The take-home message

The course was for me a very good opportunity to network with likeminded experts. I learnt a lot from my colleagues in Rwanda who struggle with the challenge of balancing population coverage and quality, or from my friends from Ghana who struggle to balance expenditure with income of the national health insurance scheme, and of course from experts in Indonesia whose reform to capture the middle class into the country’s UC health insurance is yielding fruits. Above all it was obvious to me and all other participants in the course that countries have reached UHC and that even more countries can and will reach UHC through different paths and trajectories. We agreed, though, that political commitment, community ownership, desire for social change as well as innovative financing options and efficient utilization of resources are all key to the attainment of UHC in countries.


Note:
[1] The “Casa Convalescència”, as the venue was called, is a magnificent cultural edifice of humanity that forms part of the complex of the "Hospital de la Santa Creu Sant Pau". It was designed in the late 19th century to alleviate the shortage of hospital space in Barcelona and was meant to serve as a relaxation center for recovering patients. It is now managed by the Universitat Autònoma  of Barcelona as a center of academic excellence. The serenity of the place, the magnificent view, the quality of the resource persons, the nice and delicious meals as well as the hospitable nature of the people all contributed in no small way to the success of the training.


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L'assurance maladie volontaire: ce que le zombie a à nous dire

6/23/2015

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Bruno Meessen

Dans ce blog, Bruno Meessen (Institut de Médecine Tropicale, Anvers) rend compte d'une conférence organisée la semaine dernière par l’Initiative de Rotterdam  sur  la Santé Mondiale (Rotterdam Global Health Initiative) et l'Institut de Politique et de Management de Santé (Université Erasmus). Voilà une belle occasion pour revenir sur le sujet controversé de l'assurance maladie volontaire comme un chemin vers la  couverture sanitaire universelle (CSU) !

Pour les personnes travaillant sur la CSU en Afrique, il y avait au moins deux événements intéressants à suivre (ou mieux, auxquels participer !) il y  a deux semaines. A New York, le premier  rapport mondial de suivi de la CSU a été lancé le vendredi 12 juin  avec  cors et trompettes. Dans le même temps, un colloque plus intime intitulé «Stratégies vers la couverture sanitaire universelle: expériences africaines» a eu lieu le jeudi 11 à l'Université Erasmus de Rotterdam. Dans ce blog, je  dirai quelques mots sur ce deuxième événement (qui se tenait sans «  Mr CSU » Tim Evans, mais tout de même avec  Eddy Van Doorslaer et Agnès Soucat, entre autres). Le symposium avait été organisé pour marquer la soutenance de la thèse de doctorat  d’Igna Bonfrer, une membre de la Communauté de Pratique  Financement Basé sur la Performance (cliquer ici pour un blog écrit par elle) – le début prometteur d'une brillante carrière, sans aucun doute.

Beaucoup de choses intéressantes ont été dites au cours de ce symposium. Je vais me focaliser ici sur le programme de la matinée, qui était consacré à l'assurance-maladie. Deux présentations concernaient des régime d’assurance maladie volontaire (AMV) en zones rurales, respectivement une  expérience pilote menée par le gouvernement éthiopien
 dans 13 districts, ainsi que le  programme d’assurance-maladie de l’Etat du Kwara (Kwara State Health Insurance program) lancé par le  Health Insurance Fund in Kwara State, au Nigéria. Nous avons également obtenu des informations sur la situation actuelle de l'assurance-maladie nationale  au Ghana (où existe un déséquilibre entre les recettes et les dépenses, comme vous le savez peut-être).

Peut-on apprendre quelque chose des récents régimes d'assurance maladie volontaire?

Au cours de la dernière décennie, plusieurs acteurs néerlandais ont été de fervents partisans de l'assurance maladie volontaire, également par le biais de compagnies d'assurance privées. Ainsi, Rotterdam était peut-être le bon endroit pour passer en revue cette stratégie. Je ne sais pas vraiment combien de temps cette passion pour l’AMV va durer au Pays-Bas, car elle est en contradiction avec les données probantes qui s’accumulent contre les régimes d’AMV: ils n’obtiennent souvent  qu’une faible couverture,  sont régressifs (ceux qui souscrivent ne sont pas les plus pauvres) et marquent une fragmentation des fonds mis en commun. Joe Kutzin, par exemple, ne mâche pas ses mots à leur sujet: «l’AMV est comme un zombie, abattue à plusieurs reprises, elle revient toujours".

Les films de zombies et autres séries de "morts-vivants" sont à nouveau en vogue, pour des raisons qui ne sont pas tout à fait claires pour moi. Pourrait-il un jour en être de même avec l’AMV?

A Rotterdam, nous avons pu entendre que les régimes en Ethiopie et au Nigeria ont obtenu d’assez bon taux de couverture (autour de 48% et 33% respectivement, ce qui est en effet  plus que décent), ont  conduit à une augmentation de l'utilisation et à une réduction du paiement direct moyen par les usagers (respectivement de 50% et 70%). Ces résultats semblent aller à l’encontre des résultats de l’AMV rapportés ailleurs -  plutôt négatifs en général. Revoyons-les, dans l'ordre inverse.

Pour la diminution des dépenses directes par les ménages, il faut un peu les circonstancier : ils sont largement dus aux lourdes subventions aux régimes (suffisamment hautes pour permettre de ne pas réclamer un ticket modérateur). Personnellement, je ne veux pas accorder trop d’importance à cet indicateur: si la situation de base est que les ménages renoncent aux soins, il est probablement optimal pour eux, une fois qu'ils bénéficient de l'assurance, de dépenser autant qu'ils le faisaient avant (pourvu que cette consommation plus élevée s’oriente vers des services de meilleure qualité).

Le résultat de l'utilisation des services de santé de qualité me semble beaucoup plus important, étant donné la situation de sous-utilisation considérable que nous observons dans la plupart des milieux ruraux. De ce fait, il est essentiel que ces régimes conduisent à une plus grande utilisation de services de santé (de qualité !). Une question importante est bien sûr de savoir si l'utilisation accrue des assurés entraîne des effets positifs ou négatifs pour les non-assurés. Les deux situations sont possibles, et nous avons compris que des résultats différents sur cette question particulière avaient obtenus par des groupes de recherche différents travaillant sur  l'expérience de Kwara (Nigéria).

Le paramètre du taux de couverture reçoit souvent beaucoup d'attention. Bien sûr, si le taux d’enrôlement est très faible, vous ne réalisez pas grand-chose (comme un participant me disait au cours de la pause, si ce taux est tellement bas, vous pouvez même décider de ne pas avoir une enquête de suivi pour mesurer l'impact de votre régime, créant ainsi un biais dans l’évidence globale). Un taux de couverture élevé est certainement ce dont les pays sont le plus fiers. Malheureusement, cela indique que les gens continuent à se méprendre sur que la CSU est: ils assimilent à tort la CSU à  l’enrôlement  dans un régime d'assurance formel. Pour rappel, si votre pays a un système « Beveridgien » qui est très accessible à votre population et tend à fournir des soins de santé de qualité, votre taux de couverture n’est probablement pas loin d'être universel (certes, c’est une configuration rare dans les pays à revenu faible et intermédiaire, mais c’est possible).

Quel taux de couverture indique le succès?

La question dont nous avons débattu à Rotterdam est de savoir si un taux de 40-50% de couverture peut déjà être considéré comme un bon résultat. Dans l’ensemble, les participants ont convenu que oui ; plus fondamentalement, la conversation s’est par la suite déplacée  sur l'idée que la dynamique politique dans votre province ou votre pays est en fait la tendance clé à surveiller.

Après le lot d’expériences décevantes avec l’AMV, nous savons que si vous atteignez d’aussi hauts  niveaux de couverture, cela signifie probablement que vous avez réuni toutes les conditions préalables, y compris le fait que «quelque chose s’est passé au niveau communautaire et gouvernemental». Nous avons appris qu’à Kwara, le taux élevé d’enrôlement (et la décision d’étendre le régime à plus grande échelle) est en grande partie dû au leadership personnel du gouverneur de la province (un médecin, par chance). En Ethiopie, il y a un fort engagement de l'appareil d’Etat qui, entre autres choses, se matérialise par une mise sous contrainte des ménages par les autorités locales (puisque ces dernières  sont les canaux fiduciaires d'un régime d'assistance sociale pour les plus pauvres, elles  sont en mesure de déduire la prime pour l’assurance maladie avant de payer l’allocation).

Le fait que «quelque chose semble se passer sur le plan collectif" est probablement la vraie question à propos de la CSU et l'une des dimensions clés que nous devrions essayer de capturer dans le cadre de nos efforts de suivi.

Ghana-France: 1-1

Par exemple, nous pouvons appliquer cette perspective de «quelque chose se passe» pour une quatrième variable utilisée parfois pour évaluer un régime d'assurance maladie: l'équilibre financier entre les recettes et les dépenses. Quand j‘ai écouté la présentation sur le Ghana, qui est confronté à d'énormes problèmes avec le financement de son assurance maladie nationale, je me suis penché vers l'experte française assise à côté de moi pour la taquiner : "hé, ça ressemble à la France!". La vice-ambassadrice du Ghana, également présent dans la salle, a reconnu que le pays est confronté à un grand défi, mais a confirmé que le pays n’allait pas  arrêter son assurance maladie nationale - la dynamique reste forte et cette politique figure parmi les priorités de différents partis politiques. Ainsi, comme Agnès Soucat  l’a si bien dit à la session de clôture, les difficultés rencontrées par le Ghana sont probablement plus un signe de maturité et de dynamisme que l’expression  d'un échec: le progrès vers la CSU  apporte habituellement de nouveaux problèmes, des problèmes plus importants (puisque qu’ils  ont tendance à être à une plus grande échelle), et des problèmes plus visibles; en bref, le progrès de la CSU met la pression sur votre système de gouvernance. Dès lors, ressembler à la France est un compliment!

Le lien entre la CSU et la gouvernance

Il est clair que nous avons abordé une question importante à Rotterdam: le lien bidirectionnel entre la gouvernance et  la CSU. Par exemple, le cas de l'Éthiopie a déclenché une discussion sur le fait que plusieurs régimes d’AMV ou de mutuelles communautaires sont en fait des régimes obligatoires. Cette nécessité de rendre obligatoire la souscription semble offrir un avantage aux Etats autoritaires et administrativement forts (1). Mais l’on pourrait également faire valoir que cette supériorité est à court terme, étant donné que la CSU est fondamentalement une question de cohésion sociale. Dans une certaine mesure, ceci fait écho à la question du meilleur modèle de développement: le modèle  chinois (un parti unique au pouvoir avec une forte croissance économique) ou le modèle indien (une démocratie forte avec une croissance économique plus faible)? D’importantes questions de gouvernance et de développement comme celles-ci ne seront jamais loin avec le programme de la CSU  que l’on veut tous mettre en œuvre dans les années à venir. Et de ce point de vue, le taux de couverture élevé atteint à Kwara pourrait en effet être une réalisation majeure, le Nigeria étant probablement moins réceptif à la contrainte (ceci dit, cela ne dit pas encore grand-chose sur la possibilité d’étendre la stratégie à grande échelle).

Plus j’interagis avec les décideurs des pays et autres parties prenantes nationales (principalement à travers les communautés de pratique désormais), plus je crois que l'approche internationale dominante actuelle vers la CSU est beaucoup trop technique. La CSU peut et doit certainement être mesurée par rapport à certains objectifs clairs, nous avons donc besoin de rapports comme celui présenté à New York  il y a deux semaines. Mais ils ne suffiront pas.

La CSU sera un long voyage et le processus sera crucial. Bien sûr, vous devez  vous diriger dans la bonne direction dès le début, et vous devez être conscient que votre chemin sera en partie déterminé par vos choix initiaux (« path dependency »). La clé, cependant, est de lancer la dynamique et de la maintenir. Si votre système de CSU est en mode ‘apprentissage’ (nous reviendrons sur ce point plus tard cette année), et si vos citoyens estiment que la CSU est une composante essentielle de la nation, comme cela semble être le cas au Ghana désormais, vous êtes très probablement sur la bonne voie.

 

Note:
(1) Fait intéressant, la Chine, le Rwanda et les autorités régionales impliquées dans le projet pilote éthiopien ont tous les trois (1) introduit des  indicateurs de performance pour mesurer la performance de leurs autorités administratives locales et (2) intégré le «taux d’enrôlement dans l’assurance» comme l'un des indicateurs pour l'évaluation de ce critère.


Traduction : Kéfilath Bello ; Christian Tekam


Symposium, 11 juin 2015 (photo par Michelle Muus)
Symposium, 11 juin 2015 (photo par Michelle Muus)
Igna Bonfrer, soutenance de thèse (photo par Michelle Muus)
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Voluntary health insurance: what the zombie tells us

6/17/2015

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Symposium, 11th of June 2015 (picture by Michelle Muus)
Igna Bonfrer's PHD thesis (picture by Michelle Muus)
Igna Bonfrer, PHD defence (picture by Michelle Muus)
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Bruno Meessen 

In this blog post, Bruno Meessen (Institute of Tropical Medicine, Antwerp) reports on a recent conference organized by the Rotterdam Global Health Initiative and the Institute of Health Policy and Management (Erasmus University) in Rotterdam, the Netherlands. A nice opportunity to come back on the controversial topic of voluntary health insurance as a track to universal health coverage (UHC), it turns out.
                                                                                                                            
 For people working on UHC in Africa, there were at least two interesting events to follow (or even better, attend!) last week. In New York the first Global monitoring report on UHC was launched on Friday 12th with all bells and whistles; meanwhile, a more intimate symposium entitled “Strategies towards Universal Health Coverage: African Experiences“ took place on Thursday 11th at Erasmus University, Rotterdam. In this blog post, I will say a couple of things on the second event (without Tim Evans, but still with the likes of Eddy Van Doorslaer and Agnès Soucat, among others). The symposium marked the PhD graduation of Igna Bonfrer, a member of the PBF CoP (check here for a blog by her) - a promising start of a bright career, no doubt.   Plenty of interesting things were said during the symposium. I will focus here on the morning program which was dedicated to health insurance. There were two presentations on voluntary health insurance schemes (VHI) in rural areas, a pilot government-led experience in 13 districts in Ethiopia and the Kwara State Health Insurance program initiated by the Health Insurance Fund in Kwara State, Nigeria, respectively; we also got some information on the current situation of the national health insurance in Ghana (where there’s quite an imbalance between revenue and expenditure, as you may know).

Can one learn something from recent voluntary health insurance schemes?

Over the last decade, several Dutch actors have been strong proponents of voluntary health insurance, also through private insurance companies, so Rotterdam was perhaps the right place to review this strategy. It is unclear to me how long this passion for VHI will last in the Netherlands, as it is at odds with growing evidence that there are real issues with VHI: they often only achieve low coverage, they are regressive (those who subscribe are not the poorest) and mark a fragmentation of the pooling. Joe Kutzin, for example, does not mince words about them : “VHI is like a zombie, shot many times, but always coming back”.   

Nevertheless, zombie movies and other ‘Walking Dead’ series are in vogue again, for reasons not entirely clear to me. Could the same happen one day with VHI?

In Rotterdam, we heard evidence that the schemes in Ethiopia and Nigeria achieved rather good coverage rates (around 48% and 33% respectively, which is indeed more than decent), led to an increase in utilization and to a reduction of average out-of-pocket payment (50% and 70% respectively). So results seemed to be going against the - typically rather negative - reported VHI outcomes elsewhere. Let’s review them, in reverse order.

As for the out-of-pocket decreases, we have to qualify them a bit: they are largely due to the heavy subsidies to the schemes (which allow for instance not to request co-payment). Personally, I don’t really want to put emphasis on the out-of-pocket result: if the overall baseline situation is that households forego care, it could even be optimal for them, once they are entitled to the insurance package, to spend as much as they did before (as long as their higher consumption entails better health services).

The metric of utilization of quality health services seems much more important to me, given the pattern of dramatic underutilization we observe in most rural settings. So it is key that these schemes lead to higher utilization of (quality!) services. An important question is of course whether the increased utilization of the insured has positive or negative spillover effects for the non-insured. The two situations are possible, and I understood that there were different findings on this particular issue in the Kwara experience.

The coverage rate metric often receives a lot of attention. Obviously, if the enrolment rate is very low, you are not achieving a lot (as a participant told me during the break, you may even decide not to have a follow-up survey to measure the impact of your scheme which thus creates a bias for the global evidence base). A high coverage rate is certainly what countries are most proud of. Unfortunately, this indicates that people continue to misunderstand what UHC is: they wrongly equate UHC to the enrolment in a formal insurance scheme.  As a reminder, if your country has a Beveridge system that is highly accessible to your people and tends to provide quality care, your coverage rate is probably not far from universal (ok, this is a rare configuration in low and middle-income countries, but it is possible).

Which coverage rate indicates success?

The question we debated in Rotterdam is whether a coverage rate of 40-50% could be already considered as a good result. By and large, participants agreed; more fundamentally, the conversation then focused on the idea that the policy momentum in your province or in your country is the key trend to watch.

After the bulk of disappointing experiences with VHI, we know that if you reach such high levels of coverage, it probably means that you got all the preconditions right, including that ‘something has happened at community and governmental level’. We learnt that in Kwara, the high enrollment (and the decision to scale up the scheme) owes a lot to the personal leadership developed by the governor of the province (a medical doctor, by chance). In Ethiopia, there is strong commitment from the State apparatus which, among other things, materializes into household coercion by the local authorities (as the latter are the fiduciary channels of a social assistance scheme for the poorest, they are able to deduct the premium for the VHI from the allowance).   

Evidence that “something seems to be happening” is probably the real issue about UHC and one of the key dimensions we should try to capture in our monitoring efforts.

Ghana-France: 1-1

For instance, we can apply this lens of ‘something happening’ to a fourth metric sometimes used to assess a health insurance scheme: the balance between revenue and expenditure. When I listened to the presentation on Ghana which is facing huge problems with financing its national health insurance, I leaned over to the French expert sitting next to me and half-jokingly said, “hey, it looks like France!”. The vice-ambassador of Ghana, also present in the room, acknowledged that the country is facing a big challenge, but confirmed that the country would not stop its national health insurance – the momentum remains strong and the policy is very high on the agenda of different political parties. So, as Agnès Soucat put it nicely at the wrap-up session, the difficulties met by Ghana are probably more a sign of maturity and momentum than an indication of failure: progress towards UHC typically brings new problems, bigger problems (as they tend to be at a larger scale), and more visible problems; in short, UHC progress puts pressure on your governance system. Looking like France is a compliment!

The link between UHC and governance

It is clear we touched upon an important issue in Rotterdam: the bidirectional link between governance and UHC. For instance, the Ethiopian case sparked a discussion on the fact that several VHI/CBHI schemes are in fact mandatory schemes. The need to make subscription compulsory seems to provide a premium to authoritarian states with a strong administrative apparatus.(1) But one could also argue, instead, that this premium is short term, as UHC is fundamentally about societal cohesion. To some extent, this echoes the question of the best developmental model: the Chinese one (one ruling party with strong economic growth) or the Indian one (a strong democracy with lower economic growth)? Important governance and development questions like these will never be far away as the UHC agenda is to be implemented in the coming years. And from this perspective, the high coverage rate achieved in Kwara could indeed be a major achievement, as Nigeria is probably less receptive to coercion (however, this is not saying much yet about the scalability of the strategy).

The more I interact with countries’ decision makers and other domestic stakeholders (mainly through the communities of practice nowadays), the more I believe that the current dominant international approach to UHC is far too technical. UHC can and should certainly be measured against some clear objectives, so we need reports like the one presented in New York last Friday. But they won’t suffice.

UHC will be a long journey and the process will be key. Of course, you must head in the right direction from the start, and you should be aware of path dependency. The key, however, is to kickstart the momentum and maintain it. If your ‘UHC system’ is in a learning mode (we will come back on this point later this year), and if your citizens reckon that UHC is a core component of the nation, like seems to be the case in Ghana now, you are most probably on the right track.

 

Note:
(1)    Interestingly enough, China, Rwanda and the regional authorities involved in the Ethiopian pilot have all three (1) introduced performance indicators to measure the performance of their local administrative authorities and (2) incorporated the ‘insurance enrolment rate’ as one of the indicators for this yardstick evaluation.



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Knowledge management and the national health system: launch of a hub of 'CoPs' in Benin

6/3/2015

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PhotoPicture of a USB hub for computer
Facilitation Team of the Benin hub of 'CoPs'

You are an avid reader of the blog ‘Health Financing for Africa’? Then you are probably familiar with the philosophy and the regional activities of the Communities of Practice (CoPs). In this blog post, Jean-Paul Dossou, Patrick Makoutodé and the whole facilitation team of the new Benin hub express their ambition: to launch a national platform, a "hub", in other words, intended to further develop and boost the activities of the various CoPs, and embrace a CoP-style approach at country level, in Benin. If you are active in this country, do not hesitate to join this collaborative project ! If you are based elsewhere, this blog could be a source of inspiration.

A Brief History

Before presenting our vision, let’s provide a quick brief history of how we got this idea in the first place.

Benin established an early link with the CoPs. The first step had to do with the FEMHealth project. This research project, which focused on the policies of free maternal health care, played a major role in the launch of the CoP Financial Access to Health Services (CoP FAHS). Benin was one of the four countries involved in the research, through the ‘Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD)’ or the Centre for Research in Human Reproduction and Demography. In this context, one of us, Patrick Makoutodé had been designated as focal point of the "CoP FAHS” for Benin. At the time, the CoP strategy at the country level was quite unclear. Very clear though, was the fact that the focal point had facilitated the enrolment of several Beninese experts in the CoP. True, other important actors also directly joined  the CoP, such as the Deputy Secretary General of the  Ministry of Health and the Coordinator of the ‘Programme de Renforcement de la Performance du Système de Santé au Benin’ (Health System Performance Strengthening coordinator) in Benin who currently prove to be strong supporters of the CoP  hub project. Several Beninese experts also quickly joined other CoPs, more in particular the CoP Performance Based Financing  (Benin has a nationwide ambition for its RBF strategy), the Health Service Delivery CoP  and the CoP Planning and Budgeting of Health Systems  .


The idea of a ‘hub’ emerged on the 28th of February 2015, during a meeting between experts based in Benin and CoP facilitators who just happened to be in Benin at the time (Bruno Meessen, Michel Muvudi and Carine Bruneton). On that particular Saturday morning there were several “triggers”.

First, all national experts in the room (there were officials from the Ministry of Health present, but also researchers and actors from decentralized levels) acknowledged that in our country, the management of knowledge concerning the health system is currently failing; during our discussions, we suddenly began to realize that the Benin situation is actually very similar to the situation which motivated the launch of CoPs at regional level: we operate in silos, we rarely share our respective knowledge,….  The new vision presented by Bruno Meessen was another trigger: we saw in the new strategy promoting collaborative projects an opportunity to start something by ourselves. Finally, Michel Muvudi made an inspiring presentation on a project led by a group of Congolese experts: to launch a CoP hub for the Democratic Republic of Congo.

This inspiration remained with us like a seed that only waited to sprout. We thought: why not us too? The next step was obvious: we would meet again soon; this time, a whole day would be devoted to the launch of a national “CoP” initiative.


The Benin hub: vision and first activities

There are words or expressions that you think you “know” naturally, while their real meaning is actually quite different. Indeed, when we heard Michel, we imagined a hub as a derivative or diminutive of the French word “hublot" (a porthole), the small moving window of a ship or the sealed one of an airplane. Likewise, we imagined the Benin hub as a window, an opening, a light of the CoPs shining on Benin.

It was only later that we discovered the meaning of the word "hub" as used in aviation, that is to say a busy airport that airlines use as a transfer point to get passengers to their intended destination.   Well after that still, we discovered the computer meaning of the word "hub", a common connection point for devices in a network. These last two meanings of the word ‘hub’ are truly in harmony with the verb "OPTIMIZE", the key aim of our initiative. More in particular, the Benin CoP hub aims to promote and exploit the different energies and different opportunities from the CoPs to optimize their impact on the health system of our country.

In practice, this is what Beninese experts gathering on 18th April decided.
1- Our hub of CoPs will embrace the CoP philosophy: it will be a national organization gathering the expert members of the HHA Communities of Practice (CoP), active in Benin. The general objective is to apply the "recipes" of CoPs (horizontal dialogue between experts, continuity in the learning agenda ...) to promote knowledge transfer in the country. Our hypothesis is that in this way we can contribute to better implementation of health policies.
2. At the meeting of 18 April 2015, these experts organized their discussions around three collaborative projects that will be open to all experts: 1) revitalization of Technical Working Groups (TWG) of the Ministry of Health; 2) realization of the Wiki RBF Benin and 3) organization of an international conference on Results-Based Financing in 2016.


The game is on

The proposed revitalization of TWG has already been presented to the Extended Executive Committee of the Ministry of Health. This has generated much interest at the highest level. The TWG are indeed essential knowledge management tools for the Ministry of Health, but they are barely functional at present. Our ambition is that current expert members of TWG and those who are not yet members but are interested in this collaborative project will contribute via strategic thinking and advocacy for evidence-based health policies, initiation and contextualized knowledge management agendas, and monitoring of their transformation in health policies.

The RBF wiki project will be launched soon at the regional level by the CoP PBF. Informed by Bruno on 28 February, we decided to take the lead and already started organizing ourselves. More specifically, Beninese experts must commit to producing synthesized knowledge on RBF in Benin  and to putting this knowledge online (freely available, that is). The experts who join this wiki-project will be involved in the production, archiving and putting online of documentation articles on various key aspects of RBF in Benin. As far as we are concerned, this pilot initiative can later be extended to other major themes of health in Benin.

The organization of an international conference on RBF in Benin in 2016 is just as exciting. The conference will build on current RBF knowledge in Africa. Interested experts will be involved in all phases of the organization both in terms of practical organization of the event as well as in producing  high quality content. This ambitious event could still be preceded in 2015 by a smaller meeting on social media as a strategy to support local health systems (in partnership with the Health Service Delivery CoP).

The facilitation team which launches this hub is aware that the challenges are many and that the process will require energy and stamina. Our secret pill: a big dose of enthusiasm and a strong belief that we can turn it into practical ideas.

We will all have to take up an important stewardship role and maximize the opportunities offered by new technologies, but also develop a rigorous and quick learning process. The lessons we learn will improve the process continuously. This is an essential capability of learning organizations, indispensable if we aim for better performance of health systems. So we will have be quick learners, but we feel more than ready for the challenge.

Benin emerges! If you are active in Benin and interested to join us, we invite you to read the project form on this important collaborative project for our health system. We hope many of you will join us.


Access to the project form : Click here



Translation : Zakariaou Njoumemi

Acknowledgements: We express our sincere gratitude to all experts who actively participated in the meetings of 28th February and 18th April 2015 at the Institute of Applied Biomedical Sciences in Cotonou (Benin).

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